Reoperative Surgery for Organic Hyperinsulinism: Indications and Operative Strategy

Abstract

Organic hyperinsulinism has a good chance of cure by operation, although patients with diffuse or multiple disease run a high risk of recurrence or persistence of disease. Surgical management and outcome in these patients are presented and discussed. Between 1986 and April 1997 a total of 62 patients were operated on for organic hyperinsulinism [solitary 48, multiple 3, multiple endocrine neoplasia type I (MEN-I) 2, diffuse 4, malignant 5]. Persistence or recurrence occurred in 10 patients (16%). Among the six that persisted, four were malignant and two benign. All four of those that recurred were benign. Patients with benign disease presented with multiple tumors (n = 3), MEN-I syndrome (n = 1), and diffuse/nodular hyperplasia (n = 2). The duration between diagnosis and reintervention ranged from 1 to 10 years. Preoperative diagnosis was able to localize tumors in three patients (computed tomography 1, angiography 2, calcium stimulation 1). Operative procedures were multiple enucleations in two patients with sporadic disease, subtotal resection plus enucleation in the case of MEN-I syndrome, subtotal resection for diffuse hyperplasia, left resection for adenomatosis, and tumor extirpation after multiple previous operations. Long-term clinical and biochemical cure was achieved in five of six patients (mean follow-up 5 years). Octreotide therapy shows good symptomatic control in the patient with operative failure. Reintervention for organic hyperinsulinism is successful (80% cure) and requires preoperative imaging and individual surgical management.

Long-term results of the surgical management of insulinoma patients with MEN1: a Groupe d'étude des Tumeurs Endocrines (GTE) retrospective study

“…By consequence, controversies exist regarding the extent of surgery which is performed in these patients. Distal pancreatectomy (DP) is considered to be the procedure of choice as it yields a high rate of cure in several series (5,10,11,15,16,17,18,19,20,21). However, DP exposes patients to the risk of secondary diabetes and exocrine secretion deficit especially in the context of MEN1, for which additional surgery is frequently required (22,23).…”

Enucleation and Limited Pancreatic Resection Provide Long-Term Cure for Insulinoma in Multiple Endocrine Neoplasia Type 1

“…Surgical resection is generally recommended, as long as diffuse unresectable metastatic disease is excluded [1,4]. However, there are less than 20 retrospective case series with more than 5 patients about this entity reported in the literature [6,10,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. Only five previous studies with more than 10 patients collected over time periods from 13 to 41 years provide detailed information on the extent of pancreatic disease, pathology, type of surgery, and pancreatic disease during follow-up [ [17,19,22,23,24](table 3).…”

“…Most experts advocate subtotal distal pancreatectomy to the level of the portal vein with enucleation of pNENs of the pancreatic head as the procedure of choice for MEN1 insulinoma in the absence of diffuse metastatic disease [17,18,19,20,21]. This recommendation is based on few small retrospective cohort studies with at most 44 patients [6,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. This procedure provides cure rates of 80-100% compared to 40-60% after enucleations or limited resections [6,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32].…”

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

“…4 Morbidity rates increase from 21%-25% at the primary operation to 50%-58% after reoperation. 4,27 At times, insulinomas are missed because there are multiple tumors, and these subjects should raise strong suspicion of MEN-I syndrome. 27 Surgical complications include pancreatic fistula, pseudocyst, intra-abdominal abscess, pancreatitis, hemorrhage, and diabetes.…”

“…4,27 At times, insulinomas are missed because there are multiple tumors, and these subjects should raise strong suspicion of MEN-I syndrome. 27 Surgical complications include pancreatic fistula, pseudocyst, intra-abdominal abscess, pancreatitis, hemorrhage, and diabetes. 9 Laparoscopic procedures carry similar rates of complication.…”