Pylorus-preserving pancreaticoduodenectomy (Longmire III operation): origins, indications and outcomes

William P. Longmire Jr popularized the pylorus-preserving pancreaticoduodenectomy or “Whipple” operation using a philosophy for preserving function that he had pursued in his 2 previously described operations—intrahepatic cholangiojejunostomy (Longmire I) and the jejunal interposition after total gastrectomy (Longmire II) operation. An analysis of the published evidence comparing the pylorus-preserving Whipple (PPW) with a standard Whipple operation shows no difference in mortality, operating time, estimated blood loss, delayed gastric emptying, length of stay, or long-term cancer survival. Although no differences were noted between the 2 operations within the same hospital or study group, marked differences were observed in quality indicators between centers, particularly in estimated blood loss. Quality indicators for the Whipple operation (whether or not the pylorus is preserved) include pancreatic anastomotic leak, delayed gastric emptying, and the volume of blood lost during surgery. These clinical quality indicators have been benchmarked and used for improvement. If differences were not observed in patients after the Whipple operation (pylorus-preserving vs standard), then to improve cancer survival surgeons would need to look beyond the 2 operations. These studies confirmed the opinion that surgery alone is not enough to improve cancer survival when the head of the pancreas is to be resected by pancreaticoduodenectomy. The focus on PPW over the years since its description in 1978 has unmasked the concept that improvement in survivorship depends on improving many steps in the performance of pancreaticoduodenectomy that culminate in the quality indicators outlined above. These postoperative outcomes can be improved only by measuring them at each hospital and employing leadership to implement measures for improving the quality indicator that may not be within a reasonable range of the benchmark. The study of the PPW operation has helped to focus on areas other than PPW to improve the results of pancreatic head resection for pancreatic cancer.