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Value Of Surgery In Patients With Negative Imaging And Sporadic Zollinger-ellison Syndrome (zes)
Jeffrey A Norton1, Douglas L Fraker1, H Richard Alexander1, Robert T Jensen*2
1Stanford University, Stanford, CA;2NIADDK, NIH, Bethesda, MD

Objectives: To address the value of surgery in sporadic ZES patients with negative imaging studies
Methods: 58 of 339 sporadic ZES patients (17%) had negative imaging studies. Patients were stratified into those who had negative conventional [Conv] imaging (CT, MRI, US) in the pre-SRS (octreoscan) period and those who had negative SRS and conventional imaging in the post-SRS period.
Results: 58 sporadic ZES patients with negative imaging, including 35 pre-SRS and 23 post-SRS, underwent surgery. These patients had long disease histories prior to surgery (mean± from onset=7.9±1[range -0.25-35 yrs]) and 25% were followed ≥2yrs from diagnosis. At surgery, gastrinoma was found in 57/58 patients (98%). Tumors were small (mean=0.8cm, 60% < 1 cm). The most common primary sites were: duodenal 64%, pancreatic 17%, and lymph node (10%). 50% had a primary only, 41% primary + LN, and 7% had liver metastases. 35/58(60%) were cured immediately postop and at last followup [mean-9.4yrs [range 0.2-22yrs], 27 patients (46%) remained cured. During followup 3 patients died, each were found to have liver metastases at surgery.
Conclusions. Imaging negative sporadic ZES patients are not rare even in the post SRS period. An experienced surgeon can find gastrinoma in almost every patient (98%) and nearly one-half (46%) are cured. Because liver metastases were found in 7%, which may have been caused by a long delay in surgery and all the disease-related deaths occurred in this group, surgery should be routinely undertaken early in ZES patients despite negative imaging studies.

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