A subpopulation of pancreas divisum patients may have pancreatic pain or pancreatitis as a result of a stenotic minor papilla. This study was undertaken to evaluate the efficacy of minor papilla sphincterotomy in 52 pancreas divisum patients who had disabling chronic pancreatic pain (n = 24), acute recurrent pancreatitis (n = 17), or chronic pancreatitis (n = 11). Patients were symptomatic for a mean time of 5.1 years and had failed to respond to conservative therapy. Minor papilla sphincterotomy was performed with a needle knife over a previously placed minor papilla/dorsal pancreatic duct stent. Clinical improvement was assessed by comparison of symptoms (using a 0 to 10 scale) and number of hospital days per month required for pain or pancreatitis for an equal period of time before and after therapy. The average duration of follow-up was 1.7 years. As compared with the chronic pain and chronic pancreatitis groups, the acute recurrent pancreatitis group had a significant reduction in the mean symptom score and number of hospital days per month. Patients with acute recurrent pancreatitis benefited from minor papilla sphincterotomy more frequently than those with chronic pancreatitis (76.5% versus 27.3%, p = 0.01) or chronic pain (76.5% versus 26.1%, p = 0.002). Complications followed 15% of the procedures; they consisted primarily of mild pancreatitis, although one additional patient died of a pancreatic abscess after a failed cannulation. Fifty percent of patients evaluated at the time of stent removal had stent-induced dorsal duct changes. The results of this study support the performance of minor papilla therapy in pancreas divisum patients who have acute recurrent pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)