González Quezada, Alberto¹; Romero Garza, Héctor Hugo²; Reina Sepúlveda, Francisco Javier¹; Hernández Guedea, Marco Antonio³; Pérez Rodríguez, Edelmiro⁴; Muñoz Maldonado, Gerardo Enrique⁵

Language: English/Spanish [Versión en español]
References: 10
Page: 291-293
PDF size: 224.08 Kb.

ABSTRACT

Insulinoma's are infrequent neuroendocrine tumors originated in pancreatic beta cells most of them are treated with surgery. We present a case of a 51 year old woman with Whipple's triad and an image of a neuroendocrine tumor identified by ultrasound. Laparoscopic enuclation of the tumor is performed.

INTRODUCTION

Insulinomas are neuroendocrine neoplasms that originate in the beta cells of pancreatic islets characterized by increased production of insulin. They are rare tumors.¹ The clinical diagnosis is based on Whipple's triad. The most frequent location of insulinomas is in the head and neck of the pancreas. The highest sensitivity for localization of insulinomas is an endoscopic ultrasound of 86.6 to 92.3%.²

The surgical approach to insulinoma depends on the size, proximity to the pancreatic duct, and the splenic vessels. Surgical resection is the treatment of choice with a cure rate in more than 90% of patients.³ Enucleation is indicated in benign small superficial tumors ≤ 3 cm in diameter, located farther than 2 mm from the pancreatic duct. Insulinomas of these characteristics are excellent candidates for laparoscopic resection.⁴

Laparoscopic approach is infrequent because of the deep location of the pancreas, the technical difficulty, and the need for experienced surgeons. Currently, the safety and efficacy of laparoscopic pancreatic resection have been described as reliable.

PRESENTATION OF THE CASE

A 51-year-old woman with no significant family history. She started her condition three years before her hospital admission with intermittent episodes of diaphoresis and palpitations. On arrival, she reported an oppressive frontal headache and had a capillary glycemia of 28 mg/dl. Her symptoms improved after ingestion of glucose-rich food. She was admitted because of a seizure. Her thorax was found with no alterations, her abdomen with abundant adipose panniculus, soft, non-painful, peristalsis present and normal, and the rest of the examination also without pathological data. Her laboratory studies showed glycosylated hemoglobin of 4.5%, negative blood sulfonylureas, glucose 37 mg, insulin 64.1 IU/ml, C-peptide 8.36 ng/ml, TSH 1.8 IU/ml, T4L 1.11 ng/dl. A contrast-enhanced CT scan of the abdomen was reported normal. Magnetic resonance imaging (MRI) showed a nodular lesion between the head and body of the pancreas of 2.0 × 1.8 × 1.6 cm, which did not produce obstruction. Endoscopic ultrasound (Figure 1) corroborated the superficial location of the tumor, distant more than 2 mm from the splenic vessels and the pancreatic duct. Given its size and location, a laparoscopic enucleation was done. Pneumoperitoneum was produced, ports placed in the umbilicus (10 mm), another one for the hepatic retractor in the right anterior axillary line (10 mm), two left and one right port (5 mm). After dissection of the gastrocolic omentum, the stomach retracted upwards and the tumor was detected between the body and tail of the pancreas (Figure 2). Enucleation was done with a harmonic scalpel and the tumor was removed from the abdominal cavity using a bag through the assistant's port.

The glucose concentration elevated after removal of the tumor and insulin administration by infusion pump was started. Ports were removed under direct vision, the skin was closed in planes with Vicryl 0-0. A closed Jackson-Pratt drain was placed. Cephalexin 500 mg was given every eight hours for three days. The patient was discharged on the seventh day. She tolerated her diet and her glucose was within normal parameters. The drain was removed after 14 days without complications. The histopathological diagnosis was insulinoma.

