Abstract
Introduction
Presently, the need for and choice of preoperative localization tests for insulinomas remain controversial. We report the results from a single institution experience whereby the management policy adopted was that of accurate preoperative localization before surgical exploration.
Materials and Methods
From 1990 to 2008, 17 patients with a clinical and biochemical diagnosis of an insulinoma who underwent surgery were retrospectively reviewed. The diagnosis of all insulinomas were confirmed pathologically.
Results
All tumors were localized preoperatively and an average of 2.2 preoperative localization studies including 1.4 noninvasive studies and 0.8 invasive studies were utilized per patient. Invasive localization modalities were more sensitive (92%) than noninvasive modalities in localizing insulinomas (71%). Intra-arterial calcium stimulation with hepatic venous sampling was the most sensitive invasive modality (100%), whereas magnetic resonance imaging was the most sensitive noninvasive modality (63%). Fifteen of 17 tumors (88%) were localized intraoperatively via inspection/palpation and/or intraoperative ultrasonography. Both insulinomas which were not localized intraoperatively were localized correctly to the distal pancreas via preoperative transhepatic portal venous sampling. None of the patients required a blind resection or surgical reexploration for failed localization. All 17 patients underwent complete surgical resection which included eight enucleations and nine distal pancreatectomies with a cure rate of 94% (16/17) at a median follow-up of 35 (range, 1–217) months. The postoperative morbidity and long-term outcome of enucleation was similar to distal pancreatectomy despite a higher rate of microscopic margin involvement.
Conclusion
Accurate preoperative localization of insulinomas is useful as it eliminates the need for blind distal pancreatectomy and avoids reoperation. Complete surgical resection is the treatment of choice, and whenever possible, a pancreas-sparing approach such as enucleation should be adopted.
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References
Service FJ, McMahon MM, O’Brien PC, Ballard DJ. Functioning insulinoma-incidence, recurrence, and long-term survival of patients: a 60-year study. Mayo Clin Proc 1991;66:711–719.
Liu H, Peng C, Zhang S, Wu Y, Fang H, Sheng H, Peng S. Strategy for the surgical management of insulinomas: analysis of 52 cases. Dig Surg 2007;24:463–470. doi:10.1159/000111822.
Tucker ON, Crotty PL, Conlon KC. The management of insulinoma. Br J Surg 2006;93:264–275. doi:10.1002/bjs.5280.
Lo CY, Lam KY, Kung AW, Lam KS, Tung PH, Fan ST. Pancreatic insulinomas: a 15-year experience. Arch Surg 1997;132:926–930.
Rothmund M, Angelini L, Brunt LM, Farndon JR, Geelhoed G, Grama D, Herfarth C, Kaplan EL, Largiader F, Morino E, et al. Surgery for benign insulinoma: an international review. World J Surg 1990;14:393–398. doi:10.1007/BF01658536.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13. doi:10.1016/j.surg.2005.05.001.
Heitz PU, Komminoth P, Perren A, et al. WHO histological classification of tumours of the endocrine pancreas. In DeLellis RA, Lloyd RV, Heitz PU, Eng C, eds. Pathology and Genetic Tumours of Endocrine Organs, 1st ed. Lyon, France: IARC, 2004, pp 177–182.
Nikfarjam M, Warshaw AL, Axelrod L, Deshpande V, Thayer SP, Ferrone CR, Castillo CF. Improved contemporary surgical management of insulinomas. A 25-year experience at the Massachusetts General Hospital. Ann Surg 2008;247:165–172.
Daggett PR, Goodburn EA, Kurtz AB, Le Quense LP, Morris DV, Nabarro JD. Is preoperative localization of insulinoma necessary. Lancet 1981;1:483–486. doi:10.1016/S0140-6736(81)91859-6.
Ravi K, Britton BJ. Surgical approach to insulinomas: are preoperative localization tests necessary. Ann R Coll Surg Engl 2007;89:212–217. doi:10.1308/003588407X179008.
