Surgery For Gastrinoma Research Articles

Surgery for Gastrinoma: Short and Long-Term Results

IntroductionZollinger–Ellison syndrome (Z–E) is characterized by gastrin-secreting tumors, responsible for causing refractory and recurrent peptic ulcers in the gastrointestinal tract. The optimal approach and the extension of tumor resection remains the subject of debate. MethodsDuring the period February 2005 and February 2014, 6 patients with Z–E underwent surgery, 4 men and 2 women with a median age 46.8 years (22–61). Two patients were affected with multiple endocrine neoplasia type-1 (MEN-1). Fasting gastrin levels greater than 200pg/ml (NV: <100) was diagnostic. Radiologic imaging to localize the lesion included octreoscan 6/6, computer tomography (CT) 6/6, and endoscopic ultrasonography (EUS) 1/6. ResultsThe octreoscan was positive in 5 patients. The CT localized the tumor in the pancreas in 2 patients, in the duodenum in 3 patients (1 confirmed by EUS) and between the common bile duct and vena cava in one patient. The laparoscopic approach was used in 4 patients, 2 patients converted to open surgery. The following surgical techniques were performed: 2 pylorus-preserving pancreatico-duodenectomy (PPPD), one spleen-preserving distal pancreatectomy, one duodenal nodular resection, 1 segmental duodenectomy and one extrapancreatic nodular resection. Pathological studies showed lymph nodes metástasis in 2 patients with pancreatic gastrinomas, and in one patient with duodenal gastrinoma. The median follow-up was 76.83 months (5–108) and all patients presented normal fasting gastrin levels. ConclusionsSurgery may offer a cure in patients with Z–E. The laparoscopic approach remains limited to selected cases.

Surgery for Primary Pancreatic Neuroendocrine Tumors

Currently, surgery for insulinoma is curative in nearly every patient, even those with MEN1, and fu-ture direction seems to be to make it more cosmeti-cally acceptable and less morbid by trying to accomplish the same procedure laparoscopically. Surgery for gastrinoma and nonfunctional NE tu-mors is curative in approximately 50% of patients. Duodenotomy is indicated during surgery for gastri-noma, because it increases tumor detection and cure rate. Patients with MEN1 with gastrinoma remain a challenge. With our current approach in these pa-tients, the cure rate is low, but the long-term survival remains excellent. The role of routine pancreaticoduodenectomy for sporadic and MEN1 NE tumors is currently unclear. It may increase cure rate, but it may also increase morbidity in pa-tients with a low, long-term tumor death rate.

Surgery for Gastrinoma and Insulinoma in Multiple Endocrine Neoplasia Type 1

The surgical management of pancreatic endocrine tumors in patients with multiple endocrine neoplasia type 1 remains controversial. Gastrinoma and insulinoma are the 2 most common functional pancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1. Gastrinomas cause gastric acid hypersecretion and peptic ulcer disease that are best managed using proton pump inhibitors. Surgery to remove the gastrinoma in patients with multiple endocrine neoplasia type 1 is seldom curative unless a more extensive Whipple pancreaticoduodenectomy is performed. Because the prognosis is excellent, aggressive resections such as a Whipple procedure are only indicated for large, locally metastatic, advanced tumors. Furthermore, surgery to remove imageable tumors that are 2 cm in diameter is associated with excellent outcomes and decreased probability of liver metastases. Because gastrinomas are commonly multiple and most originate in the duodenum and develop lymph node metastases, the duodenum should be opened and all tumors and lymph nodes excised. Insulinomas cause hypoglycemia that results in neuroglycopenic symptoms. Medical management of the hypoglycemia is less effective than that of the gastric acid hypersecretion. Fortunately, the insulinoma is usually clearly identified using routine pancreatic imaging studies. There is a high likelihood of cure when the insulinoma is excised surgically. However, recurrent hypoglycemia may occur, and careful follow-up is indicated.