Is total gastrectomy still a viable option in the management of patients with the Zollinger-Ellison syndrome?

Abstract

It is generally held that landmarks in the evolution of the medical treatment of the Zollinger-Ellison syndrome (ZES)have also had a profound effect on the surgical approach to peptic ulcer disease. After 1955 when Zollinger and Ellison initially described the syndrome, total gastrectomy remained the treatment of choice until a new generation of antisecretory agents were introduced over 30 years ago. The introduction of histamine receptor 2 antagonists (H2RAs) in 1974, and the development of proton pump inhibitors (PPIs) in 1980, are quite rightly considered to be landmarks in the medical treatment of acid hypersecretory states. However, it soon became evident that the administration of H2RAs was not without problems. There were troublesome side-effects and 25% of patients developed complications because of inadequate control. However, the early 1980s heralded a new era that differed fundamentally from the H2RA approach when the introduction of PPIs revolutionised the management of peptic ulcer disease. With the advent of PPIs, gastric hypersecretion could be controlled in almost every case. In the early 1990s gastric surgery was considered to be an unresolved issue in ZES cases. However, based on numerous studies showing that acid hypersecretion can be controlled in ZES patients for long periods, Norton and Jensen5 currently hold that total gastrectomy is not indicated for hypersecretory control. The following clinical presentation describes a patient with peptic ulceration of the duodenum and a stenosed oesophagus as a result of a peri-pancreatic gastrinoma. As the patient enjoys excellent quality of life 13 years after total gastrectomy for ZES, this provided the impetus to reconsider the advantages of total removal of the target organ as an alternative to lifelong medical treatment of the lethal hypersecretory effects of residual gastrin-producing tumour tissue.