'Head-first Approach' for small duct chronic pancreatitis.

Small duct pancreatitis is a rare variant of chronic pancreatitis characterized by a main pancreatic duct (MPD) measuring less than 5 mm. Traditionally, resectional procedures have been advocated as a treatment for small duct pancreatitis. However, these procedures are associated with worse post-operative results and a gradual functional decline over the long term. Parenchyma-preserving hybrid extended drainage procedures have been shown to provide more comprehensive pain relief, improved functional outcomes, and enhanced quality of life (QOL). However, the identification of the MPD in these patients presents a technical challenge. We describe the 'head-first approach' for the identification of the MPD in patients with small duct pancreatitis undergoing extended drainage procedures. The study includes patients of small duct pancreatitis who underwent the extended drainage procedure during a 6-year period from April 2017 to March 2023. During the study period, 41 patients underwent surgical management for chronic pancreatitis. Thirty-two patients underwent an extended drainage procedure, with pain being the indication for surgery in all cases. Twelve of these patients had small duct disease. The 'head-first approach' for identification of the MPD was successfully employed in all 12 patients. The median blood loss during surgery was 180 mL, and the median duration from the beginning of head coring to the identification of the duct was 45 min. Of the 32 patients, post-operative bleeding was seen in 4, external pancreatic fistula was observed in 2, and superficial surgical site infection was seen in 2 patients. All four patients with bleeding were managed conservatively with blood transfusions, and no re-explorations or re-interventions were required. There were no mortalities in this cohort. The 'head-first approach' for pancreatic duct identification is a safe and feasible technique to enable an extended drainage procedure with all the advantages of a parenchyma-preserving procedure for surgical palliation of pain in small duct chronic pancreatitis.