Laparoscopic pancreatic resection of an insulinoma in a child

Insulinoma is a rare neuroendocrine tumour infrequently reported in children. Operative excision is the treatment of choice, but requires a disproportionately large incision to remove a small and benign tumour located deep in the retroperitoneum. Laparoscopic resection of benign tumours of the pancreas has been increasingly reported in adults and seems to be ideal for pancreatic insulinomas. We present the case of pancreatic insulinoma in a 13-year-old boy treated by laparoscopic distal pancreatectomy.     

Is preoperative localization of insulinomas justified?

STUDY AIM: To appreciate the impact of preoperative localization in surgical treatment of insulinomas. PATIENTS AND METHOD: From 1986 to 2001, 29 patients were surgically treated for suspected insulinoma. Preoperative imaging assessment was performed in 26 patients: ultrasonography (n = 21), computed tomography (n = 23), endoscopic ultrasonography (n = 13), intraoperative ultrasonography (n = 22) (2 of them under laparoscopic approach). RESULTS: The sensibility of the localization procedures was as follows: ultrasonography = 9.6%, computed tomography = 39%, endoscopic ultrasonography = 92.3%, surgical exploration 79.3%, intraoperative ultrasonography 86.3%. The sensibility of intraoperative palpation associated which intraoperative ultrasonography was 100%. Surgical procedures included: 11 enucleations, 10 segmental resections of the tail, 1 left pancreatectomy, 3 median pancreatectomies, 4 subtotal pancreatectomies. There was no postoperative mortality and postoperative morbidity rate was 17%, including 4 pancreatic leakages. Histological examination found solitary tumor in 22 patients (1 of them was a malignant tumor), multiple tumors (MEN 1) in 4 patients and factitious hypoglycemia in 3 patients. All the insulinomas were resected. CONCLUSION: Intraoperative evaluation of the pancreas with intraoperative ultrasonography was associated which a right localization in 100% of insulinomas. The place for preoperative imaging seems to be limited. A laparoscopic approach in sporadic insulinomas could modify this attitude.     

The management of insulinoma

BACKGROUND: Insulinomas are rare tumours. Their clinical presentation, localization techniques and operative management were reviewed. METHODS: An electronic search of the Medline, Embase and Cochrane databases was undertaken for articles published between January 1966 and June 2005 on the history, presentation, clinical evaluation, use of imaging techniques for tumour localization and operative management of insulinoma. RESULTS AND CONCLUSION: Most insulinomas are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained during a supervised 72-h fast. Non-invasive preoperative imaging techniques to localize lesions continue to evolve. Intraoperative ultrasonography can be combined with other preoperative imaging modalities to improve tumour detection. Surgical resection is the treatment of choice. In the absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.     

Exérèse vidéolaparoscopique des insulinomes. Étude de cinq observations *

Study aimEvaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases.Patients and methodFrom 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head (n = 1), body (n = 3) or tail (n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used.ResultsFour resections were exclusively performed with videolaparoscopy: three enuclations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up.ConclusionSelected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.     

Insulinoma: an Evaluation by a Single Institution

Introduction: Insulinoma is a rare pancreatic islet cell tumour that is associated with hypoglycaemia. Diagnosis of the disease, localisation of the tumour and surgical therapy may be challenging and the aim of this study is to evaluate the problems concerning insulinoma.

Materials and methods: The surgical records of patients who were operated on for insulinoma at Hacettepe University Department of General Surgery between January 1980 and December 2006 were evaluated retrospectively. The evaluated parameters were the gender and ages of the patients with symptoms, signs, diagnostic tools and surgical methods. Results: Twenty-six patients were included in the study. There were 17 male and nine female patients. The median age was 34. The median diagnostic period was 285 days. Abdominal computer tomography was the most frequently used diagnostic method. A total of 15 enucleations, nine distal pancreatectomies and three pancreaticoduodenectomies were performed. Histopathologically most of the tumours were benign islet cell tumours.

