Abstract
Occult insulinomas are adenomas not visualized by routine preoperative imaging studies, including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and arteriography. Reliance for detecting occult insulinomas has been placed on portal venous sampling (PVS), a sensitive (> 75%) but invasive procedure that requires considerable experience to enable sampling of small veins about the pancreatic head. For the past 2 years we have attempted to localize insulinomas by stimulating the release of insulin with a selective intraarterial injection of calcium gluconate and sampling for insulin gradients in the hepatic veins. This study replaces PVS by indicating the region of the pancreas within which the tumor lies, although, like PVS, it does not directly visualize the tumor. Our experience in 9 patients with surgically proved insulinomas is reviewed, comparing the results with PVS as well as with US, CT, MRI, and arteriography.
Résumé
Les insulinomes occultes sont des adénomes sécrétant l'insuline qui ne sont par détectés par l'imagérie préopératoire habituelle comme l'échographie (EG), la tomodensitométrie (TDM), la résonance magnétique nucléaire (RMN) et l'artériographie. Par le passé, on a beaucoup compté sur les résultats du dosage de l'insuline dans le sang porte, un examen sensible (> 75%) mais invasif, nécessitant une technique particulière pour prélever des échantillons sanguins dans les veines de petite taille de la tête du pancréas. Pendant ces deux dernières années, nous avons essayé de stimuler la sécrétion d'insuline par l'injection intra-artérielle sélective de gluconate de calcium et de mesurer le gradient d'insuline dans les veines sus-hépatiques. Cette méthode remplace le dosage porte pour localiser la lésion dans le pancréas mais, tout comme le dosage du système porte, ne visualise pas la tumeur directement. Notre expérience de cette technique utilisée chez 9 patients ayant un insulinome retrouvé chirurgicalement est comparée aux résultats obtenus par le dosage veineux porte, l'EG, la TDM, la RMN et l'artériographie.
Resumen
Los insulinomas ocultos son adenomas no visibles en las imágenes rutinarias preoperatorias; éstas incluyen ultrasonido (US), tomografía computadorizada (CT), resonancia magnética (MRI) y arteriografía. En el pasado se utilizó el muestreo de sangre venosa portal, un procedimiento de buena sensibilidad (>75%), pero tedioso y de carácter invasivo, que exigía considerable experiencia para lograr el muestreo de las pequeñas venas que circundan la cabeza del páncreas. En los últimos dos años hemos tratado de localizar los insulinomas mediante el estímulo de la liberación de insulina por medio de la inyección intraarterial selectiva de gluconato de calcio y el muestreo a nivel de las venas hepáticas para determinar gradientes en la concentración de insulina.
El estudio reemplaza el muestreo venoso portal al indicar la región del páncreas donde reside el tumor, aunque, al igual que el muestreo venoso portal, no visualiza el tumor. Nuestra experiencia en 9 pacientes con insulinomas comprobados en la cirugía es revisada, para comparar los resultados con los del muestreo venoso portal, la US, la CT, la MRI y la arteriografía.
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Doppman, J.L., Miller, D.L., Chang, R. et al. Intraarterial calcium stimulation test for detection of insulinomas. World J. Surg. 17, 439–443 (1993). https://doi.org/10.1007/BF01655101
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DOI: https://doi.org/10.1007/BF01655101