If the location of the tumor is not known, a duodenotomy is essential, because duodenal gastrinomas often may only become detectable by this method. The surgeon can palpate the tumor within the wall of the duodenum between the index finger within the duodenal lumen and the thumb on the serosal side.
If the duodenal tumor has been identified, the duodenal incision used to remove the duodenal gastrinoma can be used to explore the remainder of the duodenum.
Because the neoplasm arises from the submucosa and can invade the mucosa, the gastrinoma should be excised via a full thickness specimen with a rim of normal duodenal wall around the tumor. In patients with MEN-1, multiple duodenal neoplasms may be present, and the surgeon must carefully palpate and inspect the remainder of the inner surface of the duodenum after it is open to exclude the presence of other neoplasms. Do not confuse the ampulla of Vater or the entrace of the minor pancreatic duct with a gastrinoma. After excising a duodenal gastrinoma, the duodenum is closed with a single-layer, full-thickness, monofilament absorbable suture in a transverse direction so as not to narrow the lumen. If a long duodenotomy is necessary, a longitudinal closure is performed. A periduodenal or peripancreatic closed suction drain is left.
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