Surgical Management

Primary intrapancreatic tumors less than 2 cm and located away from the main pancreatic duct may be treated with enucleation. Otherwise, deep, large, or malignant intrapancreatic tumors may need to be resected by pancreaticoduodenectomy. Gastrinomas of the duodenal wall can be locally excised with primary closure of the duodenal defect. Up to 35% of patients who undergo exploration for gastrinoma with curative intent have been rendered eugastrinemic at follow-up. When only those patients thought to be successfully resected at the time of surgery are considered, cure rates are about 60-70%. In patients with associated MEN I syndrome, omeprazole should be used to control gastric acid secretion while surgical therapy of hyperparathyroidism is performed first. MEN I patients frequently demonstrate multiple gastrinomas and overall cure rates are lower than with sporadic forms.

If preoperative localization demonstrates the tumor in the gastrinoma triangle but no tumor can be found intraoperatively, there are several surgical strategies. Total gastrectomy is one option. The introduction of omeprazole has drastically reduced the need for this approach.

This approach leaves behind tumor with the potential for growth and metastasis. For this reason, blind pancreaticoduodenectomy to include the pylorus has been advocated by some. Some patients are rendered eugastrinemic by this approach. In addition, in a small number of cases a pathologically confirmed gastrinoma can be demonstrated in the surgical specimen.

Findings of unresectable hepatic disease are confirmed by biopsy of liver lesions. If the patient has confirmed hepatic metastases, exploration and resection are not indicated and the patient is managed with antisecretory therapy. If the patient suffers complications of disease due to lack of efficacy of antisecretory medication than total gastrectomy may be considered. Objective response to chemotherapy is < 50% and has not been shown to improve survival. Hormonal therapy with octreotide has been reported to improve symptoms, decrease hypergastrinemia, and reduce hyper-chlorhydria in patients with metastatic gastrinoma.

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