Surgery for gastrinoma includes meticulous technique and a thorough exploration. The lesser sac is widely opened, and the entire pancreas is mobilized throughout its length. This allows for careful bimanual palpation of the gland. Although many of the lesions are palpable, some are quite deeply located in the gland, and may not feel dissimilar to the adjacent normal pancreatic parenchyma. Intraoperative ultrasound has been shown by a number of investigators to be useful, and should be performed in any patient undergoing exploration for gastrinoma. Intraoperative ultrasound is useful in identifying difficult to palpate and non-palpable lesions. It is also may detect signs suggestive of malignancy, as well as the relationship of the tumor to the main pancreatic duct and major blood vessels [64, 65]. Intraoperative ultrasound is not particularly useful in identifying duodenal wall gastrinomas, however. Intraoperative endoscopy with transillumination of the duodenum is capable of locating duodenal wall gastrinomas [66]. However it is not useful in identifying the more than 50% of duodenal wall gastrinomas located along the medial wall. The most accurate method of detecting duodenal wall gastrinomas remains duodenotomy with careful palpation, a technique employed by experienced teams during surgical exploration for gastrinoma [4, 6]. Duodenotomy has been shown to increase the gastrinoma detection rate to 98% compared to 76% without duodenotomy, as well as the short term cure rate (65% vs. 44%), and long term cure rate (52% vs. 26%) [67]. Because primary duodenal gastrinomas are associated with lymph node metastases in 60% of patients, a more aggressive lymphadenectomy has been recommended [68].

The use of endoscopic and/or laparoscopic approaches for the management of neuroendocrine tumors including gastrinomas has been recorded in small numbers of patients[69-72]. However, the role for such an approach in gastrinoma patients appears to be limited for a variety of technical issues including the multiciplicity of lesions, the small size of duodenal tumors, the frequent presence of lymph node metastases, and the presence of critical structures in the usual gastrinoma location in the pancreatic head region. These difficulties tend to favor an open surgical approach [73].

The treatment of the patient with MEN-I and gastrinoma remains controversial [17, 21, 74]. Few data are available on patients with MEN-I syndrome and gastrinomas who have undergone careful preoperative evaluation followed by possible palliative or curative surgery. Therefore, a definitive statement about optimal management in these patients cannot be made at the present time, and treatment should be individualized. If a clear-cut source of the hypergastrinemia can be identified using functional and anatomic studies, then surgical exploration, with enucleation or resection, should be strongly considered. Such an approach may offer excellent palliation, if not cure. Other groups take an even more aggressive posture (See MEN-1 Section). The malignant potential of these lesions should also be taken into account. Patients with tumors more than 3cm in size should be considered for resection, even in the absence of clear-cut function. The relatively low incidence of malignancy in gastrinoma patients with MEN-I compared to those without MEN-I does not mean that a more cavalier approach can be taken in these patients.