Excisional Therapy for Ulcerogenic Tumors of the Duodenum

Oberhelman, Harry A.

doi:10.1001/archsurg.1972.04180040061011

Cited by 67 publications

(27 citation statements)

References 10 publications

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“…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.…”

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confidence: 99%

Duodenal gastrinomas, duodenotomy, and duodenal exploration in the surgical management of Zollinger‐Ellison syndrome

1993

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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 ZoUingerEllison 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 ZollingerEllison 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 exploration because of the assumption that, short of total pancreatectomy, their hypergastrinemia could not be controlled surgically [5]. Our experience during the last 10 years, during which time transhepatic selective venous sampling for gastrin (TSVS) was used to regionalize the source of gastrin secretion, convinced us that small duodenal tumors (microadenomas) could easily be overlooked during a standard exploration and thus be the cause of a failed procedure [4,6]. Recent studies have shown that the duodenum is a more common site of primary gastrinomas than previously thought [7][8][9][10][11]. It is currently ...

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Duodenal gastrinomas, duodenotomy, and duodenal exploration in the surgical management of Zollinger‐Ellison syndrome

1993

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“…[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.…”

Section: Surgery For Gastrinomas In Patients Without Men-1 (Sporadic mentioning

confidence: 99%

“…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.…”

Section: When the Sasi Test Localizes Gastrinomas In The Head Of The mentioning

confidence: 99%

“…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.…”

Section: Surgery For Gastrinomas In Patients With Men-1mentioning

confidence: 99%

“…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.…”

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

Imamura

Komoto²,

Ota³

2005

World j. surg.

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We overviewed the recent development of curative surgery for gastrinoma that has been rapidly improved since the development of new localization techniques, especially the selective arterial secretagogue injection test (SASI test) and somatostatin receptor scintigraphy (SRS). A number of new pathological findings of gastrinomas in patients with Zollinger-Ellison syndrome have been accumulated in accordance with the increase of curative resection of gastrinomas, and these new findings also have contributed to the progress of the treatment strategy for grastrinomas.U ntil recently, medical treatment with a proton pump inhibitor or an H2 blocker has been the treatment of choice for patients with Zollinger-Ellison syndrome (ZES) because of the difficulty in accomplishing curative resection of gastrinomas, which are often metastatic and multiple. 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), 1-12 and localization of small functioning gastropancreatic-endocrine tumors (GEPET) has been unsuccessful. [1][2][3][4] All gastrinomas are potentially metastatic. Liver metastases are the significant prognostic factor in patients with gastrinoma, and only R0 resection can achieve a disease-free survival. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] For all of these reasons, curative resection of gastrinomas guided by an accurate localization technique has long been awaited. Such a technique has been realized with the development of the selective arterial secretagogue injection test (SASI test) with secretin or calcium and somatostatin receptor scintigraphy (SRS). 2-6,14-17 Increased curative resection surgery for gastrinomas in patients with ZES has elucidated several important findings.In patients with ZES without multiple endocrine neoplasia type 1 (MEN-1), gastrinoma is located in either the duodenum or the pancreas. In either location, gastrinomas are often single, but occasionally they co-exist. In the most recent reports, duodenal gastrioma is reported more frequently than pancreatic gastrinoma. [2][3][4][5][6][7][8][9][10][11][12] In patients with ZES and MEN-1, gastrinoma is located mostly in the duodenum, although there are numerous endocrine tumors in the pancreas. In about a half of these patients, multiple duodenal gastrinomas are diffusely located in the duodenum and sometimes they are numerous. 6,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Incidence of lymph node metastases in patients with either duodenal or pancreatic gastrinomas has been reported to be greater than 40%. [19][20][21][22][23][24][25][26][27] The incidence of hepatic metastases has been reported to be more than 60% in patients with the pancreatic gastrinoma, although it has consistently been less than 10% in patients with duodenal gastrinoma. 11,[22][23][24][25][26][27] Liver metastases are a significant prognostic factor in patients with...

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