Laparoscopic ultrasound enhances diagnosis and localization of insulinoma in pancreatic head and neck for laparoscopic surgery with satisfactory postsurgical outcomes

This study explored the value of laparoscopic ultrasonography (LUS) for tumor localization in laparoscopic pancreatic surgery of insulinomas, especially for tumors located at anatomically unfavorable positions. Twenty-eight patients with insulinomas were enrolled in this study between July 2007 and March 2009. Various image examinations were performed preoperatively. An iU22 ultrasound system equipped with a 5.0-9.0 MHz transducer was used for LUS. The tumor localization and postsurgical outcomes were evaluated. Intraoperative LUS precisely localized 33 insulinomas in 26 of 28 patients, whereas the preoperative imaging studies detected 27 of 33 (82%) tumors. No definite tumor in the pancreas and extra-pancreatic organs was identified in two patients by both preoperative and intraoperative imaging examinations. Of 33 tumors, 32 (97%) were localized in the pancreas (14 in the head and neck, 18 in the body and tail), whereas one (3%) was found in the duodenal ligament. Successful laparoscopic resection of insulinoma was performed in 21 of 26 patients, including resection of 11 tumors located in the head and neck of the pancreas. Five patients required conversion to open surgery. All insulinomas were benign with a mean size 13.8 mm. Four patients had pancreatic-related complications that spontaneously healed within 3 weeks after surgery. The median hospital stay was 8.5 days. Our study demonstrates that laparoscopic pancreatic resection under the guidance of advanced LUS is not only feasible and safe for tumors located at the body and tail but also for tumors located at the head and neck of the pancreas.     

术中超声在胰岛素瘤定位诊断中的价值

目的 探讨术中超声在胰岛素瘤定位诊断中的价值。方法 对２８例胰岛素瘤患者的术前Ｂ超,ＣＴ,ＭＲＩ和选择性动脉造影检查的定位资料进行分析,统计了术中超声与术中门诊,术中脾门静脉穿刺置管分段取血快速胰岛素测定（ＰＶＳ）３种方法对胰岛素瘤的定位准确率,并进行了比较研究。     

胰岛素瘤定位方法的比较研究

目的　探讨胰岛素瘤术前术中定位方法的诊断价值。方法　对 3 0例胰岛素瘤患者的术前B超、CT、MRI和选择性动脉造影 (DSA)检查的定位资料进行分析 ,统计了术中超声 (IOUS)、术中触诊、术中脾门静脉穿刺置管分段取血快速胰岛素测定 (PVS)三种方法对胰岛素瘤的定位准确率 ,并进行了比较研究。结果　超声、CT、MRI和DSA对胰岛素瘤的术前定位准确率分别为 3 0 .0 %、3 3 .3 %、41.7%、60 .0 % ,而IOUS ,术中触诊和术中PVS的定位准确率分别为 93 .3 %、80 .0 %和 92 .9%。结论　术中三种定位方法明显提高了胰岛素瘤的定位准确率 ,IOUS不但对胰岛素瘤的定位准确率高 ,而且可以清楚显示肿瘤与周围重要结构如主胰管、胆总管及血管的关系 ,帮助外科医生选择手术方法、降低术后并发症     

Insulinoma in a patient with annular pancreas

Intraoperative ultrasonography has facilitated the localization of insulinomas. In this report, we describe a patient who was found to have an insulinoma in association with an annular pancreas. Because such tumors can be in close approximation to major pancreatic ductal structures, intraoperative ultrasonography can be useful for not only localizing the lesion but also delineating the related anatomic features. Although the optimal management of an asymptomatic annular pancreas has not been determined, our patient had no evidence of chronic pancreatitis and no narrowing of the duodenal lumen; therefore, no bowel bypass procedure was done.     

胰岛素瘤的诊断和外科治疗32例临床分析

目的 探讨胰岛素瘤的诊断及外科治疗方法.方法 回顾性分析我院收治的32例胰岛素瘤患者的临床资料,行单纯肿瘤摘除术19例,胰体、尾切除术10例,胰十二指肠切除术3例.结果 32例患者术前经腹部B超及增强螺旋CT初步诊断和定位20例,术中超声定位12例.肿瘤位于胰头部9例,胰体部15例,胰尾部8例.32例患者术后临床症状消失,包括2例胰瘘.术后病理示良性28例,恶性4例.结论 胰岛素瘤的主要临床表现为典型的Whipple三联征.根据临床表现和实验室检查行术前定性诊断不难,联合影像学检查有助于提高检出率,术中探查和术中B超是定位的主要手段.手术方式需根据肿瘤部位、大小、数目及深浅等情况具体决定.     

