Figure 16-10. Somatostatin receptor scintigraphy in one patient in consecutive annual examinations, demonstrating the development of a left lateral segment liver metastasis from a known pancreatic body tumor. A, On the initial study, a focus of uptake was noted in the body of the pancreas, but no increased activity was appreciated in the liver, including evaluation with single-photon emission computed tomography (SPECT). The pancreatic lesion (light arrow in B) was confirmed on abdominal computed tomographic (CT) scan but measured only about 1 cm, and after discussion with the patient, it was elected to follow this abnormality. B, One year later, repeat imaging showed a clear left lateral segment liver lesion (darkarrow), which was clearly visible on SPECT and not appreciable on the earlier study, even in retrospect. This lesion was confirmed on CT scan. At subsequent laparotomy, a single focus of liver disease was identified by ultrasonography and resected. He remains disease free at 3-year follow-up.

morbidity as low as possible and to preserve pancreatic function. For that reason, we tend to use enucleation for lesions in the head of the pancreas, avoiding pancreaticoduodenectomy when possible. Duodenal lesions are resected through a longitudinal duodenotomy, which is then closed transversely (see Figures 16-3 and 16-11). In the classic operation, often called the "Thompson operation," tumors are removed from the wall of the duodenum, a peripan-creatic lymph dissection is performed, and a subtotal pancreatectomy is performed leaving only a small portion of the pancreatic head (Figure 16-12).

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