Book Description: The classic step-by-step atlas of general surgery procedures – now in color and updated with the latest laparoscopic. Title, Atlas de cirugía. Author, Robert M. Zollinger. Translated by, Jorge Orizaga Samperio. Illustrated by, Marita Bitans. Edition, 8. Publisher, McGraw Hill, ZOLLINGER ATLAS DE CIRUGIA, Author:Milton, Robert, ISBN: , Theme: GASTROINTESTINAL SURGICAL TECHNIQUES.
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Zollinger—Ellison syndrome Z—E is characterized by gastrin-secreting tumors, responsible for causing refractory and recurrent peptic ulcers in the gastrointestinal tract. The optimal approach and the extension of tumor resection remains the subject of debate. During the period February and February6 patients with Z—E underwent surgery, 4 men and 2 women with a median age Two patients were affected with multiple endocrine neoplasia type-1 MEN The octreoscan was positive in 5 patients.
The CT localized the tumor in the pancreas in 2 patients, in the duodenum in 3 patients 1 confirmed by EUS and between the common bile duct and vena cava in one patient. The laparoscopic approach was used in 4 patients, 2 patients converted to open surgery. The following surgical techniques were performed: The median follow-up was Zlllinger may offer a cure in patients with Z—E.
The laparoscopic approach remains limited to selected cases. El octreoscan fue positivo en 5 pacientes. Gastrinomas are uncommon endocrine tumors, with an incidence of 0. Their incidence is greater in men than in women, and mean age at presentation is between 45 and The diagnosis and localization of gastrinomas has changed favorably in recent years with the use of computed tomography CTendoscopic ultrasound EUS ciruyia especially scintigraphy through the injection of octreotide, a somatostatin analog that binds with tumor somatostatin receptors.
The control of the disease involves the administration of proton pump inhibitors. The aim of this study is to analyze the immediate and long-term results of surgery in patients with sporadic gastrinomas and in patients with gastrinomas associated with MEN From February to February6 patients 4 men and 2 women were diagnosed with Zollinger—Ellison syndrome and treated surgically.
Mean age was Patients had experienced gastrointestinal discomfort, and multiple gastric or duodenal ulcers were detected by gastroscopy. Demographic data of the diagnosed patients are presented in Table 1. Cirhgia patient case 5 was treated surgically due to perforation of a duodenal ulcer, and another patient case 6 had upper gastrointestinal bleeding due to erosive esophagitis.
Síndrome de Zollinger-Ellison – Diagnóstico y tratamiento – Mayo Clinic
Two patients had a family history of MEN Over the last year, this latter patient zollinyer experienced episodes of acute recurring pancreatitis with hyperamylasemia.
Octreotide scan was positive in 5 patients. EUS confirmed the diagnosis in case 4 Fig. Approximately 2 cm distal to this lesion, there is a second hypervascular image measuring 7 mm, which was a gastrinoma of the 3rd portion of the duodenum Endoscopic ultrasound showing a nodule in the wall of the 2nd portion of the duodenum 11 mm.
Laparoscopy was performed in 4 patients. In one patient case 1a nodule was found on the posterior side of the entry of the common bile duct into the pancreas, which was removed. Intraoperative biopsy confirmed the presence of a gastrinoma in a lymph node and ruled out the presence cirufia metastasis in the regional lymph nodes Fig. The definitive pathology study confirmed the diagnosis of primary lymphatic gastrinoma. In another patient case 3distal pancreatectomy with pylorus preservation was done successfully, following the Warshaw technique.
Two patients required conversion to open surgery. In one patient case 6an extrapancreatic nodule was found in the region of the uncinate process of the pancreas; biopsy showed it was a lymph node metastasis.
Pylorus-preserving pancreaticoduodenectomy PPPD was performed. In the surgical specimen, a 4 mm gastrinoma was found in the second portion of the duodenum. In another patient case 4intraoperative ultrasound demonstrated an 11 mm nodule located on the posterior side of the duodenum adjacent to the duodenal papilla. By means of conversion to open surgery, a longitudinal duodenotomy was completed.
A plastic cannula inserted through the papillary orifice in the common bile duct made it possible to extract the gastrinoma, with identification after exiting the pancreatic duct Fig. Gastrinoma in the body of the pancreas 1 that partially occluded the Wirsung duct, causing distal dilatation The pathology study of the resected specimen demonstrated the presence of a pancreatic gastrinoma measuring 8 mm and lymphatic metastases in one of the 10 resected lymph nodes.
In another patient case 5 segmental duodenectomy was performed distal part of the second portion of the duodenum and up to the medial region of the third portion of the duodenum in conjunction with a peripancreatic lymphadenectomy. The pathology study demonstrated a 7 mm duodenal gastrinoma and 2 lymph node metastases.
Patients who were treated by laparoscopy had no complications during the postoperative period and were discharged 11 days after surgery. The 2 patients with PPPD had no further incidences and were discharged 14 days after surgery.
Hospitals stays without complications were 14 days in the patient with local resection of the periampullary gastrinoma and 10 days in the patient with segmental duodenal resection.
