Abstract
Sir—I read the recent article by McAuley et al. 1 McAuley G. Delaney H. Colville J. Lyburn I. Worsley D. Govender P. et al. Multimodality preoperative imaging of pancreatic insulinomas. Clin Radiol. 2005; 60: 1039-1050 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar with interest. The paragraph on “Selective arteriography and hepatic venography” appears to confuse the technique and complications of ASVS (arterial stimulation venous sampling by hepatic vein catheterization) with “transhepatic venous sampling”—in other words portal venous sampling. It is generally agreed that selective pancreatic angiography is a sensitive investigation for insulinoma, with a very low complication rate in experienced hands. The simply performed supplement of ASVS adds very significantly to the sensitivity of the test and can localize insulin (and C-peptide) overproduction to one of three areas of the pancreas (body/tail, anterosuperior or posteroinferior pancreatic head), even if the arteriogram is negative, and with minimal additional morbidity. Non-selective hepatic vein catheterization is about as non-invasive as selective angiography gets; the complications listed in the article: epigastric pain, haemobilia, hepatic haematoma and biliary leak, are complications of portal (transhepatic) catheterization, a procedure now rarely, if ever, needed. To argue that by comparison with, for example, endoscopic ultrasound (EUS) or positron emission tomography (PET) angiography with ASVS is “invasive, associated with significant risks, operator dependent, time-consuming, costly and requiring specialized facilities” seems a little unbalanced, especially as the sensitivity of angiography is up to 65%, that of ASVS in some reports 100%, and the complication rate extremely low. 2 Sung Y.M. Do Y.S. Shin S.W. et al. Selective intra-arterial calcium stimulation with hepatic venous sampling for preoperative localisation of insulinomas. Korean J Radiol. 2003; 4: 101-108 Crossref PubMed Scopus (12) Google Scholar
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