Combining the selective arterial calcium injection test and intraoperative blood glucose monitoring for multiple insulinomas: Report of two cases

Abstract

To date, no precise methods of preoperatively localizing multiple insulinomas or intraoperatively confirming their complete removal have been established. We describe herein the effectiveness of combining the selective arterial calcium injection (SACI) test to locate tumors preoperatively, with intraoperative continuous blood glucose monitoring (IOBGM) to confirm their complete removal. During the 8-year period from 1990 to 1997, we experienced two patients with multiple insulinomas. The first patient required resection of a residual tumor in the remnant pancreas for persistent hyperinsulinemia after a distal pancreatectomy performed under conventional diagnostic procedures. In the second patient, a SACI test was performed in addition to other diagnostic imaging procedures, and while computed tomography scan, endoscopic ultrasonography, and arteriography demonstrated multiple tumors in the body and tail of pancreas, the SACI test suggested that there were also tumors in the head of pancreas. Intraoperative ultrasonography showed a tumor measuring 5 mm in diameter on the surface of the head of the pancreas, apart from the multiple tumors in the body and tail of the pancreas. Complete removal of all tumors was assessed by the hyperglycemic rebound after resection of the tumors, determined by IOBGM. Based upon our experience, we believe that the SACI test and IOBGM are helpful for establishing precise localization and achieving complete removal of multiple insulinomas.

The future: diagnostic and imaging advances in MEN1 therapeutic approaches and management strategies

“…If an insulinoma cannot be detected by EUS, crosssectional or PET imaging, especially in the presence of multiple pNENs >1 cm, a selective arterial calcium injection (SACI) angiography can be performed to regionalize the source of insulin excess with high sensitivity and specificity of >85% (Haji et al 2000, Gimm et al 2007, Thakker et al 2012.…”

Intra-operative quick insulin assay to confirm complete resection of insulinomas guided by selective arterial calcium injection (SACI)

“…In 2002, Carneiro et al reported on the effectiveness of a rapid insulin assay to confirm the complete resection of insulinomas intra-operatively [3]. The method proved very helpful and was more reliable than determining the glucose level intra-operatively [11].…”