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The first 25 slides, exactly as they appear. The full deck has 145 content slides.
General Surgery
Endocrine Tumors of the Pancreas
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 145 slides
Overview
- What this topic covers
- Terms used in this topic
- Definition of a pancreatic endocrine tumor
- Functioning and nonfunctioning tumors
- How the diagnosis is established
- Role of surgical resection
Islet structure, cell types and pathology
Where these tumours come from, and how the pathologist recognises them
- Structure of the pancreatic islet
- Islet cell types and the tumors they give rise to
- Where each cell type sits inside the islet
- Cell components of a pancreatic islet
- Distribution of endocrine cells across the gland
- Islet cell types, hormones, syndromes and their distribution
- Islet cell types, hormones, syndromes and their distribution (continued)
- Histologic appearance of pancreatic endocrine tumors
- Normal pancreatic islet and pancreatic endocrine tumor on H and E staining
- Chromogranin and gastrin staining of a pancreatic endocrine tumor
- Defining malignancy and functional status
Historical descriptions and relative frequency
How each syndrome was recognised, and how common each tumour is
- Landmarks in the recognition of islet cell tumors
- First descriptions of islet cell tumors
- Recognition of the glucagonoma and gastrinoma syndromes
- Recognition of the watery diarrhea syndrome
- Radioimmunoassay and the study of these syndromes
- Relative frequency of the tumor types
- Relative incidence of pancreatic endocrine tumors
Genetics and multiple endocrine neoplasia type 1
Why these tumours are not driven by the usual cancer genes, and which families are at risk
- Genetic changes in pancreatic endocrine tumors
- Chromosome losses and what they predict
- Multiple endocrine neoplasia type 1
- Tumors and features of multiple endocrine neoplasia type 1
- Behaviour of MEN1-associated tumors
- Screening and treatment order in MEN1
Insulinoma
The commonest of these tumours, and the one most often cured by a simple operation
- Insulinoma: incidence and patient profile
- 60%
- Location and gross appearance of insulinomas
- Biological behaviour of insulinomas
- How an insulinoma produces hypoglycemia
- Symptoms of hypoglycemia in insulinoma
- Timing of attacks and the eating pattern
- Consequences of chronic hypoglycemia
- Whipple's triad
- Whipple's triad and the fast that precipitates it
- The monitored 72-hour fast
- Results of the fast
- Laboratory thresholds that support insulinoma
- Glucose and insulin during a fast in insulinoma
- Glucose levels before and after removal of an insulinoma
- Conditions that mimic insulinoma
- Provocative testing for insulinoma
Gastrinoma and Zollinger-Ellison syndrome
Ulcers that will not heal, and the hormone behind them
- Gastrinoma: incidence and patient profile
- Gastrin and the loss of normal control
- How a gastrinoma causes ulcers and diarrhea
- Malignant behaviour and spread of gastrinomas
- The gastrinoma triangle
- MEN1 in Zollinger-Ellison syndrome
- Ulcer disease in Zollinger-Ellison syndrome
- Other symptoms of Zollinger-Ellison syndrome
- Endoscopic findings and when to suspect the syndrome
- Measuring gastrin and documenting acid output
- Causes of hypergastrinemia
- Preparing the patient for gastrin testing
- Gastrin levels and the secretin stimulation test
VIPoma and the Verner-Morrison syndrome
Litres of watery diarrhoea, and the potassium loss that can kill
- Vasoactive intestinal peptide in health
- VIPoma: frequency, site and behaviour
- Age distribution and associations of VIPoma
- How VIP produces watery diarrhea
- Verner-Morrison syndrome
- Features that separate VIPoma diarrhea from other causes
- Stool findings in VIPoma
- Differential diagnosis of chronic diarrhea
- Differential diagnosis of chronic diarrhea (continued)
- Metabolic consequences of VIPoma
- Diagnosis of VIPoma
Glucagonoma, somatostatinoma and nonfunctional tumors
The rare syndromes, and the silent tumours that are found only when they grow large
- Glucagonoma: frequency, size and site
- The four Ds of the glucagonoma syndrome
- Metabolic effect of excess glucagon
- Blood findings in glucagonoma
- Necrolytic migratory erythema
- Course of the rash in glucagonoma
- Necrolytic migratory erythema in glucagonoma
- Diagnosis of glucagonoma
- Somatostatinoma: frequency and site
- Associations of somatostatinoma
- Effects of excess somatostatin
- Diagnosis of somatostatinoma
- Nonfunctional pancreatic endocrine tumors
- Behaviour and presentation of nonfunctional tumors
- Rarer hormone-producing tumors
Imaging and localization
Finding a tumour that the blood test has already proved must exist
- Why localization is the central problem
- Computed tomography technique and yield
- Insulinoma on arterial and venous phase CT
- Magnetic resonance imaging
- Somatostatin receptor scintigraphy
- Yield and limits of receptor scintigraphy
- Somatostatin receptor scintigram in metastatic gastrinoma
- Endoscopic ultrasound
- Insulinoma on transgastric endoscopic ultrasound
- Fine-needle aspiration during endoscopic ultrasound
- Endoscopic ultrasound-guided needle biopsy of a pancreatic endocrine tumor
- Angiography and venous sampling
- Insulinoma on angiography and on triphasic CT
- Transhepatic selective venous sampling for insulin
- Intraoperative localization
- Stepwise localization of insulinoma
- Localization pathway for insulinoma
- Stepwise localization of gastrinoma
- Localization pathway for gastrinoma
- Routine duodenotomy in gastrinoma surgery
- Localizing the larger endocrine tumors
- Nonfunctional pancreatic endocrine tumor in the head of the pancreas
Surgical management
Preparing the patient, exposing the gland, and choosing between shelling out and resecting
- Preoperative control of hypoglycemia in insulinoma
- Exposure of the pancreas at operation
- Solitary insulinoma in the tail of the pancreas at operation
- Matching the operative finding to the preoperative scan
- Enucleation of an insulinoma
- When formal resection is needed
- Laparoscopic resection
- When the tumor cannot be found at operation
- Results after insulinoma resection
- Treatment of metastatic insulinoma
- Indications and goals of gastrinoma surgery
- Operative steps for gastrinoma
- Choice of resection for gastrinoma
- When the gastrinoma is not found at operation
- Medical control of acid in Zollinger-Ellison syndrome
- Remaining indications for total gastrectomy
- Survival predictors in gastrinoma
- Outcome after resection in gastrinoma
- Survival in gastrinoma according to liver metastases
- Treating metastatic gastrinoma
- Preparing a patient with VIPoma for surgery
- Preparing a patient with glucagonoma for surgery
- Resection of VIPoma, glucagonoma and nonfunctional tumors
- Outcomes for VIPoma
- Outcomes for glucagonoma
- Surgery for somatostatinoma and nonfunctional tumors
Conclusions
What to carry away from this topic
- Key points on diagnosis and localization
- Key points on surgical treatment
- References
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- Maingot's Abdominal Operations, 12th Edition