LOCALIZATION, MALIGNANT POTENTIAL, AND SURGICAL-MANAGEMENT OF GASTRINOMAS

Between 1987 and 1996 a total of 25 patients with proved Zollinger-Ell ison syndrome (ZES) have been treated in our department. If preoperati ve imaging studies did not show diffuse metastatic disease, patients w ere scheduled for operation with a standardized: surgical approach inc luding thorough exploration and intraoperative ultrasonography (IOUS) of the pancreas and a longitudinal duodenotomy, with separate palpatio n of the anterior and posterior walls, Postoperatively, patients were followed up by physical examination, fasting gastrin levels, and the s ecretin stimulation test. Altogether 10 patients had duodenal wall gas trinoma, 14 patients pancreatic gastrinoma, and the tumor was not foun d in 1 patient, Only 15 tumors (60%) (2 duodenal wall and 13 pancreati c gastrinomas) could be visualized preoperatively. Intraoperatively, 2 4 of 25 primary gastrinomas were localized, The mean size of duodenal wall gastrinomas (9.6 mm) was significantly smaller than that of pancr eatic gastrinomas (28.7 mm) (p < 0.05). At the time of surgical explor ation, five duodenal and seven pancreatic gastrinomas had metastasized , The incidence of lymph node metastases was similar for both tumor si tes, whereas patients with pancreatic gastrinomas more frequently had liver metastases. The presence of liver metastases was the most import ant determinant for survival, Four patients (40%) with duodenal and se ven with pancreatic (50%) gastrinomas (mean follow-up 5.2 gears) were biochemically cured by operation. Of the remaining patients, eight are still alive with recurrent disease. Our results suggest that preopera tive localization of gastrinomas often fails despite all modern imagin g methods, Therefore a standardized surgical exploration of the pancre as including IOUS and a duodenal exploration should be performed to ac hieve optimal results, Preoperative diagnostic imaging tests should in clude computed tomography, ultrasonography, :and somatostatin receptor scintigraphy to exclude diffuse metastases. In contrast to liver meta stases, lymph node metastases do not have a significant influence on s urvival.