Small pancreatic tumour verdicts, insulinoma localisation ladders, and gastrinoma cure operations

(A) Surgery is default above one centimetre and selective below it: pooled pancreatic analysis gives operative mortality hazard 0.30 with 5-year survival 77% against 46%, yet sub-centimetre disease shows comparable survival either way.^[10] Surveillance is defensible for the small asymptomatic lesion — five-study review at 540 patients with up to half showing growth, one in seven crossing to resection, and zero disease-related deaths on watch.^[11] The database sharpens it: 2,004 localised well-differentiated tumours with resection improving survival above one centimetre, and age, comorbidity, stage, location and resection as independent prognostics.^[12] Score her nodes before watching: the 1-to-7 location-plus-proliferation score bands low, intermediate and high risk — distal low-proliferation watches, proximal higher-proliferation resects with nodes.^[13]

(B) Expect a 10-month median symptom-to-diagnosis delay, then localise with everything: CT, MRI and endoscopic ultrasound combined, ultrasound most sensitive with MRI and ultrasound each rescuing CT-negative tumours; spare parenchyma in suitable cases with formal resection for vessel, duct or malignancy concern.^[16] Approach it minimally invasively when localised and feasible: 71-patient enucleation comparison with shorter minimally invasive times excluding conversions, equivalent late complications, 5.6% functional recurrence at 75 months, and no disease recurrence after R1 resection.^[15]

(C) Open every sporadic duodenum: routine duodenotomy finds gastrinoma in 98% against 76% with duodenal primaries at 62% against 18%, lifting immediate cure to 65% against 44% and long-term cure to 52% against 26%.^[17] Counsel honestly from the 10-year protocol: 78% found and resected, 11% morbidity without deaths, half the disease-free recurring by five years, yet excellent overall survival against 20% once metastatic at presentation — most found, about one-third cured.^[18]