The surgical management of insulinoma.

Insulinoma is the most common endocrine tumor of the pancreas. Over 90% of the insulinomas are benign and single, and can be cured by simple excision. Depending on the location, insulinomas can be enucleated, might require partial or distal pancreatectomy or pancreaticoduodenectomy. Five cases with insulinoma successfully treated by surgical intervention, two by enuclation, two by distal pancreatectomy and splenectomy, and preservation of the spleen have been summarized. The management of insulinoma involves the diagnosis, localization of the tumor and treatment. Insulinomas are rare tumors of the pancreas. Nevertheless, it is the most common endocrine tumor of the pancreas. Specifically arising from the beta cells, of the islets of Langerham, that produce insulin (fig.1). Its incidence is one in 250,000 inhabitants. It can be seen at any age, but is more frequent in females between 4 and 82 years of age, with a mean of 45.5 years. Insulinomas are evenly distributed between the head, body and tail of the pancreas. Over 90% are benign and single and can be cured by simple excision. Depending on the location insulinomas can be enucleated, might require partial or distal pancreatectomy or a pancreaticoduodenectomy. Ten percent could be malignant when metastasis to peripancreatic lymph nodes or to the liver is detected. The course of the patient with malignant insulinoma is an indolent one. The release of insulin leads to fasting hypoglycemia producing confusion, loss of consciousness, coma or convulsions. The hypoglycemia in turn can induce the release of cathecolamines producing tachycardia, tremulousness and diaphoresis. The Whipple's triad must be present for the diagnosis of insulinoma; symptoms of hypoglycemia, glucose level below 50 mgs/dl and relief of symptoms by the administration of glucose. In large series the interval between the onset of symptoms and a definitive diagnosis of insulinoma was 37 months, with a range of 0 to 14 years.

The surgical management of insulinoma

Insulinoma is the most common endocrine tumor of the pancreas. Over 90 of the insulinomas are benign and single, and can be cured by simple excision. Depending on the location, insulinomas can be enucleated, might require partial or distal pancreatectomy or pancreaticoduodenectomy. Five cases with insulinoma successfully treated by surgical intervention, two by enuclation, two by distal pancreatectomy and splenectomy, and preservation of the spleen have been summarized. The management of insulinoma involves the diagnosis, localization of the tumor and treatment. Insulinomas are rare tumors of the pancreas. Nevertheless, it is the most common endocrine tumor of the pancreas. Specifically arising from the beta cells, of the islets of Langerham, that produce insulin (fig.1). Its incidence is one in 250,000 inhabitants. It can be seen at any age, but is more frequent in females between 4 and 82 years of age, with a mean of 45.5 years. Insulinomas are evenly distributed between the head, body and tail of the pancreas. Over 90 are benign and single and can be cured by simple excision. Depending on the location insulinomas can be enucleated, might require partial or distal pancreatectomy or a pancreaticoduodenectomy. Ten percent could be malignant when metastasis to peripancreatic lymph nodes or to the liver is detected. The course of the patient with malignant insulinoma is an indolent one. The release of insulin leads to fasting hypoglycemia producing confusion, loss of consciousness, coma or convulsions. The hypoglycemia in turn can induce the release of cathecolamines producing tachycardia, tremulousness and diaphoresis. The Whipple's triad must be present for the diagnosis of insulinoma; symptoms of hypoglycemia, glucose level below 50 mgs/dl and relief of symptoms by the administration of glucose. In large series the interval between the onset of symptoms and a definitive diagnosis of insulinoma was 37 months, with a range of 0 to 14 years

[Endocrine tumors of the pancreas at a Mexican institution]. / Los tumores endocrinos del páncreas en una institución mexicana.

