Pancreatic division

　　Pancreatic division is a congenital malformation characterized by the complete non-fusion or only fine branch duct fusion of the main and accessory pancreatic ducts during the development of the pancreas. Pancreatic division (PD) is a congenital anatomical abnormality, with some patients showing no clinical symptoms at all, and only experiencing obstructive abdominal pain, pancreatitis, or both when there is a stricture at the opening of the accessory papilla and poor drainage.

　　Pancreatic division (PD) is a congenital anatomical abnormality, with some patients showing no clinical symptoms at all, and only experiencing obstructive abdominal pain, pancreatitis, or both when there is a stricture at the opening of the accessory papilla and poor drainage. Lehman et al. reported 52 cases of PD patients, including 24 cases of refractory abdominal pain (46%), 17 cases of acute recurrent pancreatitis (32.7%), and 11 cases of chronic pancreatitis (21.1%). Warshaw et al. reported 100 cases of patients with episodic acute pancreatitis and pancreatic abdominal pain, of which 71 were typical PD cases. Another report described 10 cases with chronic abdominal pain and 5 cases with a history of recurrent pancreatitis attacks.

　　There is currently no effective preventive measure for pancreatic divisum (PD), and early detection and early diagnosis are the key to the prevention and treatment of the disease. At the same time, it can also reduce the occurrence of complications such as pancreatitis. For patients who have shown symptoms of pancreatitis, active treatment should be carried out, including fasting, energy support, and suppression of glandular secretion, among other comprehensive treatments.

　　The main clinical examination methods for pancreatic divisum (PD) are as follows:

　　One, ERC, ERCP (Endoscopic Retrograde Cholangiopancreatography)

　　From the main papilla, the ventral pancreatic duct is visualized, appearing short and small, located on the right side of the spine, with branching patterns resembling a tree or a horse's tail, and the accessory pancreatic duct is not visible. From the accessory papilla, a pancreas similar to the usual main pancreatic duct can be seen, extending to the tail of the pancreas. This dorsal pancreatic duct is not connected with the ventral pancreatic duct or only has a small communicating branch.

　　Two, accessory papilla catheterization

　　Technically, the following points should be noted:

　　1. There are many difficulties in using routine contrast catheters, and it is recommended to use a catheter with a fine tip.

　　2. The insertion of the scope is easier to succeed when using a push-in method.

　　3. Once the image appears, take a picture quickly.

　　After ERCP examination, the injection of contrast medium may cause distension and pain, and cannot show its distal part. The dorsal pancreatic duct of PD opens at the accessory duodenal papilla. If the catheter fails to successfully insert into the opening of the pancreatic duct, the pancreatic duct cannot be visualized.

　　Three, Magnetic Resonance Cholangiopancreatography (MRCP)

　　The principle of water imaging can display the pancreatic and bile ducts very well. Pancreatic divisum is manifested in imaging as the simultaneous display of the ventral and dorsal pancreatic ducts, with the original ventral pancreatic duct presenting as a short tubular cavity, opening at the duodenal papilla, which can open together with the common bile duct or open separately. MRCP is non-invasive, without radiation, painless to the patient, simple and convenient, and has gradually become popular in recent years. Many scholars have also proposed that using MRCP examination that promotes pancreatic juice secretion can improve the imaging quality and diagnostic accuracy of MRCP.

　　Four, other imaging examinations

　　CT and ultrasound can show pancreatic enlargement or ductal dilation, but cannot confirm the diagnosis of pancreatic divisum.

　　Patients with pancreatic divisum (PD) should mainly consume light and bland foods, pay attention to dietary regularity, and eat rationally according to the doctor's advice. Pancreatic divisum is mainly due to congenital underdevelopment of the pancreas, and it is recommended to limit diet or fasting and seek medical treatment. Nutritional support through veins can reduce pancreatic juice secretion, which is conducive to the regression of inflammation. After the disappearance of abdominal pain, small amounts of food can be eaten, which is completely free of fat, low in protein, and high in carbohydrates, such as congee, vegetable juice, fruit juice, and lotus root starch, and can also be replaced by enteral nutrition. Only after the complete recovery of the condition can low-fat and low-protein diets be gradually introduced; only after the complete recovery of the condition can normal diet be gradually resumed. In daily life, it is necessary to strictly avoid alcohol, chili, coffee, strong tea, and other irritants to reduce the occurrence of pancreatitis.

　　Patients with asymptomatic pancreatic divisum (PD) do not require special treatment, and symptomatic treatment can be given to those with mild symptoms. Dietary guidance is provided, and pancreatin inhibitors can be given when there are signs of acute pancreatitis. For severe abdominal pain and recurrent pancreatitis, endoscopic treatment can be adopted using the following methods, the purpose of which is to enlarge the opening of the accessory papilla to ensure sufficient drainage of pancreatic juice.

　　First, endoscopic treatment
　　The main treatment methods include accessory papilla sphincter dilation, accessory papilla sphincter incision, and accessory pancreatic duct stent drainage. It is effective for acute recurrent pancreatitis and should be the first choice; for chronic pancreatitis, endoscopic treatment has shown significant progress in recent years.

　　Second, surgical treatment

　　1. Transduodenal accessory papilla incision and molding: Warshaw et al. reported 61 cases, including 48 cases in the accessory papilla stenosis group, with 85% of symptoms relieved after surgery; 13 cases in the accessory papilla without stenosis group, with 15% of symptoms relieved after surgery. It is believed that accessory papilla without stenosis is ineffective for transduodenal accessory papilla incision and molding, and pancreatectomy should be performed.

　　2. Anastomosis of the accessory pancreatic duct with the jejunum: Rusnak et al. treated 6 cases, and the symptoms were relieved after surgery, and pancreatitis did not recur.

　　3. Partial or total pancreatectomy: At present, most scholars believe that pancreatic divisum with macroscopic changes (fibrosis) associated with chronic pancreatitis is not suitable for papillary切开成形术, but should be treated with partial or total pancreatectomy. Pancreatic divisum with chronic pancreatitis who still have pain after endoscopic treatment should undergo partial or total pancreatectomy.

   　The overall effective rate of endoscopic treatment is relatively high. In the surgical treatment, the postoperative symptom relief rate of the subgroup with accessory papilla stenosis is 85%, and the postoperative symptom relief rate of the subgroup without accessory papilla stenosis is 15%.