Preservation of the pylorus during pancreaticoduodenectomy — Evolution and current indications

The Whipple procedure has been improved by preservation of a functioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with hemigastrectomy, more patients can gain weight postoperatively. The most common indications for this procedure are severe complication of chronic pancreatitis and periampullary tumors. In patients with pancreatic adenocarcinoma, the pylorus‐preserving variety results in equal or better survival rates than those of the standard Whipple procedure with hemigastrectomy. Surgery alone is not sufficient to improve survival rates in patients with adenocarcinoma of the pancreas. Improved imaging modalities are required to diagnose the disease earlier. The most likely combination of treatment to prolong survival time is a combination of resection for cure in a patient with an early diagnosis plus an aggressive adjuvant chemoradiotherapy protocol. This protocol is most likely to be completed if a patient has preserved endocrine, exocrine, and digestive ability. A radical (R1) pylorus‐preserving Whipple procedure would have the following advantages to result in the best survival rates — the patients can gain weight and thereby withstand the chemoradiotherapy protocol while, at the same time, the weakest aspect of the radical resection is addressed, i.e., the retroperitoneal margin of the pancreatic head.