Early surgical treatment of gastrinoma (original) (raw)
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Annals of Surgery, 1986
In 1982, a prospective study was initiated of 52 consecutive patients ts with proven Zollinger-Ellison syndrome (ZES), involving surgical exploration with the goal of removing the gastrinoma after an extensive protocol to localize the tumor. Each patient underwent ultrasound, computed tomography (CT) with oral/ intravenous (IV) contrast, and selective arteriography. Eighteen patients had metastatic disease identified by imaging studies and confirmed by percutaneous biopsies, and two patients had multiple endocrine neoplasia type I (MEN-I) with negative imaging studies; therefore, these 20 patients did not undergo laparotomy. Each of the remaining 32 patients (3 with MEN-I and positive imaging studies) underwent laparotomy, and gastrinomas were removed in 20 patients. Preoperative ultrasound localized tumors in 20% of patients, CT in 40%, arteriography in 60%, and any of the modalities in 70% of patients. Infusion CT and arteriography were 100% specific. In 18 patients with either negative imaging (17) or false-positive imaging (1 ultrasound), gastrinomas were found and removed in six patients (33%). Twenty-four gastrinomas were found in 20 patients at laparotomy: eight in lymph nodes around the pancreatic head, four in the pancreatic head, one in the pancreatic body, three in the pancreatic tail, three in the pyloric channel, one in the duodenal wall, two in the jejunum at the ligament of Treitz, one in the ovary, and multiple liver metastases in one patient. If one excludes patients with MEN-I or liver metastatic disease, 12/28 (43%) of patients were biochemically "cured" immediately after operation. This result decreased to 7/23 (30%) with greater than 6 months follow-up. No patients with gastrinomas resected have developed recurrent gastrinoma on follow-up imaging studies (longest follow-up: 4 years). This study indicates that 95% of metastatic gastrinoma can be diagnosed before operation and that, by a combination of careful imaging studies and thorough exploration at surgery, 30% of patients with gastrinomas may be curable. I N 1954, ZOLLINGER AND ELLISON first described a syndrome associated with severe peptic ulcer diathesis and pancreatic tumors.' The syndrome would later bear their name, and their initial treatment, total
Gastrinomas: Medical or Surgical Treatment
Endocrinology and metabolism clinics of North America, 2018
This article reviews the role of surgical and medical management in patients with Zollinger-Ellison syndrome (ZES) due to a gastrin-secreting neuroendocrine tumor (gastrinoma). It concentrates on the status at present but also briefly reviews the changes over time in treatment approaches. Generally, surgical and medical therapy are complementary today; however, in some cases, such as patients with ZES and multiple endocrine neoplasia type 1, the treatment approach remains controversial.
Surgical treatment of gastrinomas: a single-centre experience
HPB, 2012
Background: Gastrinomas are rare neuroendocrine tumours, and responsible for Zollinger-Ellison syndrome (ZES). Surgery is the only treatment that can cure gastrinomas. The success of surgical treatment of gastrinomas in a single centre was evaluated.
Surgery Increases Survival in Patients With Gastrinoma
Annals of Surgery, 2006
To determine whether the routine use of surgical exploration for gastrinoma resection/cure in 160 patients with Zollinger-Ellison syndrome (ZES) altered survival compared with 35 ZES patients who did not undergo surgery. Summary Background Data: The role of routine surgical exploration for resection/cure in patients with ZES has been controversial since the original description of this disease in 1955. This controversy continues today, not only because medical therapy for acid hypersecretion is so effective, but also in large part because no studies have shown an effect of tumor resection on survival. Methods: Long-term follow-up of 160 ZES patients who underwent routine surgery for gastrinoma/resection/cure was compared with 35 patients who had similar disease but did not undergo surgery for a variety of reasons. All patients had preoperative CT, MRI, ultrasound; if unclear, angiography and somatostatin receptor scintigraphy since 1994 to determine resectability. At surgery, all had the same standard ZES operation. All patients were evaluated yearly with imaging studies and disease activity studies. Results: The 35 nonsurgical patients did not differ from the 160 operated in clinical, laboratory, or tumor imaging results. The 2 groups did not differ in follow-up time since initial evaluation (range, 11.8-12 years). At surgery, 94% had a tumor removed, 51% were cured immediately, and 41% at last follow-up. Significantly more unoperated patients developed liver metastases (29% vs. 5%, P ϭ 0.0002), died of any cause (54 vs. 21%, P ϭ 0.0002), or died a disease-related death (23 vs. 1%, P Ͻ 0.00001). Survival plots showed operated patients had a better disease-related survival (P ϭ 0.0012); however, there was no difference in non-disease-related survival. Fifteen-year disease-related survival was 98% for operated and 74% for unoperated (P ϭ 0.0002). Conclusions: These results demonstrate that routine surgical exploration increases survival in patients with ZES by increasing diseaserelated survival and decreasing the development of advanced disease. Routine surgical exploration should be performed in ZES patients.
Pathomorphologic, biochemical, and diagnostic aspects of gastrinomas (Zollinger-Ellison syndrome
Human Pathology, 1975
The clinical symptomatolog y of the Zollinger-Ellison syndrome and the pathologic anatomy of gastrinomas are reviewed. Experience with 17 patients with the Zollinger-Ellison syndrome is presented with special reference to stimulation tests (secretin, glucagon, calcium infnsion, test meal) and to localization and immunohistologic, tdtrastructural, and biochemical findings in gastrinomas. Muhiple hormone production by the tumors is frequent. The ultrastructure and the Sephadex G-50 gel filtration patterns of imnaunol'eactive gastrin in sera and tumors are not uniform and are not related to localization of the tumors in the pancreas or duodenum or to the gastrin concentration. Hyperplasia of the pancreatic islets is a frequent finding in gastrinorna patients, suggesting that hypergastrinemia may stimnlate islet growth.
Cancer Control, 1997
Management of the primary gastrinoma has replaced the focus on control of gastric ulceration. Background: The Zollinger-Ellison syndrome, implicating a gastrinoma, was first recognized as a disease entity in 1955. At that time, total gastrectomy was the most common treatment approach. Advances in several aspects of the disease have occurred since that time. Methods: The authors reviewed the changes that have developed since 1955 in the diagnosis, imaging studies, operative and nonoperative management, and follow-up of patients with this disease. Results: The presence of a gastrinoma can be confirmed by a secretin stimulation test. A variable number of patients have hyperparathyroidism as part of the multiple endocrine neoplasm syndrome type 1 (MEN 1). Localization of the primary gastrinoma has been assisted by selective angiography, endoscopic ultrasonography, and the octreotide scan. H2-blockers or omeprazole, sometimes at high doses, usually controls acid secretion. Surgical removal of the primary gastrinoma is performed when feasible, and parathyroidectomy is indicated in those patients with hyperparathyroidism in the MEN 1 syndrome. Follow-up is facilitated by measurement of fasting serum gastrin levels. Conclusions: Several innovations have improved our capability to diagnose and effectively manage patients with gastrinoma.
Thirty years' experience with gastrinoma
World Journal of Surgery, 1984
Over a 30-year period , 40 patients with gastrinoma have been studied. Fifteen of the 19 survivors have lived 10 to 28 years following surgical treatment. Recent multiple endocrine studies in the long-term survivors have verified the clinical importance of including at least prolactin, parathormone, and catecholamine levels in addition to gastrin and calcium in every patient whose risk of other endocrine adenomas increases with time. Five-year survival was 62.5%, and 10-year, 47.5%. The absence of gross tumor at operation, origin within the submucosa of the duodenum or antrum, or proof of hyperparathyroidism favorably influenced long-term survival, regardless of the type of surgical procedure. Survival was improved following removal of a rare solitary tumor or combined aggressive tumor removal, hemipancreatectomy, and total gastrectomy for extensive disease.
World Journal of Surgery, 1993
Studies have shown that the duodenum is a more common site (30-40%) of primary gastrinomas than previously reported. These tumors are often occult to conventional exploration, and their detection requires duodenotomy and meticulous evaluation of the mucosa by eversion and direct palpation. Furthermore, tumors as smaU as 1 to 2 mm may be associated with iymph node metastases. Seven patients with duodenal gastrinomas treated during a 2-year period are reported. Four had sporadic ZoUinger-Ellison syndrome (ZES), and three had multiple endocrine neoplasia type I (MEN-I) syndrome. Ail seven patients had malignant duodenal gastrinomas as proved by metastatic lymph nodes and in one case a large liver metastasis as well. Local excision of the tumor, iymph node excisions, and in one case liver Iobectomy resulted in eugastrinemia in the 4 with sporadic ZES. Two of the three with MEN-I were also eugastrinemic after similar procedures, with the addition of distal pancreatectomy. Duodenotomy is considered an essential procedure in sporadic ZES patients when no pancreatic tumor is found and in ail MEN-I/ZES patients, regardless of the pancreatic findings. Regional lymph node excisions are essential when a duodenal tumor has been found. At one time it was assumed that most patients with Zollinger-Ellison syndrome (ZES) had malignant pancreatic tumors with metastases that precluded a curative surgical resection. Therefore nearly ail patients were treated by total gastrectomy with the exception of a few with primary extrapancreatic tumors [1, 2]. Once drugs became available that adequately controlled gastric acid hypersecretion, more emphasis was placed on identifying ZES patients who were potentially curable by tumor resection. Currently, it is estimated that up to 40% of patients with sporadic ZES have tumors that can be successfully resected [3]. These patients have primary tumors arising in the pancreas or duodenum with or without regional lymph node spread but no liver metastases. However, during the past decade, as many as 40% of patients proved biochemically to have ZES who have undergone exploration have had negative findings [4]. As a result, these patients were subsequently treated with drug therapy or had palliative surgical procedures such as selective vagotomy or even total gastrectomy. Furthermore, in most centers, multiple endocrine neoplasia type I (MEN-I)/ZES patients have been treated by drugs without