Abdominal Exploration

Although preoperative studies have helped in tumor localization, the technique of abdominal exploration for gastrinoma is standardized. A generous Kocher maneuver is performed, to allow proper bimanual palpation of the duo denum and the pancreatic head. Complete palpation of the body and tail of pancreas requires entering the lesser sac and may include medial mobilization of the spleen and tail of the pancreas. Thorough palpation should be combined with intraoperative ultrasonography (IOUS), with consideration given to transillumination of the duodenum and a duodenotomy. IOUS can help detect pancreatic lesions that are not palpable and also detect previously undetected liver metastases. Seventy to 90% of gastrinomas are found in the gastrinoma triangle. This lies to the right of the superior mesenteric artery and therefore more attention should be focused on this area (the head of pancreas and duodenum). The gastrinoma triangle is bound by the junction of the cystic and common hepatic duct superiorly, the junction of the second and third portions of the duodenum inferiorly, and the junction of the neck and body of the pancreas medially.

Duodenal gastrinomas are found in decreasing order of frequency from the first (71%) to the second (21%) to the third portion (8%). Accurate preoperative or intraoperative localization helps in deciding the location and extent of duodenotomy. In the absence of preoperative localization, IOUS and intraoperative endoscopy with transillumination can help decide the location of duodenotomy. If all measures fail, a generous laterally-placed duodeno-tomy in the second portion of the duodenum is performed. Lesions on the lateral duodenal wall are excised with full-thickness 2 to 3 mm margins, whereas lesions on the medial wall are excised submucosally.

Pancreatic head gastrinomas can often be treated with enucleation. Pancreaticoduodenectomy may be required when enucleation or local resection is not possible (Udelsman et al, 1993; Phan et al, 1997; Phan et al, 1998). Distal pancreatic lesions can be treated with enucleation or distal pancreatic resection. For lesions in the neck of the pancreas, enucleation or central pancreatectomy are performed.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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