Is A Sphincterotomy a Good Idea for Pediatric Pancreas Divisum?

A recent retrospective single-center study (TK Lin et al. JPGN 2021; 72: 300-305. Clinical Outcomes Following Therapeutic Endoscopic Retrograde Cholangiopancreatography in Children With Pancreas Divisum) indicated that a minor papilla endoscopic sphicterotomy (mPES) may be beneficial for children with pancreas divisum and pancreatitis. The study included 27 children who had a total of 58 ERCPs.

Key findings:

  • After a median follow-up of ~32 months, 13 of 20 responders (65%) reported clinical improvement from endotherapy/mPES.
  • A genetic variant was identified in 19/26 (73%) tested patients
  • Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58)

Discussion:

The authors note that the beneficial finding of improvement after mPES in children is contrary to findings in adults. In addition, there is an active sham-controlled randomized clinical trial ongoing in adults (NCT03609944). They speculate that this could be related to longer disease burden in adults. In addition, they note that their findings had limitations:

  • this was a retrospective study with a small sample size
  • the results were based on a subjective non-validated questionnaire with concerns for recall bias

My take: I am not convinced that sphincterotomy is beneficial in most children with pancreatitis and pancreas divisum –the majority of whom have an underlying genetic variant which likely triggers pancreatitis. The only way to answer this question definitely is to perform a randomized clinical trial similar to the sham-controlled study in adults.

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