Conclusions: There are still difficulties in the diagnosis, localisation and histopathologic evaluation of insulinoma. Appropriate pre-operative evaluation, through exploration and palpation of the pancreas during the surgery, as well as experienced centres are important to increase the success of the surgery of insulinoma.     

Localization and surgical treatment of the pancreatic insulinomas

OBJECTIVES: Insulinomas are rare tumours that originate from the islet cells of the pancreas. The aims of this study were to gain an understanding of the clinical features of insulinomas and to establish the diagnostic and therapeutic strategies. METHODS: A review was carried out in 20 patients with insulinoma surgically treated in our institution over the last 10 years. Presenting symptoms, biochemical studies, preoperative and intraoperative localization studies, operative management and complications were analysed. RESULTS: The male-to-female ratio was 8:12, with a mean age of 46.4 years. Each patient suffered from significant neuroglycopenic symptoms, usually manifested by dizziness, sweating, headache and confusion. The preoperative median serum levels of glucose, insulin and C-peptide at the termination of the fast were 37.5 mg/dL, 23.5 microU/mL, 5.6 ng/mL, respectively. Preoperative tumour localization was achieved by means of ultrasonography (US), computed tomography, selective angiography or intra-arterial calcium injection with hepatic venous sampling, and sensitivities of these examinations were 81.8, 73.7, 94.1 and 100%, respectively. Intraoperative localization was carried out by a combination of manual palpation and intraoperative US with retrospective sensitivities of 80 and 100%, respectively. Enucleation was carried out in 16 patients and distal pancreatectomy in 4. The mortality and morbidity rates were 0 and 10%, respectively. One patient developed late diabetes mellitus type 1 after distal pancreatectomy. CONCLUSIONS: We conclude that the diagnosis of insulinoma can be made on the basis of the results of a supervised fast, careful palpation with intraoperative US is essential for intraoperative detection of insulinomas and surgical resection is the best choice for treatment of benign insulinomas.     

胰腺内分泌肿瘤的诊断与外科治疗

目的提高胰腺内分泌肿瘤的诊断和治疗水平。方法回顾性分析1978年1月至2004年12月经手术治疗、病理证实的38例胰腺内分泌肿瘤病人的临床资料。结果胰腺内分泌肿瘤以胰岛素瘤和无功能性胰岛细胞瘤最常见,分别占57．9%和36.8%,恶性胰岛素瘤和多发性胰岛素瘤各占胰岛素瘤的13．6%,无功能性胰岛细胞瘤中恶性占64．3%;21例(95%)胰岛素瘤成功术前定位和手术切除,1例多发性胰岛素瘤摘除术后 4年后复发,再次手术治愈;86％无功能性胰岛细胞瘤患者以无痛性肿块入院,肿瘤平均大小为8．5cm,6例行胰体尾部切除,4例行胰十二指肠切除,2例行肿瘤摘除,1例行囊肿内引流术,1例行活检术;全组术后并发胰瘘7例(18%)。结论 B超、CT是胰腺内分泌肿瘤有效的诊断方法,肿瘤局部剜出与规范切除是治疗胰腺内分泌肿瘤的有效方法,其预后较好。     

胰岛素瘤外科诊断与治疗的变革

Insulinoma is derived from beta cells, and the yearly incidence of insulinoma is 1-4 per one million. Insulinoma patients were often misdiagnosed with epilepsy or cerebrovascular diseases because of the clinical and epidemiological features of insulinoma. The diagnosis of the insulinoma is usually made biochemically with the presence of low blood glucose ( <2.5 mmol/L), elevated insulin ( ≥6 mU/L) and C-peptide levels ( ≥ 200 pmol/L), and no sulfonylureas in the blood.Supervised 72-hour fasting test has been verified as the gold standard in establishing a biochemical diagnosis of insulinoma.Localization of insulinoma is useful for selecting surgical procedures, and the methods for localization can be divided into noninvasive (transabdominal ultrasound, computed tomography,magnetic resonance imaging and endoscopic ultrasound), invasive (angiography and arterial stimulation venous sampling) and intraoperative diagnosis. Surgical treatment is the only curative method at present, and the common approaches include enuclea tion, partial pancreatic resection, resection of the body and tail of pancreas and duodenum-preserving pancreatic head resection.Most patients with sporadic insulinoma had long-term survival after the surgery. For insulinoma patients with multiple endocrine neoplasia type 1, an aggressive surgical approach is recommended.     

