title: Pancreas divisum: a differentiated surgical approach in symptomatic patients.
abstract: BACKGROUND
  Some patients with pancreas divisum (PD) develop symptoms of recurrent pancreatitis. This is probably caused by insufficient drainage of the pancreatic duct. We report the results of our follow-up of patients who underwent surgery for symptomatic pancreas divisum according to an individualized surgical approach.
  
  
  METHODS
  Between October 2001 and April 2009, 28 patients with symptomatic pancreas divisum were operated at the University Hospital of Heidelberg. According to the localization and type of morphological changes of the pancreas, patients received a reinsertion of the papilla (SP; n=11), duodenum-preserving pancreatic head resection (DPPHR; n=10), pylorus-preserving Whipple (ppWhipple; n=4), or other pancreatic resections (n=3). Hospitalization, morbidity, mortality, pain course, and patient satisfaction were analyzed.
  
  
  RESULTS
  Before surgery, patients received a median of three endoscopic interventions and were hospitalized for 77 days. The median postoperative follow-up was 4.1 years. Surgical morbidity was 11% and mortality 0%. We performed an SP when the pancreas was soft (n=10). When the pancreas was inflammatory altered, a DPPHR was performed in ten, ppW in four, segmental resection in two, and SP and pancreatic left resection in one case. A redo operation for persisting symptoms was needed in six patients (3 soft and 3 altered pancreas). Compared with the preoperative situation, pain was significantly reduced in the follow-up (median Visual Analogue Scale 0 vs. 10). Ninety-six percent of patients were without symptoms during the follow-up.
  
  
  CONCLUSIONS
  The individualized surgical approach for patients with symptomatic PD achieves significant reduction of pain in all patients. Reinsertions of the papilla should be performed as a first surgical intervention in patients with a soft pancreas when symptoms persist despite adequate endoscopic treatment. DPPHR should be performed when fibrotic alterations of the pancreas are present.
authors.affiliation: Department of General Surgery, University of Heidelberg, Heidelberg, Germany. lutzschneider2@gmx.de
authors.forename: Lutz
authors.initials: L
authors.lastname: Schneider
authors.forename: Elias
authors.initials: E
authors.lastname: Müller
authors.forename: Ulf
authors.initials: U
authors.lastname: Hinz
authors.forename: Lars
authors.initials: L
authors.lastname: Grenacher
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Jens
authors.initials: J
authors.lastname: Werner
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D002908:Chronic Disease; D015331:Cohort Studies; D004065:Digestive System Abnormalities / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D010179:Pancreas / Q000002:abnormalities* / Q000601:surgery*; D010180:Pancreatectomy / Q000379:methods* / Q000401:mortality; D010195:Pancreatitis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D011300:Preoperative Care / Q000379:methods; D019651:Plastic Surgery Procedures / Q000379:methods* / Q000401:mortality; D012008:Recurrence; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult