Blind Distal Pancreatectomy for Occult Insulinoma, an Inadvisable Procedure1

Hirshberg, Boaz; Libutti, Steven K.; Alexander, H. Richard; Bartlett, David L.; Cochran, Craig; Livi, Andrea; Chang, Richard; Shawker, Thomas H.; Skarulis, Monica C.; Görden, Phillip

doi:10.1016/s1072-7515(02)01177-8

Cited by 106 publications

(63 citation statements)

References 15 publications

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“…The combination of SACS with EUS achieved tumor localization in all patients diagnosed in the period 1998-2007 at the Mayo Clinic, avoiding blind pancreatic exploration (28). Occult insulinomas are usually located within the pancreatic head (43,44). Given the associated morbidity and lack of surgical success, blind distal pancreatectomy and progressive pancreatectomy are not recommended in cases of occult insulinoma at the present time (26,44).…”

Section: Insulin-secreting Tumorsmentioning

confidence: 99%

“…Occult insulinomas are usually located within the pancreatic head (43,44). Given the associated morbidity and lack of surgical success, blind distal pancreatectomy and progressive pancreatectomy are not recommended in cases of occult insulinoma at the present time (26,44). Palpation and intraoperative ultrasonography (IOUS) permit detection of virtually all insulinomas, including reoperated cases (26,44,45).…”

Section: Insulin-secreting Tumorsmentioning

confidence: 99%

“…Given the associated morbidity and lack of surgical success, blind distal pancreatectomy and progressive pancreatectomy are not recommended in cases of occult insulinoma at the present time (26,44). Palpation and intraoperative ultrasonography (IOUS) permit detection of virtually all insulinomas, including reoperated cases (26,44,45). Lastly, the use of gamma-probe intraoperatively after 111 In-DOTA-exendin-4 administration permitted the detection and successful surgical removal of all insulinomas in a series of six patients, one of them with ectopic insulinoma (42).…”

Section: Insulin-secreting Tumorsmentioning

confidence: 99%

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MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

Iglesias

Díez

2014

European Journal of Endocrinology

139

144

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Tumor-induced hypoglycemia (TIH) is a rare clinical entity that may occur in patients with diverse kinds of tumor lineages and that may be caused by different mechanisms. These pathogenic mechanisms include the eutopic insulin secretion by a pancreatic islet b-cell tumor, and also the ectopic tumor insulin secretion by non-islet-cell tumor, such as bronchial carcinoids and gastrointestinal stromal tumors. Insulinoma is, by far, the most common tumor associated with clinical and biochemical hypoglycemia. Insulinomas are usually single, small, sporadic, and intrapancreatic benign tumors. Only 5-10% of insulinomas are malignant. Insulinoma may be associated with the multiple endocrine neoplasia type 1 in 4-6% of patients. Medical therapy with diazoxide or somatostatin analogs has been used to control hypoglycemic symptoms in patients with insulinoma, but only surgical excision by enucleation or partial pancreatectomy is curative. Other mechanisms that may, more uncommonly, account for tumor-associated hypoglycemia without excess insulin secretion are the tumor secretion of peptides capable of causing glucose consumption by different mechanisms. These are the cases of tumors producing IGF2 precursors, IGF1, somatostatin, and glucagon-like peptide 1. Tumor autoimmune hypoglycemia occurs due to the production of insulin by tumor cells or insulin receptor autoantibodies. Lastly, massive tumor burden with glucose consumption, massive tumor liver infiltration, and pituitary or adrenal glands destruction by tumor are other mechanisms for TIH in cases of large and aggressive neoplasias.

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Section: Insulin-secreting Tumorsmentioning

confidence: 99%

Section: Insulin-secreting Tumorsmentioning

confidence: 99%

Section: Insulin-secreting Tumorsmentioning

confidence: 99%

See 1 more Smart Citation

MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

Iglesias

Díez

2014

European Journal of Endocrinology

139

144

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“…Laparoscopic ultrasound can be now performed in many expert centres and can localize the insulinoma and evaluate its proximity with the pancreatic duct and the possibility of performing tumour enucleation. When no insulinoma was found intra-operatively, blind distal pancreatectomy had been recommended several years ago, but to date, such procedure must not be performed (Hirshberg et al 2002), due to its short-term and long-term morbidity and its frequent failure to achieve a cure of the disease. If no insulinoma is found, it is recommended to stop the operation, then to perform new investigations in order to localize the insulinoma, including invasive techniques.…”

Section: Treatment 241 Surgerymentioning

confidence: 99%

Diagnosis and Treatment of Insulinomas in the Adults

Vezzosi¹,

Bennet²,

Maïza³

et al. 2011

Basic and Clinical Endocrinology Up-to-Date

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“…This procedure, however, is now discouraged owing to the inaccuracy and lack of therapeutic success of the procedure, its morbidity, and advancements in intraoperative imaging. 23 The operative steps of open insulinoma surgery involve the following key maneuvers (Figures 4-8): After laparotomy, the abdomen is explored for evidence of metastasis. The lesser sac is then entered through the gastrocolic ligament, exposing the anterior surface of the pancreas.…”

mentioning

confidence: 99%

Diagnosis and management of insulinoma: current best practice and ongoing developments

Taye¹,

Libutti²

2015

RRED

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Insulinoma is a predominantly benign and rare neuroendocrine tumor. Patients with insulinoma typically present with neurologic symptoms from hypoglycemia, such as confusion, dizziness, and behavioral changes, as well as symptoms from a surge in catecholamine levels, such as palpitations, diaphoresis, and tachycardia. Symptomatic patients usually have glucose levels below 55 mg/dL and are relieved of their symptoms when carbohydrate is administered. The 48-hour test, performed by measuring blood glucose levels of insulin, C peptide, and proinsulin collected every 4-6 hours in fasting patients, accurately confirms the diagnosis of insulinoma in the majority of the patients. Once the diagnosis is confirmed, the next step in management involves identifying the location of the tumor and successfully removing it surgically. In the last two decades, clinicians have moved away from invasive angiography for preoperative localization. A multiphase computed tomography (CT) can be used to localize the lesion and evaluate for metastasis. If CT does not detect the lesion, selective arterial calcium stimulation test is recommended to identify the region of the lesion in the pancreas. Some argue that all preoperative localization techniques are superfluous. The combination of intraoperative ultrasound and operative palpation has led to a nearly 100% success rate. Recently, in select cases, laparoscopic enucleations and resections of insulinomas have been performed with shorter length of stay and faster recovery time. Despite advances in imaging, a little over 10% of insulinoma patients undergo reexploration for missing lesions. Patients who are not candidates for tumor resections or awaiting surgery have had symptomatic relief from diazoxide and somatostatin analogs among various medical therapies. In patients with metastatic insulinoma, progressionfree survival and overall survival are reported from newly approved chemotherapeutic agents. Liver-directed therapies, such as ablation and selective radiation, and cytoreductive surgery have also been performed for symptom control and prolonging survival.

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Blind Distal Pancreatectomy for Occult Insulinoma, an Inadvisable Procedure1

Cited by 106 publications

References 15 publications

MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

Diagnosis and Treatment of Insulinomas in the Adults

Diagnosis and management of insulinoma: current best practice and ongoing developments

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