Preoperative Investigations and Preparation for the Procedure

History:

Clinical evaluation: Laboratory tests:

Medical management:

Radiologic localization studies:

Peptic ulcer disease (PUD), watery diarrhea, gastroesophageal reflux disease (GERD) and possibly a family history of the associated endocrinopathies, primary hyperparathyroidism, prolactinoma, insulinoma, Cushing's syndrome, carcinoid tumors or carcinoid syndrome.

Upper gastrointestinal endoscopy with/without endoscopic ultrasonography.

Fasting serum concentration of gastrin, basal acid output off all acid secretory inhibitors for at least 3-7days, secretin test. When indicated, serum concentrations of intact PTH, total or ionized calcium, prolactin, fasting glucose, pancreatic polypeptide, chromogranin A, and serotonin, 24-h urine excretion of free cortisol, and if indicated 5-hydroxyindole acetic acid (HIAA).

Appropriately high doses of proton pump inhibitor to stop acid hypersecretion and control PUD, GERD, and diarrhea. Often up to 80-120mg pantoprazole two or three times a day or 20-40mg of omeprazole. Pantoprazole can be given at the same dose either intravenously or orally and is indicated in the perioperative period.

CT or MR to image pancreas, duodenum, and liver, and to exclude liver metastases.

Somatostatin receptor scintigraphy, the so-called Octreo-Scan, is the best imaging study which images 90 % of gastrinomas; although it will detect distant metastases, it frequently misses the small duodenal gastrinomas. Endoscopic ultrasonography can detect small tumors within the pancreas, but may miss duodenal gastrinomas.

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