Surgery Increases Survival In Patients With Gastrinoma
Jeffrey A. Norton, MD, Douglas L. Fraker, MD, H Richard Alexander, MD, Fathia Gibril, MD*, Daniel Liewehr, PhD*, David J. Venzon, PhD*, Robert T. Jensen, MD*
Stanford University, Stanford, CA
Objective: Attempted gastrinoma resection in patients with Zollinger-Ellison syndrome (ZES) is controversial, because medical treatment of acid hypersecretion is excellent, most gastrinomas are slow growing and surgery has not been shown to increase survival. In our prospective study of ZES we have a group of patients (n=35) who were eligible for surgery but elected not to have it. We have compared them to a large cohort (n=160) who underwent surgery.
Methods: Detailed tumor imaging studies were done preoperatively and then yearly, as well as acid and hormonal studies. All surgical pts had a standard operation in which all identified gastrinoma was excised.
Results: The 35 unoperated pts did not differ from the 160 operated in age, gender, % with MEN1, disease duration, extent of tumor, BAO, fasting gastrin or time of follow-up. At surgery 94% had tumor removed, 54% were cured immediate post resection and 41% at last follow-up. During follow-up, significant more unoperated patients developed liver metastases (29% vs 5%, p<0.00001), died from any cause (54% vs 22%, P=0.0002), and had a disease-related death (23% vs 1%, p<0.00001). Operated patents had a better overall survival (P=0.0010) and better disease-related survival (p=0.0012). The increase in survival was due to gastrinoma resection because disease-related survival increased without changing death from non-ZES related causes (p=0.10). Fifteen and 20 yr disease-related survival for operated and unoperated (p=0.0002) was 99% vs. 84% and 98% vs. 74%, respectively.
Conclusions: These results show for the first time that routine surgical exploration increases survival in patients with ZES by increasing disease-related survival and decreasing the development of metastatic disease. Routine surgical resection of gastrinoma is indicated in all patients with ZES.
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