Chapter 4. Surgery of the Endocrine Pancreas

• Tumors may be functional (ie, a clinical syndrome of excessive levels of such hormones as insulin, gastrin, VIP, somatostatin, and glucagon) or nonfunctional (ie, normal serum marker levels [excluding pancreatic polypeptide, chromogranin A]).
• Tumors may be sporadic or a manifestation of an inherited endocrinopathy (multiple endocrine neoplasia type 1 [MEN-1], von Hippel-Lindau [VHL]).
• Nonfunctional tumors demonstrable via radiologic examination should be resected.
• All functional tumors should be resected.
• Sinistral portal hypertension.

• Inoperable, metastatic disease.
• Small (< 1 cm), nonfunctional tumors in patients with an inherited endocrinopathy.
• Functional tumors with a medically controlled syndrome in patients with an inherited endocrinopathy who have undergone previous pancreatic resection.
• Pregnancy (first trimester).
• Multiple comorbidities precluding safe surgical intervention.

• For major pancreatic resections, morbidity is roughly 10–12% and mortality is 1–2%.

Expected Benefits

• Treatment of pancreatic hypersecretory syndromes in patients with functional tumors.
• Treatment of potentially malignant neuroendocrine tumors.

Potential Risks

• Bleeding, possibly requiring blood product transfusion.
• Surgical site infection.
• Pancreatic fistula.
• Biliary fistula.
• Gastric outlet obstruction or delayed gastric emptying.
• Overwhelming post-splenectomy sepsis.
• Incisional hernia.
• Glucose intolerance or diabetes.
• Pancreatic exocrine insufficiency or malabsorption.

• Intraoperative ultrasound with a high-resolution 7.5–10 MHz probe should be available for primary tumor localization or identification of hepatic metastatic disease.

• Medical control of hormone excess (eg, with proton pump inhibitors or somatostatin analogue therapy) to the degree possible.
• Any patient who is to undergo splenectomy should receive the pneumococcal, Haemophilus influenzae B, and meningococcal vaccines preoperatively.
• Nothing by mouth the evening before surgery.
• Preoperative antibiotics.
• Both mechanical and pharmacologic deep venous thrombosis prophylaxis should be given.
• Anesthesiology consultation as needed.

• The patient should be supine, preferably with the arms extended.

• Figure 4–1: For patients with documented hypergastrinemia, the primary tumor will almost always lie in the gastrinoma triangle (bounded by the confluence of the cystic and common hepatic ducts, the second and third portion of the duodenum, and the confluence of the neck and body of the pancreas).
• A vertical, upper midline incision or a subcostal incision is used.
  • The former is preferred for patients with a relatively acutely angled costal margin.
  • The latter incision can either be predominantly left sided for a distal pancreatectomy or bilateral in the case of a pancreaticoduodenectomy.
• Inspection of the abdomen for metastatic disease includes visualization and palpation of the liver, peritoneal surfaces, mesentery, omentum, and, in women, the ovaries.
• Figure 4–2: The entire pancreas is mobilized for localization of the tumor.
  • This step begins with a mobilization of the pancreatic head via release of the duodenum from its lateral abdominal wall and retroperitoneal attachments (Kocher maneuver).
  • This should be continued toward the patient's left side until the aorta is encountered.
• Figure 4–3: The body and tail of the pancreas is exposed via entry through the lesser sac.
  • The gastrocolic ligament is opened, ...