Surgical Approach to Insulinomas: Are Pre-Operative Localisation Tests Necessary?

Abstract

Insulinoma is a rare and elusive, but the most common, curable endocrine tumour of the pancreas. The incidence is estimated at 4 cases per million-person years.1 The ability to localise the tumour accurately before or during surgery is an important factor in the management of these lesions. In the event of failed localisation, a blind pancreatic resection is no longer recommended. The development of sensitive radioimmunoassays to detect endogenous hyperinsulinaemia resulted in extensive investigations to localise the tumour preoperatively, in the belief that this would reduce morbidity from pancreatic exploration. These pre-operative tests included ultrasound scans (USS), computerised tomography (CT), magnetic resonance imaging (MRI), selective angiography, transhepatic portal venous sampling (THPVS), endoscopic ultrasound (EUS), octreotide scans and calcium stimulation arteriography. There is a wide variation in the sensitivity of these tests and there is no clear consensus in the choice of these tests even amongst enthusiasts.2,3 Some believe that meticulous intra-operative exploration combined with intra-operative ultrasound (IOUS) has a higher sensitivity than pre-operative localisation tests. 4,5 We have reviewed our experience of these lesions to assess if pre-operative localisation tests are necessary and to formulate a rational management strategy for these lesions. Insulinoma is a rare, but curable, endocrine tumour. The ability to localise the tumour accurately before or during surgery is an important factor in the management of these elusive lesions, which has been extensively debated. We have reviewed our experience of these lesions to establish the role of localisation tests. SURGICAL ONCOLOGY

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

“…9 Many authors cite the low preoperative detection rates which are further compounded by high costs compared to the high intraoperative detection rates reported via inspection/palpation and IOUS as reasons for minimizing preoperative localization studies. 8,10,11 However, preoperative detection rates reported in the literature vary greatly depending on the time period and type of study used. 8 In general, the sensitivity of noninvasive imaging has been reported to be low.…”

“…The mortality occurred in a patient who developed postoperative deep vein thrombosis complicated by fatal pulmonary embolism. Overall, there were six pancreatic fistulas (35%) according to the ISGPF definition, of which five were grade A and one was grade C. The median postoperative stay was 9 (range, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] days.…”

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

“…Given the relatively high accuracy for MRI in our series, prospective studies evaluating radiological confidence in the findings against the final outcome may allow prediction of which patients require invasive investigations in addition. This may in turn reduce the radiation exposure to the patients and also the overall cost of the diagnostic episode (10).…”

Acidose metabólica por hiperglicemia transitória pós enucleação de insulinoma pancreático

“…Com o progresso tecnológico, os métodos de imagem elevaram a acurácia diagnóstica da localização dos insulinomas. Foi a utilização da ultrassonografia intra-operatória associada à palpação pancreática que conseguiram índices de até 100 % na localização destas neoplasias durante a operação 7 . No caso em discussão, a neoplasia foi localizada facilmente após a ampla exposição e palpação intra-operatória do pâncreas, embora não foram utilizados métodos de imagem pré-operatórios mais acurados como a tomografia multi-slice e a ecoendoscopia.…”

“…Este tipo de abordagem pode gerar uma série de complicações, das quais a fístula pancreática é a mais observada e de evolução favorável na maioria dos casos 2 . Outras complicações são os abscessos peripancreáticos, as hemorragias e a pancreatite aguda 7,8,9 . Neste paciente teve-se a oportunidade de observar complicações decorrentes da fístula pancreática, evoluindo posteriormente com abscesso peripancreático, situação que motivou dois novos procedimentos cirúrgicos para drenagem, prolongando assim o período de internação.…”