OBJECTIVE: To analyze characteristics of patients with endocrine tumors of the pancreas seen between 1960 and 1992 at the Instituto Nacional de la Nutrición. MATERIAL & METHODS: The clinical records of 38 patients with endocrine tumors of the pancreas were reviewed. Overall characteristics, diagnostic studies, intraoperative findings, treatment and outcome were analyzed. The archival histological specimens were revised and immunohistochemical stainings were performed in the non-functioning tumors. RESULTS: Twenty patients had hyperinsulinism, 10 non-functioning tumors, and eight a Zollinger-Ellison syndrome. The mean age of patients with hyperinsulinism was 38 years (8 males and 12 females); 18 were sporadic and two associated with MEN I syndrome. In 16 patients an insulinoma was removed: (6 in the head, 5 in the body, 5 in the tail of the pancreas). A cure was documented in 14 patients with sporadic tumors but not in the two cases associated with MEN I; 15 tumors were benign. Three patients with the Zollinger-Ellison syndrome were males and five females with a mean age of 41 years. Seven tumors were sporadic and one associated with the MEN I syndrome; 70% were located in the gastrinoma triangle. Local excision was performed in five and gastrectomy in three. The cure rate was 60% and malignancy was documented in 40%. Two males and eight females with a mean age of 30 years had non-functioning tumors (9 sporadic and one associated to MEN I). There was a positive immunohistochemistry in 60% of the tumors; 90% were malignant and the cure rate was 10%. CONCLUSIONS: Insulinoma is the most common endocrine tumor of the pancreas in our hospital. The cure rate for insulinomas, gastrinomas and non-functioning tumors was 90%, 60% and 10% and malignancy was documented in 5%, 40% and 90% respectively.

Tratamiento quirúrgico del insulinoma / Insulinoma, surgeric treatment

El próposito de este trabajo es presentar nuestra experiencia en el manejo quirúrgico del insulinoma (Apudoma Intrapancreático). En el servicio de cirugía N§ 1 del H.N.G.A.I. se registraron 10 casos de hiperinsulinismo orgánico, que representa el 95 por ciento de la casuística de nuestro hospital: 9 casos corresponden a patología benigna y un caso fue catalogado como insulinoma maligno. Los casos de patología benigna fueron: 8 adenomas de menos de 2cm y una hiperplasia de los islotes de Langerhans. La localización preferente en nuestros casos se concentró en cabeza y cuerpo (incluye un caso de localización en uncus pancreático). Todos los pacientes fueron estudiados y manejados de acuerdo a un protocolo estándar para esta patología, contando con la valiosa experiencia de los servicios de Neurología, Endocrinología y Radiología intervencionista de nuestro hospital. La localización preoperatoria sólo fue posible en un caso (10 por ciento) por tratarse de un tumor de más de 5cm catalogado como insulinoma maligno. En los dos últimos casos se realizó venografía portal transhepática selectiva para medir las gradientes de insulina, y en un caso se usó ecografía intraoperatoria: sin embargo, no se acertó en la localización precisa del adenoma. Todos los pacientes fueron sometidos a laparatomía, realizándose movilización completa de la cabeza y cola para facilitar la palpación bimanual de toda la glándula. El procedimiento quirúrgico consistió en 5 enucleaciones de adenomas, 3 pancreatectomías mayores del 80 por ciento de páncreas distal (una de ellas como primer tiempo de una pancreatectomía total), una duodenopancreatectomía (segundo tiempo de pancreatectomía total) y una pancreatectomía medial. La mortalidad operatoria fue de 20 por ciento (2 casos) uno de ellos fue un insulinoma maligno en un paciente joven con daño cerebral irreversible y un segundo caso un insulinoma benigno en uncus pancreáticos que presentaba daño cerebral, y que después de 46 días de post-operatorio presenta cuadro séptico y falla multiorgánica, sin embargo, quirúrgicamente se controló el hiper insulinismo y terminó dependiendo de una bomba de infusión de insulina para controlar la hiperglicemia. En los demás casos la pancreatectomía o la enucleación corrigieron el hiperinsulinismo y la mayoría de ellos se reintegraron plenamente a sus actividades.