Insulinoma: the value of intraoperative ultrasonography

Ideally, surgical exploration for insulinomas would be met with uniform success in both finding and removing the tumor, incurring no postoperative mortality or morbidity. In reality, however, insulinomas remain undetected by even experienced surgeons in 10 to 20% of patients, including present-day series. Additionally, postoperative complications may occur in 10 to 25% of patients, principally related to the pancreatic dissection. Although dispensing with any attempt to preoperatively localize the tumor has been advocated, most authors agree that localization efforts are necessary and helpful. To review the results and surgical implications of current localization techniques, 41 adult patients who were surgically treated for insulinomas at the Mayo Clinic from 1980 through June 1987, were reviewed. Tumor size ranged from 5 mm to 4 cm, and the sensitivity of tumor localization using arteriography, computed tomography, preoperative and intraoperative ultrasonography were 55%, 27%, 59%, and 90%, respectively. Since the introduction of intraoperative ultrasonography into our clinical practice in 1982, all 29 of our adult patients' insulinomas have been identified with a combination of this technique and palpation by an experienced surgeon. There were no false positive interpretations with intraoperative ultrasonography, and tumors were imaged in four patients that were not palpable. In 18 of these 29 (62%) patients, the information gleaned from the images appeared to influence the surgical management. While there is no substitute for exploration by an experienced surgeon, his ability is enhanced by the addition of both preoperative and intraoperative ultrasonography.     

Imaging of gastrointestinal neuroendocrine tumors

Gastrointestinal neuroendocrine tumors are rare neoplasms that cause classic clinical syndromes because of the excess secretion of specific gastrointestinal hormones. The two most important tumors clinically are insulinomas and gastrinomas. The clinical management of patients with these disorders usually involves the localization and surgical removal of the responsible tumor. Many radiological techniques can be used for tumor localization, including preoperative and intraoperative ultrasound, endoscopic ultrasound, CT, MRI, radionuclide scanning, angiography, and venous sampling. However, there are conflicting claims as to the relative accuracy of these procedures, and many of these investigations are difficult to justify because of their high cost, degree of invasiveness, or lack of precise anatomic information that is obtained. If surgical resection of a neuroendocrine tumor is planned, intraoperative sonography should always be used to detect occult nonpalpable tumors and to discern the relationship of the tumor to vital adjacent pancreatic ductal anatomy. The choice of preoperative imaging is more controversial, and depends on the clinical problem, local expertise, and availability of imaging techniques. Sonography and contrast-enhanced helical CT are the most commonly used preoperative imaging methods, because of their relatively low cost and widespread availability. Radionuclide scanning with a somatostatin analogue, which is a relatively new procedure, may be valuable in patients with symptoms of tumor recurrence.     

Preoperative localization of pancreatic insulinoma by super selective arterial stimulation with venous sampling

Although most insulinomas are small, they have been successfully detected by computed tomography and magnetic resonance imaging recently. However, preoperative localization of the insulinomas by arterial stimulation with venous sampling is crucial when they show atypical findings on these imaging modalities. We report a case of a large benign insulinoma located at the pancreatic tail; this tumor was diagnosed correctly by super selective arterial stimulation with venous sampling.     

