title: Intraoperative ultrasound with palpation is still superior to intra-arterial calcium stimulation test in localising insulinoma.
abstract: OBJECTIVE
  This study assessed the sensitivities of preoperative localisation modalities such as computed tomography (CT), magnetic resonance imaging (MRI), arteriography and arterial stimulation venous sampling (ASVS) using serum insulin and C-peptide gradients to intraoperative techniques in localising insulin-secreting tumours in our institution.
  
  
  METHODS
  Fourteen patients with proven insulinoma, aged 20-66 years, who presented from 1997 to 2004, were studied retrospectively. All patients underwent ASVS where C-peptide and/or insulin gradients were calculated. The results were compared with the preoperative findings of CT, MRI, arteriography, as well as intraoperative ultrasound and palpation.
  
  
  RESULTS
  Intraoperative ultrasound with palpation correctly localised 10 of the 11 tumours with a sensitivity of 91%. Sensitivities of other localisation techniques were lower: 31% by CT, 50% by MRI, and 46% by arteriography. ASVS with insulin gradients alone allowed accurate localisation in 40% of patients while localisation using only C-peptide gradients of more than 2 was 43%. The insulinomas, measuring 10-30 mm, were successfully removed in 13 patients--6 from the body, 4 from the tail, 2 from the head and 1 from the junction of the body and tail. All except 1 were cured by selective surgery and remained free of hypoglycaemia over the next 2-60 months of follow-up. One patient had left lobectomy due to liver metastases from a malignant insulinoma and remained asymptomatic with medical therapy.
  
  
  CONCLUSIONS
  Intraoperative ultrasound with palpation is a highly sensitive method for the localisation of insulinoma compared with other preoperative localisation techniques.
authors.affiliation: Department of Medicine, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia. yiwenyixin@yahoo.com
authors.forename: M
authors.initials: M
authors.lastname: Wong
authors.forename: S H Md
authors.initials: SH
authors.lastname: Isa
authors.forename: M
authors.initials: M
authors.lastname: Zahiah
authors.forename: K Nor
authors.initials: KN
authors.lastname: Azmi
mesh_terms: D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction; D002096:C-Peptide / Q000097:blood; D002118:Calcium / Q000097:blood; D003287:Contrast Media; D005260:Female; D006801:Humans; D007328:Insulin / Q000097:blood; D007340:Insulinoma / Q000097:blood / Q000000981:diagnostic imaging* / Q000601:surgery; D007430:Intraoperative Care; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010173:Palpation; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed; D014463:Ultrasonography
chemical_list: D002096:C-Peptide; D003287:Contrast Media; D007328:Insulin; D002118:Calcium