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Resection of Duodenal Wall Gastrinoma
Operative Indications
The management of the Zollinger-Ellison syndrome has evolved through several stages over the past several decades.
Initially, total gastrectomy was the treatment of choice. Not only did it control the ulcer diathesis, but for a while it was
thought that it might result in tumor regression as well. When more effective antacid drugs became available, the disease
was primarily managed pharmacologically. If a patient was explored and a gastrinoma not found, pyloroplasty and vagoto-
my was added to aid the pharmacologic control. More recently it has been recognized that a substantial number of patients
without liver metastases can be cured at laparotomy by resecting a gastrinoma either in the pancreas, in the duodenal wall,
or elsewhere in the right upper quadrant. Therefore, currently it is believed that patients who have a diagnosis of the
Zollinger-Ellison syndrome should undergo tumor staging. If no evidence of liver metastasis is present, a laparotomy should
be performed. If a gastrinoma is identified, excision may result in long-term cure. It appears that patients most likely to be
cured long term are those in whom the gastrinoma is not in the pancreas, but in the duodenal wall.
Operative Technique
The patient is explored through an upper midline incision. The entire pancreas
must be carefully examined (1). This should start with an extensive kocherization
so that the head, neck, and uncinate process of the pancreas can be examined.
The so-called gastrinoma triangle, which includes the second portion of the duo-
denum and the head, neck, and uncinate process of the pancreas, contains most
of the resectable tumors.
Stomach
Resection of Duodenal Wall Gastinoma 193
Head of pancreas
palpated
Duodenum
kocherized
The lesser sac should be opened by removing
the omentum from the transverse colon.
There is a bloodless plane in the retroperi-
toneum posterior to the pancreas that
allows bloodless and rapid mobiliza-
tion. The entire neck, body, and tail of
the pancreas should be mobilized out
of the retroperitoneum, so they can be
1
Greater
omentum
Spleen
Posterior wall
of stomach
carefully palpated (2).
Pancreas
mobilized
out of
retroperitoneum
2
Transverse colon
194 Atlas of Gastrointestinal Surgery: The Duodenum
Pancreas
mobilized
out of
retroperitoneum
If the neuroendocrine
Duodenum
Posterior wall
of stomach
tumor can not be palpated,
ultrasonography should be
utilized. The use of ultra-
sound is of value in detect-
ing lesions less than 1 cm in
diameter that might be diffi-
cult to palpate (3). The entire
duodenum should also be carefully
examined (4). A surprising number of
gastrinomas are found submucosally in the
duodenal wall. If they are totally excised, a
long-term cure may result.
Ultrasound
probe
3
Head of
pancreas
Duodenal wall
4
palpated
5
To aid in identifying a gastrinoma in
the duodenum at the time of laparoto-
Transilumination of
submucosal gastrinoma
in duodenal wall
Resection of Duodenal Wall Gastinoma 195
Endoscope
my, the patient can undergo upper
Stomach
endoscopy with transillumination of the
duodenal wall (5, 6). In this
instance a small gastrinoma is iden-
Omentum
Colon
tified in the anterior aspect of the
second portion of the duodenum.
This could be seen on transillumina-
Duodenum
tion, as well as felt by palpation.
With the electrocautery a full-thickness
ellipse of the anterior duodenal well is excised,
completely removing the small gastrinoma (7). The resulting defect in the anterior duodenal wall is closed
in two layers. The inner layer consists of a continuous Connell suture of 3-0 synthetic absorbable suture
material (8), with an outer layer of interrupted 3-0 silk sutures placed in a Lembert fashion.
6
Ellipse of anterior
duodenal wall containing
gastrinoma excised
7 8
Inner layer
Outer layer
196 Atlas of Gastrointestinal Surgery: The Duodenum
The area surrounding the duodenal gastrinoma should be
carefully examined for the presence of lymph nodes. In this
instance a lymph node in the pancreatic duodenal groove was
identified and excised (9), which proved to contain metasta-
tic gastrinoma.
Lymph node
excised
Duodenum
9
Head of pancreas
Biliary tree
Duodenotomy
10
Pylorus
If a lesion is not palpable and is not seen on transillumination,
the duodenum may be opened for direct visualization (10). If a
lesion is identified, an alternative to full-thickness excision of the
duodenal wall is to excise the lesion from within the duode-
num with mucosa and submucosa, leaving the muscular layer
of the duodenum intact. This is particularly helpful when
exploring a patient who proves to have a gastrinoma in the
medial aspect of the duodenum or in the perivaterian area. In
this instance a small tumor is palpated in the posterior medial
aspect of the duodenal wall.
Stay sutures placed
adjacent to gastrinoma
in posterior duodenal wall
Stay sutures are placed on either side of the lesion (11).
