Operative Procedure of Choice Sporadic Gastrinoma

The choice of operation depends on the character and extent of the tumor identified by the surgeon. Ideally, all gastrinoma

FIGURE 82-5. Benign-appearing submucosal duodenal wall gastrinoma that was excised along with two adjacent lymph nodes containing metastases. Immunocytochemically, all three lesions stained positive for gastrin. The patient, now eugastrinemic, is presumably cured.

tissue should be removed to avoid the problems associated with tumor growth as well as the excess gastric acid. TG is rarely warranted now that gastric acid can be effectively inhibited. Tumor staging can predict the biologic behavior and long-term outcome, suggesting optimum operative strategies.

1. Duodenal wall tumor: The most common disease encountered by the surgeon during exploration of the Z-E syndrome patient in modern series has been duodenal wall tumors, often with metastatic gastrinoma in paraduodenal lymph nodes. The steps outlined in intraoperative maneuvers should be carefully followed.

2. Lymph nodes contain tumor and no apparent primary tumor found: The surgeon should remove as many lymph nodes as possible and search for primary and liver metastases. Excision of only one or more lymph nodes containing tumor has resulted in cure.

3. Liver metastases: Diffuse liver metastases indicate that complete tumor excision is unlikely, and lifelong antisecretory therapy is required. Single liver lesions should be excised because cures have been reported, even when a primary was not found.

4. Pancreatic tumors: Gastrinomas in the body and tail are best managed by distal pancreatectomy. Some well-encapsulated lesions might be enucleated; however, distal pancreatectomy is preferred because of the concept that gastrinomas originating in the pancreas to the left (splenic side) of the mesenteric vessels have a more aggressive biologic behavior.110 Pancreatic head gastrinomas can be enucleated in some patients. For large pancreatic head tumors not amenable to enucleation, pancreaticoduodenectomy is favored by some authorities.92 94111 Pancreaticoduodenectomy is usually not advisable when not all gastrinoma tissue can be excised.

5. Other extrapancreatic gastrinomas: Gastrinomas have been reported in the ovary, stomach wall, small bowel wall, omentum, and bowel mesentery, usually in lymph nodes. Excision may cure or improve long-term survival.

FIGURE 82-5. Benign-appearing submucosal duodenal wall gastrinoma that was excised along with two adjacent lymph nodes containing metastases. Immunocytochemically, all three lesions stained positive for gastrin. The patient, now eugastrinemic, is presumably cured.

6. Total gastrectomy: In special situations, TG may still be the operation of choice. Z-E syndrome patients who are noncompliant, do not take their omeprazole, and have recurrent ulcer complications might benefit from TG.

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