title: Blind distal pancreatectomy for occult insulinoma, an inadvisable procedure.
abstract: BACKGROUND
  Fasting hypoglycemia with neuroglycopenic symptoms corrected by administration of glucose are the hallmarks for the diagnosis of insulinoma. Surgical resection is the treatment of choice for insulinomas, but localization of these lesions can be challenging. Blind distal pancreatectomy has been advocated for occult insulinomas not detected on imaging studies or during abdominal exploration. With the advent of newer localization techniques, we challenge the wisdom of this approach.
  
  
  METHODS
  The records of patients (multiple endocrine neoplasia excluded) with pathologically proved insulinoma who were screened at our institution or referred to us after a failed blind distal pancreatectomy were reviewed. All records included patient history and results of physical examination and routine blood and urine tests. The diagnosis of insulinoma was confirmed during a supervised fast. Patients with biochemically proved insulinoma underwent localization studies and operation. Studies included CT scans, MRI, transabdominal ultrasound, intraoperative ultrasonography, angiography (more recently, Ca++-stimulated arteriography), and venous sampling.
  
  
  RESULTS
  From 1970 to 2000, 99 patients (34 men, 65 women; mean age 43 years) underwent operation. All patients with benign tumors (92) were cured after operation. Seventeen patients were referred to the NIH after a failed blind distal pancreatectomy. Of these, 5 were diagnosed as having factitious hypoglycemia. In the other 12 patients a tumor was localized in the pancreatic head. Two patients incorrectly diagnosed with nesidioblastosis after initial surgery were subsequently cured by resection of an insulinoma.
  
  
  CONCLUSIONS
  The use of preoperative imaging studies, most notably Ca++-stimulated arteriography, and intraoperative ultrasonography permits detection of virtually all insulinomas, including reopcrated cases. When a tumor is not detected, the procedure should be terminated and the patient referred to a center capable of performing advanced preoperative and intraoperative localization techniques. With the preoperative and intraoperative imaging strategies currently available, the use of blind distal pancreatectomy for occult insulinoma should be abolished.
authors.affiliation: Division of Intramural Research, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Boaz
authors.initials: B
authors.lastname: Hirshberg
authors.forename: Steven K
authors.initials: SK
authors.lastname: Libutti
authors.forename: H Richard
authors.initials: HR
authors.lastname: Alexander
authors.forename: David L
authors.initials: DL
authors.lastname: Bartlett
authors.forename: Craig
authors.initials: C
authors.lastname: Cochran
authors.forename: Andrea
authors.initials: A
authors.lastname: Livi
authors.forename: Richard
authors.initials: R
authors.lastname: Chang
authors.forename: Thomas
authors.initials: T
authors.lastname: Shawker
authors.forename: Monica C
authors.initials: MC
authors.lastname: Skarulis
authors.forename: Phillip
authors.initials: P
authors.lastname: Gorden
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D002985:Clinical Protocols; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000097:blood; D007340:Insulinoma / Q000175:diagnosis* / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D014463:Ultrasonography; D019564:Unnecessary Procedures