Laparoscopic Distal Pancreatectomy for Insulinoma

Abstract

Insulinomas are benign neuroendocrine tumors which are the most common of the pancreatic islet cell tumors, yet they remain a rarity. The incidence is 1-4 cases in one million patients a year. 60% are woman with a median age at presentation of 47 years. 90% are solitary and 10% multiple. More than 90% are benign adenomas and about 5%-6% of cases are malignant, and 5%-8% are associated with multiple endocrine neoplasms (MEN type I). Most insulinoma are 1-3 cm in size. Hyperinsulinism causes severe hypoglycemia and leads convulsion, depression and coma. Initial operation is curative in 88%, and long-term survival is normal. Recurrence rates of 7% (sporadic) and 21% (MEN type I) have been reported at 20 years. Clinical manifestation related with endogenous hyperinsulinism: autonomic (less specific) like sweat, worried, tremble, nausea, hungry palpitation and tingling. The more specific neuroglycopenic are confusion, changes of behavior, dizzy, headache, and weakness. The classic diagnostic criteria (Whipple’s triad): hypoglycemic symptoms, fasting hypoglycemic (< 45 mg/dL) and reversal of changes with glucose. The treatment is surgical, except in advanced metastatic disease, where streptozotocin is helpful. Enucleation is performed for solitary insulinoma, and pancreas resection is performed for multiple insulinomas. Sometimes ultrasonography intra operative is useful to determine the insulinoma location. The surgical can be done by laparotomy or laparoscopic surgery. The benefit of laparoscopic surgery is small incisions, less pain, faster mobilization, short hospitalization and better cosmetic. In the other side, laparoscopic pancreatectomy should be done by experience surgeon with availability of supporting instruments. We report a case insulinoma in 39 years old woman. The locations were in body and tail pancreas. Laparoscopic distal pancreatectomy with spleen preservation is done successfully. The operation time was 3, 5 hours. Post-operative care in ICU for one day. We start enteral nutrition in the third day post-operative and the patient may leave hospital in the fifth day post-operative.