Role of intraoperative ultrasonography in the surgical management of insulinomas

The findings in 35 surgically treated patients with insulinoma and 43 tumors of these patients were analyzed to confirm the efficacy of diagnostic modalities and surgical interventions. The rate of accurate preoperative tumor localization was 72% by angiography, 53% by computed tomographic scan, 55% by ultrasonography, and 83% by percutaneous transhepatic portal vein sampling. Extensive operative exposure and palpation detected 81% of the tumors and intraoperative ultrasonography demonstrated 96% of the tumors. Intraoperative ultrasonography was significantly better than any other diagnostic procedure and was able to demonstrate the anatomical relationship of the insulinoma to the essential structures of the pancreas. Intraoperative ultrasonography also helped determine the safest route for enucleating the insulinomas. Five patients (14%) in our series had metastatic diseases; 2 of these patients with metastases beyond the lymph nodes died due to the growth of tumors. The other 33 patients were free of insulinoma syndrome after the removal of the insulinomas. Streptozotocin was used in 1 patient with recurrent malignant insulinoma, with encouraging results.     

Recent advances in minimally invasive pancreatic surgery

For curative resection of pancreatic endocrine tumours, minimally invasive methods of pancreatic surgery, such as laparoscopy, should be indicated only for benign tumours. Among these uncommon tumours, pancreatic insulinomas are mostly benign and solitary. Successful management of patients with insulinomas relies on accurate localization of the tumour and the use of appropriate surgical techniques. Because of the small size of these tumours, conventional intraoperative ultrasonography combined with palpation has been widely regarded as the best localization procedure. Because contact ultrasonography, a new technique for localization of pancreatic lesions, can be used laparoscopically, several surgeons have used laparoscopy not only for localization, but also for resection of insulinomas. In the era of minimally invasive surgery for benign pancreatic lesions, we attempted laparoscopic-focused exploration of the pancreas for resecting insulinomas based on preoperative localization. We describe the use of this technique for the detection and resection of insulinomas and the results obtained, with a review of previous reports.     

31例胰岛细胞瘤诊治的回顾性分析

目的 总结分析胰岛细胞瘤的临床特点,探讨其诊断治疗方法.方法 对湖北医药学院附属太和医院10年间收治的31例胰岛细胞瘤患者的临床特点、诊断和治疗方法进行回顾性分析总结.结果 31例患者中,功能性胰岛细胞瘤占26例,无功能性5例;前者的主要表现为各种各样的低血糖症状,均有典型的Whipple三联征;后者主要是腹部包块就诊...     

胰岛素瘤误诊探讨和诊治--附17例报告

目的　探讨避免胰岛素瘤误诊 ,总结诊疗体会。方法　回顾性分析 1984～ 2 0 0 3年 12月收治的 17例胰岛素瘤的临床资料。结果　本组患者从发病到确诊 1～ 10年 ,平均 2 .5 4年 ,一年内确诊着 3例。占 17.6 4 % ,均有被误诊病史 ,最常见的误诊原因分别是反应性低血糖 (占 4 7.0 5 % )、癫痫、颅内病变。 5 2 .94 % (9/ 17)在确诊时有智力减退或反应迟钝 ,Whipple三联征 [胰岛素与血糖比值(I/G) >0 .3]。CT、MRI、术前B超、术中B超 (IOUS)诊断 ,均行手术治疗。其中肿瘤剜除术 9例 ,胰体尾切除 5例 ,楔形切除 3例 ,全组无手术死亡 ,术后无低血糖发作。术后胰瘘 2例。结论　Whipple三联征I/G >0 .3是胰岛素瘤定性诊断的主要依据。术前MRI、B超 ,术中详尽扪诊联合IOUS可取得较为满意的定位诊断 ,据胰岛素瘤大小、部位、数目采取适宜的手术方式是良好疗效的关键。     