11
With electrocautery an incision is made through the
mucosa and submucosa, and the smaller tumor excised
Resection of Duodenal Wall Gastinoma 197
Mucosal disc and
underlying tumor
excised
(12). An alternative to using the electrocautery is to
infiltrate the region with saline and 1:100,000 epineph-
rine and then excise the lesion with a scalpel. The mucosa and
submucosa can then be reapproximated with a series of
interrupted 3-0 synthetic absorbable sutures (13). The
anterior duodenal wall is closed in two layers either
longitudinally (14) or transversely (15). The inner
layer should be a continuous 3-0 synthetic
absorbable Connell suture; and the outer layer,
interrupted 3-0 silk Lembert sutures. The periduo-
denal area, particularly the groove between the duo-
denum and head of the pancreas, should be carefully
examined for evidence of metastatic lymph nodes.
12
13
Mucosal
defect closed
14
Duodenum closed
longitudinally
or transversely
15
Resection of the Third and Fourth
Portions of the Duodenum with
Duodenojejunostomy
Operative Indications
Most duodenal lesions that require resection arise in the second portion around the ampulla. Occasionally a local resec-
tion is possible if the lesion is benign, but most of these lesions require a pancreaticduodenectomy. Pathology occasional-
ly occurs in the third and fourth portions of the duodenum; resection is often possible. Adenocarcinomas, although more
common in the second portion of the duodenum, do occur in the third and fourth portions. In addition, rarely sarcomas
may occur in the third or fourth portions. A variety of rare benign neoplasms also occur, including adenomatous polyps,
lipomas, and hamartomas. Finally, there have been patients with benign strictures secondary to Crohn’s disease in the third
and fourth portions of the duodenum. In each of these instances a local resection of the third and fourth portions of the
duodenum with reconstruction by duodenojejunostomy is an acceptable way to manage these lesions.
Operative Technique
The patient is explored through an upper midline incision. The abdomen is
thoroughly examined to be sure there is no other pathology in addition to the
neoplasm in the third portion of the duodenum.
Resection of the Third and Fourth Portions of the Duodenum with Duodenojejunostomy 199
The second and third portions of the duodenum are extensively kocher-
ized (1). The kocherization of the third portion of the duodenum is
extended over to the superior mesenteric vessels. In the proximal
third portion of the duodenum, a tumor mass can be palpated. If
the gallbladder is still in place, it should be mobilized. A biliary
Duodenum
kocherized
Fogarty catheter should be placed in the cystic duct and threaded
into the common duct and down through the ampulla into the duo-
denum (2). The resection line between the second and third portions
of the duodenum may be in proximity to the ampulla; knowing its exact
location is very important. If a cholecystectomy has previously been per-
formed, a biliary catheter can be placed percutaneously and transhepatically
preoperatively, passing it down into the biliary tree, through the ampulla, and
into the duodenum (inset). Alternatively, a biliary
Fogerty catheter can be passed through
Biliary
Fogarty catheter
through cystic duct
a small choledochotomy if a
cholecystectomy has already
1
Retroperitoneum
Tumor in third
portion of
duodenum
Mobilized
gallbladder
Balloon
in second
portion of
duodenum
Tumor in
third portion
of duodenum
Liver
Stomach
Superior
mesenteric
vessels
been performed.
Jejunum
Alternative
Biliary
catheter
placed preoperatively
2
200 Atlas of Gastrointestinal Surgery: The Duodenum
the duodenum have been extensively
kocherized and the ampulla identified
by the placement of a biliary Fogarty,
the transverse mesocolon is reflect-
ed in a cephalad direction, and the
proximal jejunum and the fourth
portion of the duodenum are
mobilized. The mesentery to the
proximal jejunum is divided and lig-
ated. The ligament of Treitz is mobi-
lized, as well as the distal third por-
tion of the duodenum.
Balloon in
second portion
of duodenum
Middle colic
vessels
Tumor in
third portion
of duodenum
Transverse colon
Transverse mesocolon
Ligament of Treitz
Fourth portion
of duodenum
Proximal
jejunum
GIA
stapler
Superior
mesenteric
vessels
Mesentery
Jejunum
Fourth portion
of duodenum
Superior mesenteric
vessel pedicle
Mesentery
3
With this extensive mobilization of the third and fourth por-
tions of the duodenum on each side of the mesenteric ves-
sels, one is left with a pedicle to the small bowel, con-
sisting virtually of only the superior mesenteric artery
and superior mesenteric vein. The proximal jejunum is
divided with a GIA stapler (3) and then passed
under the mesenteric vessels to the patient’s right
side (4).
Jejunum
4
Resection of the Third and Fourth Portions of the Duodenum with Duodenojejunostomy 201
ed free of the pancreas (5). Obviously if at any
point the tumor has invaded through the duode-
nal wall and involves the pancreas, a pancre-
atic resection will be necessary. This
may require extending the procedure
into a pancreaticoduodenectomy or
perhaps performing a distal pancre-
atectomy. The dissection approach-
es the ampulla.
in third portion
Biliary Fogarty catheter
through cystic duct
Tumor
of duodenum
Pancreas
Transverse
colon
5
Fogarty
balloon at
ampulla
stapler
Second and
third portions of
duodenum
When there is a safe gross margin, the junction of
the second and third portions of the duodenum is
divided with a GIA stapler (6).
Tumor
GIA
6
Fourth portion
of duodenum
Jejunum
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