insulinoma - Forum

Dottore

insulinoma - Ärzteforum

Post#1 »

70 y.o. halthy and active
woman (colleague's mother) complaining by some weeks of crisis of cold
sweating, consciousness disturbances and arterial hypotension. These
symptoms appear on fasting (early morning) and go away with i.v. glucose
infusion. Insulin/glucose ratio during crisis close to 1. On ct scan an "
enlargment of pancreatic uncinate process, and irregularity in gastric
wall". LFT normal. US: Non dilated CBD, no stones in gallblader.
Gastroenterologist performed gastroduodenoscopy and ERCP (pancreatogram
could no be done) that were normal.
We are planning surgical
exploration. If certainly tumor is located in uncinate process, what to do?:

1) Whipple operation

2) Resect only uncinate process. Is it possible?. Any references about?


User avatar
Surgeon

Re: insulinoma - Ärzteforum

Post#2 »

She has the BIOCHEMICAL diagnosis of insulinoma, but not the ANATOMICAL one. These little tumours are notoriously hard to image (even at surgery with intra-operative ultrasonography). Our friendly radiologists often obligingly "find" the tumour by over-analysing shadows.

User avatar
Oncologist

Re: insulinoma - Ärzteforum

Post#3 »

ERCP is not indicated in the preoperative localisation of insulinomas.
Why your manic Gastroenterologist use this superfluous and unnecessary-risky
and self-serving manipulations when it is not indicated, and after all of this
he did not visualise the pancreatic duct.

Standard imaging studies (computed tomography, magnetic resonance
imaging, somatostatin receptor scintigraphy, ultrasonography, and angiography)
correctly localize insulinomas in less than 50% of patients and provide no
information about the feasibility of enucleation based on proximity of tumor to
pancreatic duct. After an insulinoma is biochemically proven and after exclusion
of a malignant metastasizing tumor by ultrasonography, all patients should be
operated on. Most of the tumors can be identified during operation by palpation.
Intraoperative ultrasonography should be performed in any case, not only to
localize the tumor but also to study the tumor's neighbouring anatomic
structures (Wirsung duct. splenic artery and vein), thus providing the
anatomical and surgical information necessary to plan the right surgical
strategy (tumor enucleation or pancreatic resection). Before re-operations one
should consider the use of costly pre-operative methods to localize insulinomas.
Here endosonography and selective portal venous sampling are recommended as the
first procedures of choice.

Enucleation of the tumor should be the first choice, if it is not malignant and
was technically possible, as assessed by intraoperative ultrasonography .
Duodenum-preserving pancreatic head resection can be done, but it is technically
very demanding and difficult operation. please see below abstracts;

Total resection of the head of the pancreas preserving the duodenum, bile duct,
and papilla with end-to-end anastomosis of the pancreatic duct.

Nagakawa T, Ohta T, Kayahara M, Ueno K

Many surgeons have recently attempted operative procedures for limited
resection of the head of the pancreas. This site-specific approach has emerged
as a result of precise diagnostic radiologic studies that have become available.
The author performed a new operative procedure in 2 patients with
mucin-producing pancreatic cysts that included total resection of the head of
the pancreas with careful regard to its vasculature. The procedure provided a
way of resecting the head of the pancreas while preserving the duodenum, bile
duct, and papilla. The pancreatic duct was cut 5 mm before the point of
confluence with the bile duct, and an end-to-end anastomosis was performed on
the pancreatic duct. Both patients were discharged within 1 to 1.5 months after
surgery, without complication. The operative procedure requires no processing of
the jejunum, only a simple anastomosis of the pancreatic duct.

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