胰岛素瘤的诊断和外科治疗

目的探讨胰岛素瘤的诊断和外科治疗方法。方法回顾性分析经手术和病理确诊的55例胰岛素瘤患者的临床资料。结果 7例为无功能性,48例(87.27%)功能性胰岛素瘤均有典型的Whipple三联征表现,且血胰岛素/血糖比值(IRI/G)0.3。术前超声,CT,MRI,内镜超声(EUS),术中超声和选择性动脉造影(DSA)诊断的阳性率分别为83.64%(46/55),62.07%(18/29),40.00%(4/10),100%(8/8),90.00%(9/10)和40.00%(2/5)。胰岛素瘤剜除术48例次,胰体尾切除术5例,胰体尾联合脾切除术3例,胰腺中段切除术1例,胰十二指肠切除术1例;肿瘤直径小于或等于2 cm者占95.00%(57个)。23.33%(14个)的肿瘤位于胰头部,33.33%(20个)位于胰体部,43.33%(26个)位于胰尾部,3例(5.46%)为多发性肿瘤。病理诊断均为胰岛素瘤,无恶性者。术后无低血糖症状发作,发生胰瘘1例。结论 Whipple三联征和IRI/G0.3可作为胰岛素瘤定性诊断的依据。联合应用超声,CT,MRI和内镜超声多种方法进行术前定位。内镜超声在胰岛细胞瘤定位诊断中的阳性率最高;术中超声是有效的定位方法。肿瘤剜除术是胰岛素瘤的最佳治疗方法。     

胰岛素瘤诊治分析：附72例报告

目的:探讨胰岛素瘤的诊断和外科治疗方法。方法:回顾性分析我院31年余诊治的72例胰岛素瘤的临床资料。结果:84.72%有典型的Whipple三联征表现。80.56%血浆免疫反应性胰岛素/血糖(IRI/G)比值>0.3。术前定位诊断方法的阳性率分别为:腹部超声78.13%,CT(平扫或增强)60.97%,多排螺旋CT胰腺灌注100%,MRI 37.50%,内镜超声(EUS)72.73%,选择性动脉造影(DSA)28.57%。术中超声联合扪诊诊断阳性率92.31%。肿瘤最大直径≤2 cm者占88.75%。37.5%的肿瘤位于胰头颈部,27.50%位于胰体部,35.0%位于胰尾部。81.58%的病例可行胰岛素瘤局部剜除术。病理诊断均为胰岛素瘤,65例(90.28%)为功能性胰岛素瘤,7例(9.72%))为无功能性胰岛素瘤;4例(5.56%)为多发性肿瘤,2例(2.78%)恶性倾向,1例(1.39%)合并多发性内分泌肿瘤1型(MEN-1)。结论:Whipple三联征和IRI/G>0.3可作为胰岛素瘤定性诊断的主要依据。应联合应用超声,CT,多排螺旋CT胰腺灌注,MRI,内镜超声和DSA多种方法进行术前定位。术中超声联合扪诊是简单有效的定位诊断方法。肿瘤的局部剜除术是多数胰岛素瘤的最佳手术治疗方式。     

