title: Does the use of routine duodenotomy (DUODX) affect rate of cure, development of liver metastases, or survival in patients with Zollinger-Ellison syndrome?
abstract: OBJECTIVE
  To determine whether routine use of duodenotomy (DUODX) alters cure rate, survival, or development of liver metastases in 143 patients (162 operations) with Zollinger-Ellison syndrome (ZES) without MEN1.
  
  
  BACKGROUND
  DUODX has been shown to increase the detection of duodenal gastrinomas, but it is unknown if it alters rate of cure, liver metastases, or survival. Data from our prospective studies of surgery in ZES allow us to address this issue because DUODX was not performed before 1987, whereas it was routinely done after 1987.
  
  
  METHODS
  All patients with sporadic ZES (non-MEN1) undergoing surgery for possible cure without a prior DUODX from November 1980 to June 2003 were included. Patients had preoperative computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound; if unclear, angiography and somatostatin receptor scintigraphy since 1994. At surgery, all had the same standard ZES operation and were assessed immediately postoperatively, at 3 to 6 months, and yearly for cure (fasting gastrin, secretin test. and imaging studies).
  
  
  RESULTS
  A DUODX was performed in 79 patients (94 operations), and no DUODX was performed in 64 patients (68 operations), with 10 patients having both (no DUODX, then a DUODX later). Gastrinoma was found in 98% with DUODX compared with 76% with no DUODX (P < 0.00001). Duodenal gastrinomas were found more frequently with DUODX (62% vs. 18%; P < 0.00001), whereas pancreatic, lymph node, and other primary gastrinomas occurred similarly. Six of the 10 patients with 2 operations had a duodenal tumor found with DUODX during a second operation that was missed in the first operation without DUODX. Both the immediate postoperative cure rate (65% vs. 44%; P = 0.010) and long-term cure rate at last follow-up (8.8 +/- 0.4 years; range, 0.1 to 21.5) (52% vs. 26%; P = 0.0012) were significantly greater with a DUODX than without. In patients without pancreatic tumors or liver metastases at surgery, both the rate of developing liver metastases (6% vs. 9.5%) and the disease-related death rate (0% vs. 2%) were low and not significantly different in patients with or without a DUODX.
  
  
  CONCLUSIONS
  These results demonstrate that routine use of DUODX increases the short-term and long-term cure rate due to the detection of more duodenal gastrinomas. The rate of development of hepatic metastases and/or disease-related mortality in patients without pancreatic tumors is low, and no effect of DUODX on these parameters was seen. Duodenotomy (DUODX) should be routinely performed during all operations for cure of sporadic ZES.
authors.affiliation: Surgical Oncology, Department of Surgery, Stanford University Medical Center, Room H-3591, 300 Pasteur Drive, Stanford, CA 94305-5641, USA. janorton@stanford.edu
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.forename: H Richard
authors.initials: HR
authors.lastname: Alexander
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.forename: David J
authors.initials: DJ
authors.lastname: Venzon
authors.forename: Fathia
authors.initials: F
authors.lastname: Gibril
authors.forename: Robert T
authors.initials: RT
authors.lastname: Jensen
mesh_terms: D004379:Duodenal Neoplasms / Q000601:surgery; D004386:Duodenum / Q000601:surgery*; D015408:Gastrinoma / Q000601:surgery; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary*; D011446:Prospective Studies; D016896:Treatment Outcome; D015043:Zollinger-Ellison Syndrome / Q000401:mortality* / Q000601:surgery*