Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1990 Nov;212(5):615–620. doi: 10.1097/00000658-199011000-00009

Localization and surgical treatment of occult insulinomas.

J A Norton 1, T H Shawker 1, J L Doppman 1, D L Miller 1, D L Fraker 1, D T Cromack 1, P Gorden 1, R T Jensen 1
PMCID: PMC1358190  PMID: 2241318

Abstract

Management of patients with biochemical evidence of insulinoma and negative preoperative imaging studies (occult) tumors is controversial, varying from primarily medical management to aggressive, blind nearly total pancreatectomy to extirpate the tumor. Since 1982, 12 consecutive patients with occult insulinoma underwent preoperative portal venous sampling (PVS) for insulin followed by surgical exploration with intraoperative ultrasound (IOUS). Eleven of twelve patients (92%) had insulinoma removed and were cured. Portal venous sampling correctly predicted the location of the insulinoma in 9 patients (75%) and that no tumor would be found in another patient. A fourfold insulin gradient in the pancreatic tail of one patient correctly predicted that a distal pancreatectomy would remove the insulinoma despite the fact that neither palpation nor IOUS identified any tumor. Intraoperative ultrasound was the single best method to identify occult tumors because it correctly identified 10 of 11 insulinomas that were found, including five pancreatic head tumors that were not palpable. Palpation identified five insulinomas. Of the 10 tumors that were identified during operation by palpation or ultrasound, IOUS identified significantly more (100% versus 50%, p = 0.03) and guided the successful enucleation of each. The results support the strategy of preoperative PVS and operation with IOUS to localize and remove insulinoma in patients with occult tumors. Most tumors (75%) will be correctly localized to a specific pancreatic region by preoperative PVS and identified by IOUS (83%), allowing simple enucleation and biochemical correction of hypoglycemia. Morbid blind pancreatic resections are no longer indicated and long-term medical management of hypoglycemia should be reserved for the occasional patient (8%) who fails preoperative PVS and operation guided by IOUS.

