Background: Pancreatic neuroendocrine neoplasias (pNENs) are uncommon but fascinating tumors with an annual incidence of 1 per 100,000 people. pNENs present either as functional tumors, causing specific hormonal syndromes like Zollinger-Ellison syndrome (ZES) or organic hyperinsulinism, or as non-functional pancreatic tumors (NF-pNENs). The natural history of pNENs is highly variable. 90% of all insulinomas or small NF- pNENs are readily curable by surgical resection. Most other functional and late detected NF-pNENs have a less favorable chance for cure. Methods: A systematic review of the literature was performed to identify the current state of the art with regard to the key issues of surgery in pNEN G1/G2. Results: This article provides a comprehensive review of the current literature addressing the current challenges in pNEN surgery. Conclusion: Patients with completely resected tumors generally have a good prognosis, and an aggressive surgical approach combined with conservative treatment options in patients with advanced disease rarely provides cure but often results in long-term survival.

1.
Falconi M, Eriksson B, Kaltsas G, Bartsch DK, Capdevila J, Caplin M, Kos-Kudla B, Kwekkeboom D, Rindi G, Klöppel G, Reed N, Kianmanesh R, Jensen RT; Vienna Consensus Conference participants: ENETS Consensus Guidelines update for the management of patients with functional pancreatic neuroendocrine tumors and non-functional pancreatic neuroendocrine tumors. Neuroendocrinology 2016;103:153-171.
2.
Baumann T, Rottenburger C, Nicolas G, Wild D: Gastroenteropancreatic neuroendocrine tumours (GEP-NET) - imaging and staging. Best Pract Res Clin Endocrinol Metab 2016;30:45-57.
3.
Mathur A, Gorden P, Libutti SK: Insulinoma. Surg Clin North Am 2009;89:1105-1121.
4.
Whipple AO, Frantz VK: Adenomas of the islet cells with hyperinsulinism. Ann Surg 1935;101:1299-1335.
5.
Fendrich V, Bartsch DK, Langer P, Zielke A, Rothmund M: Diagnosis and therapy in 40 patients with insulinoma. Dtsch Med Wochenschr 2004;129:941-946.
6.
Öberg K, Modlin IM, De Herder W, Pavel M, Klimstra D, Frilling A, Metz DC, Heaney A, Kwekkeboom D, Strosberg J, Meyer T, Moss SF, Washington K, Wolin E, Liu E, Goldenring J: Consensus on biomarkers for neuroendocrine tumour disease. Lancet Oncol 2015;16:e435-446.
7.
Zollinger RM, Ellison EH: Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas. Ann Surg 1955;142:709-723.
8.
Stabile BE, Morrow DJ, Passaro E Jr: The gastrinoma triangle: operative implications. Am J Surg 1984;147:25-31.
9.
Yu F, Venzon DJ, Serrano J, et al: Prospective study of the clinical course, prognostic factors, causes of death, and survival in patients with long-standing Zollinger-Ellison syndrome. J Clin Oncol 1999;17:615-630.
10.
Chastain MA: The glucagonoma syndrome: a review of its features and discussion of new perspectives. Am J Med Sci 2001;321:306-320.
11.
Fendrich V, Waldmann J, Bartsch DK, Langer P: Surgical management of pancreatic endocrine tumors. Nat Rev Clin Oncol 2009;6:419-428.
12.
Dedieu A, Rault A, Collet D, Masson B, Sa Cunha A: Laparoscopic enucleation of pancreatic neoplasm. Surg Endosc 2011;25:572-576.
13.
Zhao YP, Zhan HX, Zhang TP, Cong L, Dai MH, Liao Q, Cai LX: Surgical management of patients with insulinomas: result of 292 cases in a single institution. J Surg Oncol 2011;103:169-174.
14.
Mehrabi A, Hafezi M, Arvin J, Esmaeilzadeh M, Garoussi C, Emami G, Kössler-Ebs J, Müller-Stich BP, Büchler MW, Hackert T, Diener MK: A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it's time to randomize. Surgery 2015;157:45-55.
15.
