Achieving Eugastrinaemia in Zollinger-Ellison Syndrome: Resection or Enucleation?

Abstract

Background: Eugastrinaemia in Zollinger-Ellison syndrome can be an elusive goal, nearly one third of laparotomies failing to detect the tumour. Methods: A personal series of 13 patients with a mean age of 52 years operated between 1980 and 1996 was reviewed retrospectively. All patients had fasting hypergastrinaemia and recalcitrant ulcer disease with or without diarrhoea. Results: Computed tomography or selective visceral angiography localised the tumour to the pancreas in 6 of 12 elective patients; the thirteenth presented with a perforated duodenal ulcer. All underwent laparotomy with gastrinoma tissue being completely excised in every case, including the 6 patients with failed pre-operative localisation whose tumours arose from the duodenum (4), pancreas (1) and lymph node (1). Eugastrinaemia was achieved in all but 1 patient and was sustained during a mean follow-up of 5.2 years (SD = 4.2 years). These 12 patients remained clinically free of disease during a mean clinical follow-up of 7.5 years (SD = 5.0 years; range 2–19 years). There were no postoperative deaths, but 3 died from recurrent tumour at 3–7 years. Conclusion: Since normalisation of serum gastrin was achieved in 12 of 13 patients, laparotomy may well be worthwhile even if the gastrinoma cannot be localised pre-opera- tively.

Changing Treatment Strategy for Gastrinoma in Patients with Zollinger‐Ellison Syndrome

“…[6][7][8][9][10][11][12][13][14]35 In these patients, gastrinomas are located either in the pancreas or the duodenum (Fig. 6), and recently the duodenal gastrinoma has been reported more frequently than the pancreatic type.…”

“…18 But some aggressive surgeons performed PD and achieved a high rate of curability with low morbidity. 2,3,[7][8][9][10][11][12]17 The experience with PD taught us how difficult was it to find duodenal gastrinomas and metastatic lymph nodes even at operation. But because only the microscopic duodenal gastrinomas had been revealed in the resected specimen only after the PD, we changed our strategy from PD to the transduodenal enucleation of the duodenal gastrinomas.…”

“…39 For the treatment of pancreatic endocrine tumors, the main issue is the prevention of liver metastasis, because once it takes place the prognosis is limited. [7][8][9][10][11][12][13][14]38 As already mentioned, Thompson et al, have reported a good result with subtotal distal pancreatectomy and enucleations of the pancreatic head cancer, 24 although surgeons at NIH had recommend local resection of pancreatic tumors larger than 2 or 3 cm, because the rate of liver metastasis is correlated with the size of the tumor. 12,19,38 As described above, Gibril et al, also from NIH, reported recently that their strategy has brought about a high rate (23%) of development of liver metastasis during an 8-year observation period, which suggests that liver metastasis can take place no matter what the tumor size.…”

“…For patients treated between 1981 and 1988 in whom no tumor was identified with these procedures in spite of localization with the SASI test, we performed PD 2,3. During that period duodenal gastrinoma was not yet regarded as an important cause of ZES 2–8. In the early four patients who underwent PD in Kyoto University Hospital, 1–7 minute duodenal gastrinomas were found in the resected specimen, although none had been detected during surgery.…”

“…Symptoms of ZES, such as persistent peptic ulcer, regurgitation esophagitis, or diarrhea, appear even when the gastrinoma is too small to be recognized with computed tomography (CT) or magnetic resonance imaging (MRI), [1][2][3][4][5][6][7][8][9][10][11][12] and localization of small functioning gastropancreatic-endocrine tumors (GEPET) has been unsuccessful. [1][2][3][4] All gastrinomas are potentially metastatic.…”