Full text

PDF
615

Images in this article

617Fig. 1.
on p.617
618Fig. 2.
on p.618

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Cherner J. A., Doppman J. L., Norton J. A., Miller D. L., Krudy A. G., Raufman J. P., Collen M. J., Maton P. N., Gardner J. D., Jensen R. T. Selective venous sampling for gastrin to localize gastrinomas. A prospective assessment. Ann Intern Med. 1986 Dec;105(6):841–847. doi: 10.7326/0003-4819-105-6-841. [DOI] [PubMed] [Google Scholar]
  2. Doppman J. L., Brennan M. F., Dunnick N. R., Kahn C. R., Gorden P. The role of pancreatic venous sampling in the localization of occult insulinomas. Radiology. 1981 Mar;138(3):557–562. doi: 10.1148/radiology.138.3.6258193. [DOI] [PubMed] [Google Scholar]
  3. Dunnick N. R., Long J. A., Jr, Krudy A., Shawker T. H., Doppman J. L. Localizing insulinomas with combined radiographic methods. AJR Am J Roentgenol. 1980 Oct;135(4):747–752. doi: 10.2214/ajr.135.4.747. [DOI] [PubMed] [Google Scholar]
  4. Filipi C. J., Higgins G. A. Diagnosis and management of insulinoma. Am J Surg. 1973 Feb;125(2):231–239. doi: 10.1016/0002-9610(73)90033-0. [DOI] [PubMed] [Google Scholar]
  5. Frucht H., Doppman J. L., Norton J. A., Miller D. L., Dwyer A. J., Frank J. A., Vinayek R., Maton P. N., Jensen R. T. Gastrinomas: comparison of MR imaging with CT, angiography, and US. Radiology. 1989 Jun;171(3):713–717. doi: 10.1148/radiology.171.3.2655004. [DOI] [PubMed] [Google Scholar]
  6. Fulton R. E., Sheedy P. F., McILRATH D. C., Ferris D. O. Preoperative angiographic localization of insulin-producing tumors of the pancreas. Am J Roentgenol Radium Ther Nucl Med. 1975 Feb;123(2):367–377. doi: 10.2214/ajr.123.2.367. [DOI] [PubMed] [Google Scholar]
  7. Galbut D. L., Markowitz A. M. Insulinoma: diagnosis, surgical management and long-term follow-up. Review of 41 cases. Am J Surg. 1980 May;139(5):682–690. doi: 10.1016/0002-9610(80)90363-3. [DOI] [PubMed] [Google Scholar]
  8. Galiber A. K., Reading C. C., Charboneau J. W., Sheedy P. F., 2nd, James E. M., Gorman B., Grant C. S., van Heerden J. A., Telander R. L. Localization of pancreatic insulinoma: comparison of pre- and intraoperative US with CT and angiography. Radiology. 1988 Feb;166(2):405–408. doi: 10.1148/radiology.166.2.2827232. [DOI] [PubMed] [Google Scholar]
  9. Glickman M. H., Hart M. J., White T. T. Insulinoma in Seattle: 39 cases in 30 years. Am J Surg. 1980 Jul;140(1):119–125. doi: 10.1016/0002-9610(80)90427-4. [DOI] [PubMed] [Google Scholar]
  10. Grant C. S., van Heerden J., Charboneau J. W., James E. M., Reading C. C. Insulinoma. The value of intraoperative ultrasonography. Arch Surg. 1988 Jul;123(7):843–848. doi: 10.1001/archsurg.1988.01400310057009. [DOI] [PubMed] [Google Scholar]
  11. Grunberger G., Weiner J. L., Silverman R., Taylor S., Gorden P. Factitious hypoglycemia due to surreptitious administration of insulin. Diagnosis, treatment, and long-term follow-up. Ann Intern Med. 1988 Feb;108(2):252–257. doi: 10.7326/0003-4819-108-2-252. [DOI] [PubMed] [Google Scholar]
  12. Kaplan E. L., Arganini M., Kang S. J. Diagnosis and treatment of hypoglycemic disorders. Surg Clin North Am. 1987 Apr;67(2):395–410. doi: 10.1016/s0039-6109(16)44191-5. [DOI] [PubMed] [Google Scholar]
  13. Norton J. A., Cromack D. T., Shawker T. H., Doppman J. L., Comi R., Gorden P., Maton P. N., Gardner J. D., Jensen R. T. Intraoperative ultrasonographic localization of islet cell tumors. A prospective comparison to palpation. Ann Surg. 1988 Feb;207(2):160–168. doi: 10.1097/00000658-198802000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Norton J. A., Sigel B., Baker A. R., Ettinghausen S. E., Shawker T. H., Krudy A. G., Doppman J. L., Taylor S. I., Gordon P. Localization of an occult insulinoma by intraoperative ultrasonography. Surgery. 1985 Mar;97(3):381–384. [PubMed] [Google Scholar]
  15. Roche A., Raisonnier A., Gillon-Savouret M. C. Pancreatic venous sampling and arteriography in localizing insulinomas and gastrinomas: procedure and results in 55 cases. Radiology. 1982 Dec;145(3):621–627. doi: 10.1148/radiology.145.3.6292994. [DOI] [PubMed] [Google Scholar]
  16. Shawker T. H., Doppman J. L., Dunnick N. R., McCarthy D. M. Ultrasonic investigation of pancreatic islet cell tumors. J Ultrasound Med. 1982 Jun-Jul;1(5):193–200. doi: 10.7863/jum.1982.1.5.193. [DOI] [PubMed] [Google Scholar]
  17. Sigel B., Duarte B., Coelho J. C., Nyhus L. M., Baker R. J., Machi J. Localization of insulinomas of the pancreas at operation by real-time ultrasound scanning. Surg Gynecol Obstet. 1983 Feb;156(2):145–147. [PubMed] [Google Scholar]
  18. Stefanini P., Carboni M., Patrassi N., Basoli A. Beta-islet cell tumors of the pancreas: results of a study on 1,067 cases. Surgery. 1974 Apr;75(4):597–609. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES