Surgical Principles

The goal of the surgical operation in a patient with an islet cell tumor is to identify accurately, stage, and remove the tumor. The surgeon should remove all tumor in a manner that allows the mortality and morbidity of surgery to be less than those in the natural history of the tumor. The surgeon needs to know the natural history and pathology of the neuroendocrine tumor, the expected outcome of the surgical procedure, the expected survival with the tumor resected, the immediate and long-term complication rate, and the availability of alternative medical treatments to manage the disease.32,34

Most experts recommend that patients with neuroendocrine tumors undergo surgery because any neuroendocrine tumor may be malignant, medical management can only control the signs and symptoms, and tumor resection is the only potentially curative treatment. Therefore, each patient with biochemical evidence of a neuroendocrine tumor should undergo complete radiologic assessment of the extent of disease to determine the feasibility of surgery. During the radiologic evaluation, medical management should be used to ameliorate symptoms secondary to excessive hormone secretion. It is clear that in some neuroendocrine tumors (such as VIPoma) advances in medical control of the hormone production have improved the surgical outcome and reduced the operative complication rate.34 Many variables associated with an individual patient have an impact on the surgical outcome. These include the extent of disease on preoperative imaging studies, whether the primary tumor is within the pancreas or duodenum, the exact area of the pancreas involved (head, body, or tail), the presence of liver or other distant metastases and whether they are resectable, the occurrence of the neuroendocrine tumor in a familial or a sporadic setting, and the simultaneous occurrence of other medical conditions that may limit the ability of a patient to undergo major surgery. Success need not be defined as cure of the hormonal syndrome. It may be a decreased medication requirement, decreased symptoms, and increased length of survival. In each patient, it is clear that neuroendocrine tumors may be malignant, that surgery is an effective way of accurately staging the true extent of disease, and that surgery may be curative, even in the patient with metastatic neuroendocrine tumor.34"38

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