The importance of preoperative localisation procedures in organic hyperinsulinism — Experience in 67 patients

BACKGROUND: Preoperative localisation of insulinomas has been regarded unnecessary, given the significantly higher detection rates of intraoperative ultrasonography and bidigital palpation. These are mandatory before endoscopic surgery. METHODS: 67 patients operated on for organic hyperinsulinism were retrospectively analysed regarding tumour localisation within the pancreas, tumour size, histological findings, sensitivities of preoperative imaging methods, and surgical techniques. RESULTS: 59 patients (88%) had solitary insulinomas, four patients (6%) multiple insulinomas and four adult patients (6%) nesidioblastosis. Well-differentiated neuroendocrine tumours with benign behaviour (including four patients with nesidioblastosis) were diagnosed in 53 patients (79%), tumours with uncertain behaviour in nine patients (13%) and well-differentiated neuroendocrine carcinomas in five (8%). Tumours were evenly distributed throughout the pancreas. Endoscopic ultrasound localised tumours in 15 out of 21 patients (71%), conventional computed tomography (CT) in 7 out of 21 (33%), single-slice helical CT in 7 out of 12 (58%), multidetector CT in 5 out of 5 (100%), magnetic resonance imaging in 11 out of 13 (85%) and angiography in 15 out of 23 (65%). Various combinations of available methods achieved a sensitivity of 88% (49 patients true positive, 4 true negative, 7 false negative). Of 59 patients, solitary insulinomas were enucleated in 47 (80%), 11 patients underwent conventional open resection and one patient endoscopic distal pancreatic resection. Patients with nesidioblastosis or multiple tumours underwent pancreatic resections alone or in combination with enucleations. CONCLUSION: After biochemical diagnosis of organic hyperinsulinism, preoperative localisation is necessary for planning endoscopic pancreatic surgery, because of the possibility of multiple insulinomas, malignancy or nesidioblastosis in adults.     

Laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for pancreatic duct stone: A case report and review of literature

To study a more micro-invasive procedure for patients having pancreatic duct stones (PDS). Till now, there has been no report of laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for PDS in the English literature. An 82-year-old man suffered from subxiphoid pain associated with a dilated pancreatic duct (7 mm) containing one stone, but without a mass in the head of the pancreas. Laparoscopic pancreatic duct incision, stone removal, and T-type tube drainage were successfully performed without intraoperative or postoperative complications. An uneventful operation was performed with laparoscopically completed procedures in 160 min. The intraoperative loss of blood was around 50 mL. After patient a discharge on day 11, complete relief from the subxiphoid pain was reported at a follow-up visit 15 mo later. Laparoscopic pancreatic duct incision with stone removal and T-type tube drainage is applicable in carefully selected patients and can be effectively and safely used for the treatment of the abdominal pain of chronic pancreatitis.     

Endosonography in decision making and management of gastrointestinal endocrine tumors.

OBJECTIVE: gastroenteropancreatic (GEP) neuroendocrine tumors, suspected on clinical basis, are often difficult to localize. We report our experience with endoscopic ultrasonography (EUS) in the preoperative localization of pancreatic endocrine tumors (PETs), compared to other imaging modalities, and in staging and following up carcinoid tumors (CTs) of the gastrointestinal (GI) wall. METHODS: 50 patients (20 males; mean age 54 years), 39 with suspected PETs and 11 with GI CTs underwent EUS (Olympus GF-UM2 or GF-UM3). EUS data could be compared with resected specimens in 25 out of the 39 PETs and five out of the 11 CTs. RESULTS: in the PETs group 42 tumors (35<20 mm) were removed: 23 in the pancreas, eight in the duodenum, and 11 in the lymph nodes. EUS correctly localized 20 out of the 23 (87%) pancreatic tumors, included 11 out of the 12 (91.6%) insulinomas, three out of the eight (37.5%) duodenal gastrinomas, and ten out of the 11 (90.9%) metastatic lymph nodes. Furthermore EUS accurately evaluated the depth of parietal invasion of CTs in three out of four patients (75%) (two after and one prior to endoscopic resection). In three patients EUS was confirmed as normal on resected specimens (two pancreas and one stomach). In the PETs group, a correct localization was obtained by ultrasonography (US) only in 17.4% of cases, by computed tomography (CT) in 30.4%, by magnetic resonance imaging (MRI) in 25%, by angiography in 26.6%, and by somatostatin receptor scintigraphy in 15.4%. CONCLUSION: EUS must be considered the first-intention method in localizing PETs and is helpful in decision making and management of GEP endocrine tumors.     