Carrere N, Abid S, Julio CH, Bloom E, Pradere B: Spleen-preserving distal pancreatectomy with excision of splenic artery and vein: a case-matched comparison with conventional distal pancreatectomy with splenectomy. World J Surg 2007;31:375-382.
16.
Tamburrino D, Spoletini G, Partelli S, Muffatti F, Adamenko O, Crippa S, Falconi M: Surgical management of neuroendocrine tumors. Best Pract Res Clin Endocrinol Metab 2016;30:93-102.
17.
Partelli S, Cirocchi R, Crippa S, Cardinali L, Fendrich V, Bartsch DK, Falconi M: Systematic review of active surveillance versus surgical management of asymptomatic small non-functioning pancreatic neuroendocrine neoplasms. Br J Surg 2017;104:34-41.
18.
Gagner M: Early experience with laparoscopic resections of islet cell tumors. Surgery 1996;120:1051-1054.
19.
Fernández-Cruz L, Molina V, Vallejos R, Jiménez Chavarria E, López-Boado MA, Ferrer J: Outcome after laparoscopic enucleation for non-functional neuroendocrine pancreatic tumours. HPB (Oxford) 2012;14:171-176.
20.
Langer P, Bartsch DK, Fendrich V, Kann PH, Rothmund M, Zielke A: Minimal-invasive operative treatment of organic hyperinsulinism. Dtsch Med Wochenschr 2005;130:508-513.
21.
Lopez CL, Albers MB, Bollmann C, Manoharan J, Waldmann J, Fendrich V, Bartsch DK: Minimally invasive versus open pancreatic surgery in patients with multiple endocrine neoplasia type 1. World J Surg 2016; 40:1729-1736.
22.
Eckhardt S, Schicker C, Maurer E, Fendrich V, Bartsch DK: Robotic-assisted approach improves vessel preservation in spleen-preserving distal pancreatectomy. Dig Surg 2016;33:406-413.
23.
Zhan Q, Deng XX, Han B, Liu Q, Shen BY, Peng CH, Li HW: Robotic-assisted pancreatic resection: a report of 47 cases. Int J Med Robot 2013;9:44-51.
24.
Norton JA, Fraker DL, Alexander HR, et al: Surgery increases survival in patients with gastrinoma. Ann Surg 2006;244:410-419.
25.
Norton JA, Alexander HR, Fraker DL, et al: Does the use of routine duodenotomy (DUODX) affect rate of cure, development of liver metastases, or survival in patients with Zollinger-Ellison syndrome? Ann Surg 2004;239:617-625; discussion 626.
26.
Bartsch DK, Waldmann J, Fendrich V, Boninsegna L, Lopez CL, Partelli S, Falconi M: Impact of lymphadenectomy on survival after surgery for sporadic gastrinoma. Br J Surg 2012;99:1234-1240.
27.
Zogakis TG, Gibril F, Libutti SK, et al: Management and outcome of patients with sporadic gastrinoma arising in the duodenum. Ann Surg 2003;238:42-48.
28.
Pavel M, O'Toole D, Costa F, Capdevila J, Gross D, Kianmanesh R, Krenning E, Knigge U, Salazar R, Pape UF, Öberg K; Vienna Consensus Conference participants: ENETS Consensus Guidelines update for the management of distant metastatic disease of intestinal, pancreatic, bronchial neuroendocrine neoplasms (NEN) and NEN of unknown primary site. Neuroendocrinology 2016;103:172-185.
29.
Frilling A, Clift AK: Therapeutic strategies for neuroendocrine liver metastases. Cancer 2015;121:1172-1186.
30.
Vilchez V, Gedaly R: Liver transplantation for the treatment of neuroendocrine liver metastases. Best Pract Res Clin Endocrinol Metab 2016;30:141-147.
31.
Elias D, Sideris L, Liberale G, et al: Surgical treatment of peritoneal carcinomatosis from well-differentiated digestive endocrine carcinomas. Surgery 2005;137:411-416.
32.
Elias D, David A, Sourrouille I, Honoré C, Goéré D, Dumont F, Stoclin A, Baudin E: Neuroendocrine carcinomas: optimal surgery of peritoneal metastases (and associated intra-abdominal metastases). Surgery 2014;155:5-12.
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