DISCUSSION

Laparoscopic enucleation of insulinoma is a safe and effective option, with a short hospital stay and rapid patient recovery. It is indicated in cases of single benign insulinoma smaller than 2 cm and in malignant insulinomas that do not require pancreatic reconstruction.⁵ Transoperative ultrasonography is the most effective technique to confirm the pancreatic anatomy and decide the surgical technique.³ The main reason for converting to open surgery is the inability to locate the tumor, with a conversion rate of 20 to 33% of cases.⁴

Blood loss is significantly lower when resection is performed laparoscopically.⁵ Morbidity with the laparoscopic approach (32%) is lower than with laparotomy (40.5%).⁵ Surgical time does not vary significantly between the two, p > 0.71.⁶ Gastrointestinal function recovery time was lower with laparoscopy p < 0.0001 compared to hospital stay between 4 to 7 days in patients who underwent laparotomy p < 0.00001.⁵ The percentage of complications is higher with laparoscopy, 27% vs 15% laparotomy.⁷ Pancreatic fistula is the main complication in pancreatic resections with an incidence of more than 27%. The frequency is equal for both approaches.⁸ Factors favoring the formation of a pancreatic fistula are body mass index greater than 27, extensive pancreatic resection ≥ 8 cm, and a blood volume loss ≥ 150 ml.⁹ Mortality in laparotomy is 3.7%, there are no data yet for laparoscopy. Recurrence of insulinomas is rare and long-term survival is 100% at five years and 96% at 10 years.¹⁰

CONCLUSION

Surgical resection of insulinomas by laparoscopy is an appropriate technique in patients with tumors whose location and size allow it. The success of surgery will depend on an adequate preoperative study by the different imaging studies and patient characteristics. The difference in surgical time is not significantly greater with the laparoscopic approach.

REFERENCES

1. Guettier JM, Kam A, Chang R, Skarulis MC, Cochran C, Alexander HR, et al. Localization of insulinomas to regions of the pancreas by intraarterial calcium stimulation: the NIH experience. J Clin Endocrinol Metab. 2009; 94: 1074-1080.

2. Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, et al. Diagnosis and management of insulinoma. World J Gastroenterol. 2013; 19: 829-837.

3. Ayav A, Bresler L, Brunaud L, Boissel P; SFCL (Société Française de Chirurgie Laparoscopique); AFCE (Association Francophone de Chirurgie Endocrinienne). Laparoscopic approach for solitary insulinoma: a multicentre study. Langenbecks Arch Surg. 2005; 390: 134-140.

4. Sa Cunha A, Beau C, Rault A, Catargi B, Collet D, Masson B. Laparoscopic versus open approach for solitary insulinoma. Surg Endosc. 2007; 21: 103-108.

5. Su AP, Ke NW, Zhang Y, Liu XB, Hu WM, Tian BL, et al. Is laparoscopic approach for pancreatic insulinomas safe? Results of a systematic review and meta-analysis. J Surg Res. 2014; 186: 126-134.

6. Furihata M, Tagaya N, Kubota K. Laparoscopic enucleation of insulinoma in the pancreas: case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2001; 11: 279-283.

7. Nakamura Y, Uchida E, Aimoto T, Matsumoto S, Yoshida H, Tajiri T. Clinical outcome of laparoscopic distal pancreatectomy. J Hepatobiliary Pancreat Surg. 2009; 16: 35-41.

8. Richards ML, Thompson GB, Farley DR, Kendrick ML, Service JF, Vella A, et al. Setting the bar for laparoscopic resection of sporadic insulinoma. World J Surg. 2011; 35: 785-789.

9. Cho CS, Kooby DA, Schmidt CM, Nakeeb A, Bentrem DJ, Merchant NB, et al. Laparoscopic versus open left pancreatectomy: can preoperative factors indicate the safer technique? Ann Surg. 2011; 253: 975-980.

10. Crippa S, Zerbi A, Boninsegna L, Capitanio V, Partelli S, Balzano G, et al. Surgical management of insulinomas: short- and long-term outcomes after enucleations and pancreatic resections. Arch Surg. 2012; 147: 261-266.

AFFILIATIONS

¹ General Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.

² 2nd-year Resident in General Surgery. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.

³ Liver, Pancreas and Biliary Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.

⁴ Transplant Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.

⁵ Head of the General Surgery Department. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.

Ethical considerations and responsibility: Data privacy. In accordance with the protocols established at the authors\' work center, the authors declare that they have followed the protocols on patient data privacy and preserved their anonymity.

The informed consent of the patient referred to in the article is in the possession of the author.

Funding: No financial support was received for this study.

Conflict of interest: The authors declare that there is no conflict of interest.

CORRESPONDENCE

Dr. Alberto González-Quezada. E-mail: agonzalezuanl@gmail.com

Received: 03/03/2017. Accepted: 13/05/2019