Insulinoma: correlation of short-TI inversion-recovery (STIR) imaging and histopathologic findings

We studied the value of short-TI inversion-recovery (STIR) imaging for the localization of pancreatic insulinoma. Four patients (three women and one man aged 35–65 years) with surgically proven insulinoma were included in this study. All patients were examined by MR imaging with spin echo (SE) and STIR sequences. The STIR images were compared with the histopathologic findings in each case. In two patients, the tumors were markedly hyperintense on STIR images, and a 5-mm insulinoma was depicted only by this imaging method in one of the two. In the other two patients, 10-mm insulinomas were only slightly hyperintense on STIR images. The latter tumors had a higher content of collagen fibers than the former, indicating that the amount of collagen influences the signal intensity of insulinoma. Despite some limitations, STIR imaging is a useful noninvasive method for the localization of pancreatic insulinoma. Received: 11 October 1994/Accepted after revision: 10 April 1995     

Value of diagnostic localization of insulinoma

The value of diagnostic localization of insulinoma The value of diagnostic localization statements are contradictory. Basing on our own patient material (n = 41) the preoperative localization of an insulinoma was correct with sonography in 57.7%, with computed tomography in 21.4%, with computed tomography with bolus injection of contrast medium in 73.3%, with angiography 63.9% and with percutaneous transhepatic portal vein catheterisation with selective test of hormones (PTP) in 76.9%. Intraoperative 38 of 41 insulinomas were palpable and twelve of 16 insulinomas were seen during intraoperative sonography. Although we palpate more than 90% of all insulinomas we support a preoperative diagnostic localization for easier intraoperative palpation.     

胰腺CT可评估腹腔镜胰十二指肠切除术治疗胰头恶性肿瘤的效果

  目的  探讨腹腔镜胰十二指肠切除术对治疗胰头恶性肿瘤的效果，分析手术前后胰腺影像学特点。  方法  选取本院2020年1月~2021年6月收治的胰头恶性肿瘤患者110例，按手术方法的不同将患者分为两组，观察组:采用腹腔镜十二指肠切除术(n=61); 对照组:采用开腹十二指肠切除术(n=49)。分析两组患者围手术期指标、手术切除的完整性、炎性反应，并发症的发生率、术前与术后胰腺影像学特点。  结果  两组患者手术时间、手术切除的完整性及并发症的发生率差异无统计学意义(P > 0.05)，观察组术中出血量和住院时间均低于对照组，差异有统计学意义(P < 0.05); 观察组血清C-反应蛋白、白介素-6、肿瘤坏死因子-α水平低于对照组(P < 0.05); 术前CT显示胰头部可见不规则囊状低密度影，边缘分叶、内分隔、密度欠均匀，增强边界较清楚，术后有患者可见术区范围包裹性积液、局部密度稍高。  结论  腹腔镜胰十二指肠切除术治疗胰头恶性肿瘤可以减轻机体炎性反应，降低术中出血和缩短住院时间，其手术切除的完整性与开腹手术相当，且借助CT术前影像能有效指导手术过程和识别术后胰瘘等并发症。      

Successful laparoscopic distal pancreatectomy for a large solid pseudopapillary neoplasm: A case report

A 30‐year‐old Japanese woman presented at our hospital with a pancreatic tumor. Contrast‐enhanced CT revealed a tumor with a 12‐cm diameter in the pancreatic body and tail. In the preoperative setting, endoscopic ultrasound‐guided fine‐needle aspiration permitted a histopathological diagnosis of solid pseudopapillary neoplasm. Twhe patient underwent laparoscopic distal pancreatectomy with splenectomy. Our procedure involved three steps. Firstly, the splenic artery was occluded to block inflow of blood to the tumor. Then, we transected the neck of the pancreas using radical antegrade modular pancreatosplenectomy. Finally, hand‐assisted laparoscopic surgery allowed us to secure the operating field and easily handle the large tumor. This enabled us to accomplish laparoscopic distal pancreatectomy, and en‐bloc resection was completed. The patient was discharged without major complications. Laparoscopic distal pancreatectomy for huge solid pancreatic tumors can be completed safely.     

