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  • Tumors may be functional (ie, a clinical syndrome of excessive levels of such hormones as insulin, gastrin, VIP, somatostatin, and glucagon) or nonfunctional (ie, normal serum marker levels [excluding pancreatic polypeptide, chromogranin A]).
  • Tumors may be sporadic or a manifestation of an inherited endocrinopathy (multiple endocrine neoplasia type 1 [MEN-1], von Hippel-Lindau [VHL]).
  • Nonfunctional tumors demonstrable via radiologic examination should be resected.
  • All functional tumors should be resected.
  • Sinistral portal hypertension.

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  • Inoperable, metastatic disease.
  • Small (< 1 cm), nonfunctional tumors in patients with an inherited endocrinopathy.
  • Functional tumors with a medically controlled syndrome in patients with an inherited endocrinopathy who have undergone previous pancreatic resection.
  • Pregnancy (first trimester).
  • Multiple comorbidities precluding safe surgical intervention.

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  • The patient should be supine, preferably with the arms extended.

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  • Routine postoperative admission to an ICU is not mandatory. Rather, ICU observation (usually one night) is guided by intraoperative blood loss as well as preexisting cardiac and pulmonary comorbidities the patient may have.
  • Nasogastric tube decompression is continued postoperatively; the length of time the tube remains in place is guided by the volume of output.
  • Patient-controlled intravenous or epidural analgesia is routinely used.
  • Urinary catheterization continues while an epidural pain catheter is in place.
  • Early ambulation and physical therapy consultation, if indicated.
  • Oral diet is slowly introduced once ileus is fully resolved.
  • Strict management of glycemic control, with continuous insulin infusion for repeated blood glucose measurements > 140 mg/dL.
  • Closed suction drain output is tested for amylase and lipase content prior to removal.
  • Routine use of octreotide therapy to reduce the pancreatic fistula rate is not supported by published evidence.

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  • After laparotomy: intravenous catheter infection, urinary tract infection, pneumonia, cardiac dysrhythmias and ischemia, deep venous thrombosis, superficial surgical site infection, fascial dehiscence.
  • Pancreatic leakage and fistula occur in 5–8% of cases.
    • Leakage or fistula is confirmed by amylase and lipase-rich drainage in closed suction drain output.
    • Nontoxic patients are treated with maintenance of the drain.
    • Patients with fevers, tachycardia, acidosis, or leukocytosis should undergo abdominal and pelvic CT scan to evaluate for abscess or inadequately controlled fistula.
    • Inadequately controlled fistula can usually be managed with an additional percutaneous drain, replacement of lost fluid and electrolytes, adequate nutrition, and consideration of octreotide therapy for high-output fistulas.
  • Postoperative hemorrhage, most commonly resulting from a bleeding short gastric vessel or a gastroduodenal or pancreaticoduodenal pseudoaneurysm.
  • Delayed gastric emptying.

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