Boukhman MP, Karam JM, Shaver J, Siperstein AE, DeLorimier AA, Clark OH. Localization of insulinomas. Arch Surg 1999;134:818–823. doi:10.1001/archsurg.134.8.818.
Pasieka JL, McLeod MK, Thompson NW, Burney RE. Surgical approach to insulinomas. Assessing the need for preoperative localization. Arch Surg 1992;127:442–447.
Paul TV, Jacob JJ, Vasan SK, Thomas N, Rajarathnam S, Selvan B, Paul MJ, Abraham D, Nair A, Seshadri MS. Management of insulinomas: analysis from a tertiary care referral center in India. World J Surg 2008;32:576–582. doi:10.1007/s00268-007-9390-y.
Guettier JM, Kam A, Chang R, Skarulis MC, Cochran C, Alexander HR, Libutti SK, Pingpank JF, Gorden P. Localization of insulinomas to regions of the pancreas by intra-arterial calcium stimulation: the NIH experience. J Clin Endocrinol Metab 2009 (in press).
Geoghegan JG, Jackson JE, Lewis MP, Owen ER, Bloom SR, Lynn JA, Williamson RC. Localization and surgical management of insulinoma. Br J Surg 1994;81:1025–1028. doi:10.1002/bjs.1800810733.
Hiramoto JS, Feldstein VA, LaBerge JM, Norton JA. Intraoperative ultrasound and preoperative localization detects all occult insulinomas. Arch Surg 2001;136:1020–1026. doi:10.1001/archsurg.136.9.1020.
Lo CY, Chan FL, Tam SC, Cheng PW, Fan ST, Lam KS. Value of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas. Surgery 2000;128:903–909. doi:10.1067/msy.2000.109729.
Richards ML, Gauger PG, Thompson NW, Kloos RG, Giordano TJ. Pitfalls in the surgical treatment of insulinoma. Surgery 2002;132:1040–1049. doi:10.1067/msy.2002.128610.
Schumacher B, Lubke HJ, Frieling T, Strohmeyer G, Starke AA. Prospective study on the detection of insulinomas by endoscopic ultrasonography. Endoscopy 1996;28:273–276. doi:10.1055/s-2007-1005452.
Van Heerden JA, Grant CS, Czako CS, Czako PF, Service FJ, Charboneau JW. Occult functioning insulinomas: which localizing studies are indicated? Surgery. 1992;112:1010–1014. doi:10.1007/s00268-004-7645-4.
Proye CA, Lokey JS. Current concepts in functioning endocrine tumors of the pancreas. World J Surg 2004;28:1231–1238. doi:10.1007/s00268-004-7645-4.
Simon D, Starke A, Goretzi PE, Roeher HD. Reoperative surgery for organic hyperinsulinism: indications and operative strategy. World J Surg 1998;22:666–671. doi:10.1007/s002689900450.
Placzkowski KA, Vella A, Thompson GB, Grant CS, Reading CC, Charboneau JW, Andrews JC, Lloyd RC, Service FJ. Secular trends in the presentation and management of functioning insulinoma at the Mayo Clinic, 1987–2007. J Clin Endocrinol Metab 2009. doi:10.1210/jc.2008-2031.
Berends FJ, Cuesta MA, Kazemier G, van Eijck CH, de Herder WW, van Muiswinkel JM, Bruining HA, Bonjer HJ. Laparoscopic detection and resection of insulinomas. Surgery 2000;128:386–391. doi:10.1067/msy.2000.107413.
Fernandez-Cruz L, Cesar-Borges G. Laparoscopic strategies for resection of insulinomas. J Gastrointest Surg 2006;10:752–760. doi:10.1016/j.gassur.2005.08.012.
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Goh, B.K.P., Ooi, L.L.P.J., Cheow, PC. et al. Accurate Preoperative Localization of Insulinomas Avoids the Need for Blind Resection and Reoperation: Analysis of a Single Institution Experience with 17 Surgically Treated Tumors over 19 Years. J Gastrointest Surg 13, 1071–1077 (2009). https://doi.org/10.1007/s11605-009-0858-y
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DOI: https://doi.org/10.1007/s11605-009-0858-y