Role of intraoperative insulin monitoring in surgical management of insulinoma

BACKGROUND AND PURPOSE: Precise localization and surgical excision is the therapeutic strategy for insulinomas. However, it is often difficult to localize the insulinomas, because of their small size. Surgeons may not localize and remove all of them together, particularly in patients with multiple insulinomas. We reviewed our experience to confirm the efficacy of blood glucose and intraoperative immunoreactive insulin (IRI) monitoring for surgical management of insulinomas. PATIENTS AND METHODS: Thirty-nine patients with insulinoma were surgically treated in our department. Perioperative blood glucose monitoring was performed in 14 patients, intraoperative quick IRI assay of the peripheral blood in 10 patients, and assay of a portal sample in 4 patients by an IMX analyzer. RESULTS: Rebound response of blood glucose to insulinoma removal was not always noted (8/14; 57%). Seven of ten patients showed a decrease of peripheral serum IRI levels within 15 minutes after removal of the insulinoma. The other two patients showed a rebound response of peripheral blood glucose or portal IRI. All the patients who had intraoperative monitoring of peripheral blood and peripheral and portal IRI had no recurrent insulinoma syndrome after surgical removal of their insulinomas. CONCLUSION: Combined monitoring of peripheral blood glucose and peripheral and portal IRI are helpful in the surgical management of insulinomas, as they can indicate that no insulinoma remains.     

Preoperative localization of insulinomas is not necessary.

BACKGROUND: Insulinomas are infrequent but are important to recognize and surgically remove. Several diagnostic tests have been used to increase the chances of operative success. The value of preoperative testing for insulinomas is the subject of this review. STUDY DESIGN: All patients treated at the Cleveland Clinic for insulinoma between 1985 and 1995 were retrospectively reviewed. All patients had biochemical evidence of primary hyperinsulinemia. RESULTS: There were 21 patients, 10 men and 11 women, with a median age of 58 years. Eighteen patients (85%) had a single insulinoma, two patients (10%) had multiple insulinomas, and one patient (5%) had nesidioblastosis. In addition, two patients (10%) had malignant insulinoma. A total of 13 patients (62%) had successful preoperative localization of their tumors, and all of these were found during exploration either by the surgeon (12 patients) or by intraoperative ultrasonography (1 patient). The remaining eight patients (38%) did not have their lesion localized by preoperative tests. In seven patients these tumors were found at operation, three by the surgeon and four by intraoperative ultrasonography. One patient failed preoperative and intraoperative localization and was later diagnosed with nesidioblastosis. Enucleation was performed in 13 patients and distal pancreatectomy in 7; the patient with nesidioblastosis had a negative laparotomy and a subsequent distal pancreatectomy. The mortality and morbidity rates were 0% and 14%, respectively. Only two patients, including the patient with nesidioblastosis, remained symptomatic after operation. CONCLUSIONS: The diagnosis of an insulinoma does not require extensive localization studies before operation. The combination of surgical exploration and intraoperative ultrasonography identified more than 90% of insulinomas. When technically feasible, enudeation is curative and can be accomplished with low morbidity.     

Blind distal pancreatectomy for occult insulinoma,an inadvisable procedure

BACKGROUND:

Fasting hypoglycemia with neuroglycopenic symptoms corrected by administration of glucose are the hallmarks for the diagnosis of insulinoma. Surgical resection is the treatment of choice for insulinomas, but localization of these lesions can be challenging. Blind distal pancreatectomy has been advocated for occult insulinomas not detected on imaging studies or during abdominal exploration. With the advent of newer localization techniques, we challenge the wisdom of this approach.

STUDY DESIGN:

The records of patients (multiple endocrine neoplasia excluded) with pathologically proved insulinoma who were screened at our institution or referred to us after a failed blind distal pancreatectomy were reviewed. All records included patient history and results of physical examination and routine blood and urine tests. The diagnosis of insulinoma was confirmed during a supervised fast. Patients with biochemically proved insulinoma underwent localization studies and operation. Studies included CT scans, MRI, transabdominal ultrasound, intraoperative ultrasonography, angiography (more recently, Ca⁺⁺-stimulated arteriography), and venous sampling.

