ABSTRACT
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Subject(s)
Humans , Male , Middle Aged , Nesidioblastosis/diagnostic imaging , Nesidioblastosis/drug therapy , Octreotide/administration & dosage , Pancreatectomy/methods , Hyperinsulinism/complications , Hypoglycemia/complications , Hypoglycemia/drug therapy , Diagnosis, DifferentialSubject(s)
Nesidioblastosis/diagnostic imaging , Organometallic Compounds , Peptides , Aged , Female , Humans , Positron-Emission TomographyABSTRACT
CONTEXT: Hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass (RYGB) has been increasingly reported. It is induced by ß-cell hyperplasia often referred to as nesidioblastosis. Positron emission tomography (PET) with [11C]-5-hydroxytryptophan ((11)C-HTP) and 6-[18F]fluoro-3,4-dihydroxy-l-phenylalanine ((18)F-DOPA) has been successfully applied to image neuroendocrine tumors. No data are available of the usefulness of these functional imaging techniques in post-RYGB in this new endocrine disorder, neither for diagnostic purposes nor for follow-up. OBJECTIVE: We present a patient with post-RYGB hypoglycemia who underwent (11)C-HTP and (18)F-DOPA PET scintigraphy for diagnostic purposes and to evaluate the effect of additional laparoscopic adjustable banding of the pouch as a surgical therapy for this disorder. PATIENT: We describe a woman with biochemically confirmed post-RYGB hypoglycemia who showed diffuse uptake of the (11)C-HTP and (18)F-DOPA tracers in the entire pancreas. After failure of dietary and medical treatment options, she underwent a laparoscopic adjustable banding for pouch dilatation. Subjective improvement was noted, which coincided with decreased uptake of (18)F-DOPA and (11)C-HTP in the head of the pancreas. CONCLUSIONS: Functional imaging by (18)F-DOPA- and (11)C-HTP-PET can accurately visualize diffuse endocrine pancreatic activity in post-gastric bypass hyperinsulinemic hypoglycemia. Both (11)C-HTP- and (18)F-DOPA-PET imaging appear to have a similar diagnostic performance in the presented case, and uptake of both tracers potentially relates to disease activity after surgical intervention.
Subject(s)
Gastric Bypass/adverse effects , Hypoglycemia/diagnostic imaging , Obesity, Morbid/surgery , Positron-Emission Tomography/methods , Postoperative Complications/diagnostic imaging , Adult , Carbon Radioisotopes , Dihydroxyphenylalanine/analogs & derivatives , Female , Fluorodeoxyglucose F18 , Humans , Hyperinsulinism/diagnostic imaging , Hyperinsulinism/etiology , Hypoglycemia/etiology , Nesidioblastosis/diagnostic imaging , Nesidioblastosis/etiologyABSTRACT
Congenital hyperinsulinism (CHI), syn. nesidioblastosis, is the most frequent cause of persistent, recurrent hypoglycemia in infancy. One third of patients show a single circumscribed focus. Enucleation of the focus and the removal of all affected ß-cells with preservation of healthy tissue is the treatment of choice. The intrapancreatic choledochus as well as the ductus pancreaticus major must remain intact. The diagnostic gold standard is 18F-DOPA-PET/CT. Intraoperative sonography is carried out to correctly visualize the focus preoperatively localized by PET/CT in situ during the operation. The enucleation of the focus was carried out 3 - 20 days after PET/CT in 5 patients at an age of 3.5 - 14 months. Intraoperative ultrasound was carried out with high-capacity devices of different manufacturers under use of broadband probes (9 - 14 MHz). The localization by intraoperative ultrasound was accurate in all 5 patients with focal CHI, with regard to the intraoperative localization as previously described by PET/CT and histology. D. choledochus and D. pancreaticus major were separated intraoperatively by ultrasound. 3 of 5 patients were cured by complete enucleation of the focus. Nevertheless, the entire intraoperative identification of the segmented focus is still problematic. Characteristic sonographic features of a CHI focus are: hypoechogenicity, variable homogeneous and inhomogenous texture, blurred, irregular limitation without capsule, filiform, lobular processes, and insular dispersal into the surrounding tissue. Intraoperative high-resolution sonography helps the pediatric surgeon to determine size, configuration and topography of a CHI focus.
Subject(s)
Image Processing, Computer-Assisted/methods , Nesidioblastosis/diagnostic imaging , Nesidioblastosis/surgery , Pancreas/diagnostic imaging , Pancreas/surgery , Ultrasonography/methods , Common Bile Duct/diagnostic imaging , Common Bile Duct/surgery , Equipment Design , Female , Humans , Image Processing, Computer-Assisted/instrumentation , Imaging, Three-Dimensional , Infant , Insulin-Secreting Cells/diagnostic imaging , Intraoperative Period , Male , Pancreatic Ducts/diagnostic imaging , Pancreatic Ducts/surgery , Positron-Emission Tomography , Sensitivity and Specificity , Tomography, X-Ray Computed , Ultrasonography/instrumentationSubject(s)
Endosonography , Hyperinsulinism/etiology , Hypoglycemia/etiology , Nesidioblastosis/pathology , Pancreatic Neoplasms/pathology , Adenocarcinoma/diagnosis , Adenocarcinoma/surgery , Aged , Biopsy, Fine-Needle , Esophageal Neoplasms/diagnosis , Esophageal Neoplasms/surgery , Esophagectomy/methods , Follow-Up Studies , Humans , Hyperinsulinism/physiopathology , Hypoglycemia/physiopathology , Immunohistochemistry , Male , Neoplasm Invasiveness/pathology , Nesidioblastosis/complications , Nesidioblastosis/diagnostic imaging , Nesidioblastosis/surgery , Pancreatectomy/methods , Pancreatic Neoplasms/complications , Pancreatic Neoplasms/diagnostic imaging , Pancreatic Neoplasms/surgery , Recurrence , Risk Assessment , Severity of Illness Index , Treatment OutcomeABSTRACT
BACKGROUND: Nesidioblastosis is often resistant to medical therapy and requires near-total pancreatectomy. There is little information on the postoperative imaging findings of these patients. OBJECTIVE: To demonstrate by US the late imaging findings in these patients. MATERIALS AND METHODS: Children diagnosed with nesidioblastosis and who had undergone 90-95% pancreatectomy received preoperative, immediate-postoperative (within 10 days of surgery) and long-term annual US examinations. In the preoperative study, three anterior-posterior (AP) measurements were obtained of the head, body and tail of the pancreas. In the postoperative and long-term follow-up US, AP and transverse measurements of the pancreatic remnant were obtained. Pancreatic echogenicity was also assessed. The results were compared with normal pancreatic dimensions as a function of age. Glucose metabolism and pancreatic enzymes were also analysed. RESULTS: The study group comprised 22 patients (aged 9 days to 2 years). The pancreas was normal in all preoperative US examinations. The first postoperative examination showed, in all patients, a remnant of the pancreatic head measuring 8-13 mm. The last follow-up US was similar to the first postoperative study in 6 patients, and 12 showed complete pancreatic regeneration (normal size, echogenicity and function), and 4 had incomplete regeneration with head and body normal in size, but lack of a pancreatic tail. All patients were asymptomatic and showed normal laboratory tests. CONCLUSIONS: US measurements indicated normal age-dependent growth after near-total resection in 54% of patients. The function and echogenicity of the regenerated pancreas indicate that the increase in organ size was due to normal pancreatic tissue.