Tricks of the Senior Surgeon

■ Do not cut corners; do the same operation every time regardless of the preoperative localization studies.

■ Develop a dedicated team approach; an ultrasonographer willing to take the time and effort to find the gastrinoma is crucial.

■ Beware of the ampulla and the pancreatic duct on the medial wall of the duodenum as these can feel like nodules and have been mistaken for a duodenal gastrinoma. I remove the gallbladder and pass a catheter through the cystic duct into the duodenum if there is any question about the location of ampulla. On occasion, I have given secretin intraoperatively to stimulate pancreatic secretion if there is a question that I may be identifying the pancreatic duct orifice.

■ Exclude MEN-1 preoperatively by screening for other endocrinopathies and questioning family history.

■ Remember that patients with both Zollinger-Ellison syndrome and MEN-1 generally have multiple pancreatic and duodenal neuroendocrine neoplasms, and thus cure-rate is very low. If a patient also has primary hyperparathyroidism, do the parathyroid operation first as this may ameliorate the manifestations of Zollinger-Ellison syndrome.

■ Be sure to continue the patient on an aggressive pharmacologic acid suppressive medication during the perioperative and postoperative period.

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