RESULTS:

From 1970 to 2000, 99 patients (34 men, 65 women; mean age 43 years) underwent operation. All patients with benign tumors (92) were cured after operation. Seventeen patients were referred to the NIH after a failed blind distal pancreatectomy. Of these, 5 were diagnosed as having factitious hypoglycemia. In the other 12 patients a tumor was localized in the pancreatic head. Two patients incorrectly diagnosed with nesidioblastosis after initial surgery were subsequently cured by resection of an insulinoma.

CONCLUSIONS:

The use of preoperative imaging studies, most notably Ca⁺⁺-stimulated arteriography, and intraoperative ultrasonography permits detection of virtually all insulinomas, including reoperated cases. When a tumor is not detected, the procedure should be terminated and the patient referred to a center capable of performing advanced preoperative and intraoperative localization techniques. With the preoperative and intraoperative imaging strategies currently available, the use of blind distal pancreatectomy for occult insulinoma should be abolished.     

Laparoscopic detection and resection of insulinomas

BACKGROUND: Laparoscopic ultrasonography as a diagnostic tool for the localization of islet cell tumors has been described before, but few reports on laparoscopic resection of insulinomas exist. We retrospectively reviewed the results of our experience with laparoscopic detection and the resection of insulinomas to determine its feasibility. METHODS: Between February 1996 and February 1999, 10 patients underwent operation for organic hyperinsulinism at our institution. Patient and clinical characteristics were studied retrospectively. Laparoscopic ultrasonography was performed to localize the insulinoma and then laparoscopic resection was performed. RESULTS: Eight women and 2 men underwent operation for hyperinsulinism. In 6 patients the insulinoma could be resected laparoscopically, either by enucleation (5 patients) or by resection of the pancreatic tail (1 patient). Four procedures were converted to laparotomy for the proximate location of the insulinoma to the portal vein or pancreatic duct (3 procedures) and failure to identify the insulinoma (1 procedure). The overall success rate of preoperative localization of an insulinoma with the use of various imaging techniques was 60% (6/10 patients). Laparoscopic ultrasonography could identify an insulinoma in 90% of the patients (9/10 patients). The median hospital stay was 7 days. CONCLUSIONS: Laparoscopic ultrasonography followed by laparoscopic removal of the insulinoma in patients with clinically manifested hyperinsulinism is a feasible and safe technique with low morbidity and fast postoperative recovery. Preoperative localization studies appear of limited value.     

Laparoscopic ultrasonography for resection of insulinomas.

BACKGROUND: There have been few reports on the use of laparoscopic ultrasonography as an aid for the resection of insulinomas. In this study, we review our experience with laparoscopic ultrasonography for the intraoperative localization and resection of insulinomas. METHODS: We attempted laparoscopic resection of insulinomas in 7 patients (median age, 50 years) during a 4-year period. Preoperative imaging showed that 1 of the insulinomas was located in the head of the pancreas, 2 were located in the body, and 4 were located in the tail. RESULTS: We identified the insulinomas in all 7 patients with laparoscopic ultrasonography. In 6 of the patients, the insulinomas were laparoscopically resectable, either by enucleation (4 patients) or by resection of the pancreatic tail (2 patients). Conversion to laparotomy was necessary for the insulinomas in the head of the pancreas because they were close to the portal vein and the major pancreatic duct. All patients showed improvement in their hypoglycemia after the operations. Minor leakage of pancreatic juice occurred in 4 patients, and this was resolved with conservative treatment. CONCLUSIONS: Laparoscopic ultrasonography is useful for the intraoperative localization of insulinomas. Laparoscopy is a safe and feasible technique for resecting insulinomas located in the body or tail of the pancreas.     

Peri-operative management of a patient with insulinoma. A case report

Insulinoma is a rare tumour of the islet cells of the pancreas and was first described by Harris in 1924. It can be benign or malignant. This report emphasizes the medical, surgical and anaesthetic aspects of the treatment in a case of insulinoma.