Gastrinomas

In 1955, Zollinger and Ellison described two patients with peptic ulcer disease in the jejunum and an islet cell tumor of the pancreas.14 It is now understood that the predominant feature of the syndrome (Zollinger-

Loft gastric

Figure 15-3. Distal pancreatectomy with splenectomy for a potentially malignant lesion. A, Incision along the retroperitoneum above and below the pancreatic tail. B, Digital palpation for a small tumor in the tail of the pancreas. C, Division of short gastric vessels. D, Division of splenophrenic attachments. E, Resection of the tail of the pancreas to include lymph nodes along the superior border. F, Division of the pancreas and oversewing of the pancreatic duct and stump.

Figure 15-3. Distal pancreatectomy with splenectomy for a potentially malignant lesion. A, Incision along the retroperitoneum above and below the pancreatic tail. B, Digital palpation for a small tumor in the tail of the pancreas. C, Division of short gastric vessels. D, Division of splenophrenic attachments. E, Resection of the tail of the pancreas to include lymph nodes along the superior border. F, Division of the pancreas and oversewing of the pancreatic duct and stump.

Ellison syndrome [ZES]) that now bears their names is an increased serum gastrin level with an increased basal gastric acid production, resulting in peptic ulcers. It was not until 1960 that Gregory and associates first extracted gastrin.15 Prior to the introduction of radioimmunoassay for gastrin in 1970, the diagnosis was based on clinical presentation and a posi-

Hepatic artery

Gall bladder

Hepatic artery

Hepatic artery

Gall bladder

Hepatic artery

Duodenum

Pancreas

Duodenum

Tumor

Pancreas

Tumor

Pancreas

Figure 15-4. Pylorus-preserving pancreaticoduodenectomy for large or potentially malignant islet cell tumors of the head of the pancreas. A, (1) Mobilize hepatic flexure of the colon. (2) Duodenum by Kocher maneuver. B, Dissection of the common bile duct and hepatic artery with division of the gastroduodenal artery. C, The middle colic vein points to the superior mesenteric vein (SMV) at the inferior border of the pancreas. The SMV and portal vein (PV) must be free from the tumor. CBD = common bile duct. D, Division of the duodenum just distal to the pylorus. We preserve the right gastric vessels if possible.

tive bioassay. The usual presenting clinical features are abdominal pain, upper gastrointestinal bleeding, diarrhea, and weight loss. Particularly suggestive of a gastrinoma are peptic ulcers that fail to heal or recur after medical or surgical therapy and ulcers beyond the duodenum. About 15 to 26% of gastrinomas occur as part of MEN type I16 and about 60% are malignant.17 Some authors, however, suggest that all

Stay sutures on proximal CBD

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