Mean follow-up was All patients are currently asymptomatic and have normal fasting gastrin levels. These patients present a higher long-term risk for disease recurrence. The tumor from case 1 can be considered a primary lymphatic gastrinoma because, 9 years after surgery, there have been no further clinical or biochemical manifestations of the disease, and gastrin levels have remained normal.
The natural history of gastrinomas differs between sporadic gastrinomas and those associated with multiple endocrine neoplasia, type 1. Gastrinomas in patients with MEN-1 are frequently small some undetectable during radiology studiesmultiple, and prone toward metastatic dissemination.
There are enormous difficulties that arise in gastrinoma surgery, which explains why the technical options are a source of debate. The zol,inger approach in gastrinoma surgery is controversial. Norton and Jensen 14 have given 4 reasons to contraindicate minimal access surgery: Some of these reasons have led to conversion to open surgery in 2 of our patients.
In one case, intraoperative ultrasound demonstrated an 11 mm tumor in the posterior wall of the duodenum, in close contact with the duodenal papilla. We decided to perform pancreaticoduodenectomy and observed in the surgical specimen a 4 mm tumor in the duodenal region. In our experience, however, laparoscopy was successful in 2 patients: In the literature, there ciirugia few cases of gastrinomas in which laparoscopy has been successfully completed, so this type of approach should only be recommended in very select cases.
In sporadic gastrinoma surgery, once the tumor is located, the surgery of choice has also been debated: The limited number of patients in this series is not conclusive about the possible benefit of conservative surgery. In addition, there are other factors that have been cirufia as important in the recurrence of the disease after surgery: In a retrospective study of 48 patients with sporadic gastrinomas cirubia a follow-up period of up to 21 years, Bartsch et al.
In one group of patients, regional lymphadenectomy was used selectively, and in another group systematic lymphadenectomy was done, including the removal of pancreatic, pancreaticoduodenal and hepatoduodenal ligament lymph nodes and those situated between the aorta and vena cava. This last group associated a higher percentage of biochemical cure of the disease and demonstrated a more favorable tendency in the survival times, both disease-specific as well as disease-free.
In this study, the following poor prognosis factors were observed: The definition of a surgical sporadic gastrinoma cure depends on the follow-up time of ciruia patients and the study chosen for follow-up.
The most reliable diagnostic method is gastrin determination. The existence of a primary gastrinoma in a lymph node has created controversy. This possibility is confirmed by a study that demonstrates the presence of neuroendocrine cells in abdominal lymph nodes.
These authors indicated the difficulty that surgeons may zolligner during a procedure to predict whether a suspicious lymph node is a primary gastrinoma or zollinher of a duodenal or pancreatic gastrinoma.
In cases of doubt, the surgeon should continue to search for the primary tumor and to resect corugia biopsy other peripancreatic lymph node chains. This will help avoid overlooking a gastrinoma that would probably need more extensive surgery.
In our patient, we resected the nodule that was detected by radiology examination, which in the end was a primary lymphatic gastrinoma that met the criteria by presenting gastrin normalization immediately after surgery and absence of clinical symptoms for 9 years of follow-up.
The debate continues in gastrinoma surgery when associated with MEN Radical surgery with pancreaticoduodenectomy or subtotal pancreatectomy has not demonstrated greater benefits than other surgeries, which are not as extensive, when tumors have been able to be identified preoperatively.
The objective of the operation would be biochemical cure of the disease. Despite the high recurrence of the disease, surgery should always be indicated whenever possible for the prevention of distant metastasis. The authors have no conflict of interests to declare. Please cite this article as: Resultados inmediatos y a largo plazo. Short and Zollingr Results. Introduction Zollinger—Ellison syndrome Z—E is characterized by gastrin-secreting tumors, responsible for causing refractory and recurrent peptic ulcers in the gastrointestinal tract.
The optimal approach and the extension of tumor resection remains the subject of debate. Methods During the period February and February6 patients with Z—E underwent surgery, 4 men and 2 women with a median age Results The octreoscan was positive in 5 patients. Conclusions Surgery may offer a cure in patients with Z—E.
The laparoscopic approach remains limited to selected cases.
Gastrinoma or Zollinger-Ellison Syndrome
Resultados El octreoscan fue positivo en 5 pacientes. Introduction Gastrinomas are uncommon endocrine tumors, with an incidence of 0. Patients and Methods From February to February6 patients 4 men and 2 women were diagnosed with Zollinger—Ellison syndrome and treated surgically. Over the last year, this latter patient had experienced episodes of acute recurring pancreatitis with hyperamylasemia.
Approximately 2 cm distal to this lesion, there is a second hypervascular image measuring 7 mm, which was a gastrinoma of the zollijger portion of the duodenum 2. Endoscopic ultrasound showing a nodule in the wall of the 2nd portion of the duodenum 11 mm. Gastrinoma in the body of the pancreas 1 that partially occluded the Wirsung duct, causing distal dilatation 2.
Oncologist, 19pp. Ann Surg,pp.