Minimally invasive surgery: hepatobiliary-pancreatic and foregut

This review is confined to the liver, biliary tract, pancreas, and foregut (oesophagus and stomach). The issues relating to laparoscopic cholecystectomy mainly concern the bile duct injuries associated with this operation. This review provides some evidence that although the risk for this iatrogenic injury is declining, it continues to be a problem and is accompanied by significant morbidity, mortality, and a huge escalation in care costs. Laparoscopic clearance of ductal stones is undoubtedly safe and effective, and issues have now focused on comparisons between this form of management and orthodox endoscopic clearance. Laparoscopic cardiomyotomy may well replace other forms of treatment of achalasia, including balloon dilation and botulinum toxin injection. As the results of laparoscopic antireflux surgery have been so good in the medium term, the question of medical versus laparoscopic treatment is being addressed by two randomized clinical trials. Gastric resection is established only in respect of excision of mesenchymal tumours. Gastric surgery for advanced gastric cancer must still be regarded as developmental. Laparoscopic liver resections and in situ ablation are still confined to developing centres, but the early results are promising. However, simpler hepatic procedures, such as de-roofing of symptomatic simple hepatic cysts, are well established and in widespread practice. Only a few centres have published their results on laparoscopic pancreatic surgery. The early reported outcome for internal drainage of pancreatic pseudocysts, enucleation of benign insulinomas, and distal pancreatic resections has been good, but the experience is limited.     

A Prospective Clinical Trial to Determine the Effect of Intraoperative Ultrasound on Surgical Strategy and Resection Outcome in Patients with Pancreatic Cancer

Surgical exploration in patients with pancreatic or periampullary cancer is often performed without intraoperative image guidance. Although intraoperative ultrasound (IOUS) may enhance visualization during resection, this tool has not been investigated in detail until now. Here, we performed a prospective cohort study to evaluate the effect of IOUS on surgical strategy and to evaluate whether vascular involvement and radicality of the resection could be correctly assessed with IOUS. IOUS was performed by an experienced abdominal radiologist during surgical exploration in 31 consecutive procedures. IOUS affected surgical strategy by either (i) having no effect, (ii) determining tumor localization, (iii) evaluating vascular involvement or (iv) waiving surgery. Radicality of the resections and vascular contact were determined during pathologic analysis and compared with preoperative imaging and IOUS findings. Overall, IOUS influenced surgical strategy in 61% of procedures. In 21 out of 27 malignant tumors, a radical resection was achieved (78%). Vascular contact was assessed correctly using IOUS in 89% compared with 74% of patients using preoperative imaging. IOUS can help the surgical team to assess the resectability and to visualize the tumor and possible vascular contact in real time during resection. IOUS may therefore increase the likelihood of achieving a radical resection.     

Localisation and surgical treatment of insulinomas

Most insulinomas are solitary, benign and functional neuroendocrine pancreatic tumours which give rise to manifold symptoms. Their preoperative localisation is often unclear, but the cure rate after their excision is very high. It was the aim of this study to analyse and evaluate our group of patients with regard to preoperative tumour localisation and overall surgical results. Twelve patients with a biochemical diagnosis of organic hyperinsulinism were surgically treated. Diagnosis was made with the combination of magnetic resonance imaging, computed tomography, selective angiography and intraoperative portal vein sampling. In five patients, the tumour was enucleated, in three patients Whipple procedure was performed; while three patients underwent left pancreatectomy with spleen preserving in two cases. The twelfth patient underwent total pancreatectomy following Whipple procedure performed elsewhere. There was no postoperative death. The complications were two pancreatic fistulas and two wound infections. The fasting pre- and postoperative plasma glucose mean value was 2.8 mm/l and 4.9 mm/l, respectively; while the pre- and postoperative plasma insulin mean value was 282 pm/l and 72 pm/l, respectively. Accurate diagnosis, preoperative localisation and diligent surgical exploration by experienced surgeons are the key to a successful outcome in patients with insulinomas.     

Intraoperative sonographic identification of nonpalpable pancreatic masses

Intraoperative ultrasonography has been used for diagnosis and guidance during surgical exploration in a variety of organ systems. Use of the technique in four patients who underwent surgical exploration of the pancreas is described. Two of the patients had bile duct dilatation suggesting pancreatic carcinoma, but had otherwise unremarkable conventional imaging studies and normal palpation of the surgically exposed organ. Both proved to have small cancers, identified by sonography. Two other subjects with known pancreatic pseudocysts had additional cysts imaged during the intraoperative examination.