Sphincteroplasty for Pancreas Divisum
Andrew L. Warshaw
Indications and Contraindications
Indications
■Strong: recurrent episodes of documented acute pancreatitis (typical pain, increased serum amylase) in patients with congenital pancreas divisum or other variants of a dominant dorsal duct (absent duct of Wirsung, filamentous communication to duct of Wirsung)
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Weak: patients with pancreas divisum and episodic “obstructive pancreatic pain”
(pain with characteristics and location attributable to a pancreatic origin but without objective substantiation by hyperamylasemia or pancreatic edema).
Contraindications
■Chronic pancreatitis (fibrosis, major duct dilation, pseudocyst, segmental duct obstruction, calcification)
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Pancreatitis from alcoholism, hypercalcemia, hyperlipidemia, gallstones, or trauma
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Recent severe acute pancreatitis, significant residual inflammation/swelling
Preoperative Investigation and Preparation for the Procedure
History: Recurrent episodes of epigastric pain, especially with radiation through to the mid back; pain starts sporadically, with bouts months apart, but may become frequent and even constant; attacks are usually mild, more common in young women; mean onset is at 34years but can occur in childhood, onset is uncommon after age 50years.
Clinical evaluation: May have tenderness over the pancreas.
Laboratory tests: Serum amylase and/or lipase.
Imaging: ERCP or MRCP to elucidate pancreatic ductal anatomy; ERCP must include opacification of the dominant dorsal duct via accessory papilla. Caution: acquired obstruction of the duct of Wirsung by tumor in the pancreatic head can mimic pancreas divisum.
Functional tests: Transabdominal ultrasonography, endoscopic ultrasonography, or MRCP with secretion stimulation – demonstrates abnormally delayed return of principal pancreatic duct to normal size after hyperstimulation of pancreatic secretion.
Impaired emptying through stenotic accessory papilla results in
persistent (15- to 30-min) duct dilation.
Procedure
STEP 1
Exposure of minor papilla
An upper midline or right subcostal incision depends on patient habitus.
Extensive mobilization of the duodenum and the head of the pancreas (extended Kocher maneuver) facilitates exposure.
Cholecystectomy is performed if the gallbladder is still present; passage of a biliary Fogarty® catheter via the cystic duct or common duct through the major ampulla into the duodenum aids localization of the accessory papilla.
A transverse duodenotomy is made just proximal to the papilla of Vater, which can
usually be felt transduodenally or with the aid of the biliary Fogarty® catheter.
STEP 2
Location of minor papilla intraduodenally
Locate the accessory (minor) papilla 2–3cm proximal and anteromedial to the papilla of Vater; minimize trauma to the duodenal mucosa.
Secretin (1U/kg intravenously) helps locate the papilla by inducing visible flow of pancreatic juice and sometimes by ballooning out the papilla.
Grasp the duodenal mucosa just distal to the minor papilla to fix its position; insert a
fine probe or Angiocath into the orifice. (It may be necessary to pierce the membranous
tip of the papilla when the orifice is miniscule.)
STEP 3
Sphincterotomy of minor duct
Fine traction sutures are placed at the distal margins of the accessory papilla; the papilla is incised over a probe in the duct. Pancreatic juice should gush forth, and a dilated vestibule proximal to the papillary membrane should be immediately apparent. The smooth light pink mucosa lining the pancreatic duct is easily distinguished from the duodenal mucosa.
The incision is extended about 1cm, only as far as necessary to lay the duct vestibule widely open.
STEP 4
Sphincteroplasty of minor duct
The duodenal mucosa and the pancreatic duct epithelium are approximated with fine
absorbable synthetic sutures for hemostasis and to facilitate healing without re-stenosis.
STEP 5
Duct drainage and duodenal closure
A small catheter (e.g., 5-French pediatric feeding tube) is passed through the duodenal wall and into the pancreatic duct to insure against postoperative duct obstruction.
The catheter is inserted within the duodenal wall through a 14-gauge needle or commercial catheter fitted on a trocar, tunneled within the duodenal wall, and closed with a double-purse-string absorbable suture (A-1). The catheter is brought out through the abdominal wall for postoperative drainage and remains in place for 2–3weeks before removal (A-2,
A-3).The duodenotomy is closed transversely in two layers; no right upper quadrant drain is needed.
A-3
Postoperative Tests
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Routine postoperative surveillance.
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Serum amylase is not necessary unless there is a specific clinical indication.
Local Postoperative Complications
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Short term:
– Acute pancreatitis – Duodenal obstruction – Duodenal leak
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Long term:
– Recurrent papillary stenosis – Recurrent symptoms, pancreatitis
– Failure to cure preoperative pain syndrome
Tricks of the Senior Surgeon
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The major papilla (ampulla) of Vater is often palpable through the duodenal wall even without a transcholedochal (e.g., via cystic duct) catheter through the Ampulla of Vater.
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The accessory papilla is proximal in the duodenum, perhaps only 3cm from the pylorus; a prominent vessel on the lateral duodenal wall is often noted at this point.
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The transverse duodenotomy provides adequate exposure and is less likely to cause postoperative duodenal stenosis than a longitudinal suture line.
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The accessory papilla may be difficult to find by visual inspection, it is often small, protrudes minimally from the duodenal surface and is located more easily by gentle palpation of the medial wall of the duodenum. It feels like a small
“bump” or nipple.
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Application of methylene blue to the duodenal mucosa may help to locate the pancreatic duct orifice; pancreatic secretions, especially after secretin, wash off the blue dye at the orifice.
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After cannulating the orifice, do not remove the probing instrument until the incision into the papilla has been completed. Local trauma may make rediscovery of a small, traumatized orifice very difficult.
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