Intraoperative Steps to Find the Gastrinoma

Gastrinomas may be single or multiple and are often duodenal and extrapancreatic. Frequently, the only gastrinoma found is in paraduodenal-pancreatic lymph nodes, without a primary site identified.38,39 Gastrinomas in the duodenal wall may be submucosal and smaller than 5 mm95,106,107 (Figs. 82-4 and 82-5). Several intraoperative maneuvers to find gastrinomas have been recommended for three decades35,48,108:

1. Perform a thorough abdominal exploration, including search for tumor in the liver.

2. Open the lesser sac, inspect, and perform bimanual palpation of the body and tail of the pancreas.

3. Perform a Kocher maneuver with inspection and palpation of the head of the pancreas; tumor nodes are frequently found behind the uncinate portion of the pancreas.

4. Look for small duodenal wall, submucosal tumors. Palpation and inspection through a duodenotomy may be necessary.

5. Multiple lymph node biopsies, with emphasis on excision of paraduodenal and pancreatic capsule "nodules," are most important. Histologic examination of several dozen lymph nodes and suspicious duodenal wall nodes is often necessary to obtain a tissue diagnosis.

6. Do not terminate the search after finding a single positive node because numerous patients have been "cured" only after removing several lymph nodes.

The routine use of duodenotomy as well as the newer innovations of intraoperative US and endoscopic transillumination to search for duodenal wall tumors has resulted in the detection of a gastrinoma in more than 90% of patients explored.77,109

Resection-Tail of Pancreas (optional)

Division

Gastrolienal ligament

Duodenal Palpation

1. Intraop ultrasonography

2. Intraop endoscopy with transillumination

3. Duodenotomy

Multiple lymph node biopsies a must!

open

Kocher

Resection-Tail of Pancreas (optional)

Division

Gastrolienal ligament

FIGURE 82-4. Intraoperative maneuvers to search for gastrinomas. Endoscopy with transillumination, duode-notomy, and palpation for duodenal wall tumors increase the surgeon's chances to find tumor. Intraoperative ultrasonography of the mobilized pancreas helps to find pancreatic body and tail lesions.

A review of the pathology reports from "failed" Z-E syndrome operations (i.e., those in which a gastrinoma was not found) usually shows that few biopsy specimens were taken by the surgeon.'2 The greater the number of lymph nodes examined, the more likely it is that gastrinomas will be found. A search in the area of the "gastrinoma triangle" can be most rewarding. A gastrinoma can be found in 9 of 10 cases in this anatomic triangle, whose apices are the cystic duct-common bile duct junction, the border of the second and third portion of the duodenum, and the junction of the neck and body of the pancreas.23

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