9Insulinoma
Section snippets
Historical Review
The pancreatic islets were first described by Paul Langerhans in 18696 while still a medical student studying with Virchow. Not until 1922 was the Nobel Prize winning discovery of insulin achieved by Banting and Best.7 Ironically, the first patient operated for insulinoma was a surgeon, explored by Dr William J. Mayo, who found a malignant insulinoma.8 In retrospect, the patient presented with typical neuroglycopenic symptoms of hallucinations and other ‘quite audacious behaviour.’9
Normal glucose regulation
The elegant counter-regulation between insulin and glucose is a prototype of the negative feedback system of the endocrine system in general. Even following food ingestion, euglycemia is maintained within a relatively narrow range from about 60 to 100 mg/dL.11 The hypoglycemia due to insulinoma is predominantly due to reduced hepatic glucose output rather than increased glucose utilization.
Symptoms
Hypoglycemic symptoms can be grouped into two major categories: neurologic and from the autonomic nervous
Localization
Because the spectrum of endogenous hyperinsulinism has changed in our experience over the last decade to include diffuse β-cell hyperplasia/nesidioblastosis that accounts for almost 10% of our patients, preoperative localization has become more important. Additionally, it is very helpful in planning the operation and certainly offers a measure of comfort to both the surgeon and patient prior to entering the operating room. Because virtually all insulinomas are found in the pancreas, it should
Preoperative preparation
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The patient is admitted to the hospital the evening before the operation and an intravenous infusion of 10% dextrose is given overnight to avoid the risk of unrecognized hypoglycemia.
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Upon entry to the OR, glucose is removed from the intravenous solution so as to allow the glucose to drift down.
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During the operation the glucose level is closely monitored with an anticipated fall to approximately 40–50 mg/dL during the course of the operation.
Intraoperative management
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We continue to utilize intraoperative blood glucose
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Is preoperative localisation of insulinomas necessary?
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Preoperative localization of insulinoma is not necessary
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