title: Setting the bar for laparoscopic resection of sporadic insulinoma.
abstract: BACKGROUND
  Laparoscopic insulinoma resection (LIR) for sporadic disease is increasingly supported as a feasible and safe operation in small series of patients. To determine whether LIR is an acceptable alternative to the open operation, it is necessary to compare LIR to historical controls. The purpose of this study was to identify the skills and technology needed for LIR and establish outcome standards.
  
  
  METHODS
  A database of patients with benign sporadic insulinoma who underwent an open procedure at the Mayo Clinic was reviewed for demographics, imaging, operative/pathology reports, and outcomes. Outcomes were compared to a world-wide meta-analysis of patients who had undergone LIR reported in the English literature between 1996 and 2009.
  
  
  RESULTS
  Two hundred fifteen patients underwent a primary open operation for benign sporadic insulinoma. Solitary tumors were found in 97%. Meta-analysis identified 232 patients who underwent LIR. The open and LIR groups underwent comparable operations that included enucleations (64 vs. 68%) and distal pancreatectomies (28 vs. 35%) (p = 0.06). The mean estimated blood loss, operating time, and length of stay were comparable between the open and LIR groups (p = NS). Pancreatic fistula occurred more often in the LIR group (24 vs. 11%, p < 0.05). A curative operation was performed in 98% of control patients and in 99% of the LIR group (p = NS).
  
  
  CONCLUSIONS
  Multiple insulinomas are rare and a focused resection guided by imaging may be performed. LIR is associated with an increased incidence of pancreatic fistula. Success of LIR will depend on accurate multimodality preoperative imaging, skilled use of lap-US to replace palpation for localization, and safe methods to dissect the tumor adjacent to the pancreatic duct.
authors.affiliation: Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, USA. richards.melanie@mayo.edu
authors.forename: Melanie L
authors.initials: ML
authors.lastname: Richards
authors.forename: Geoffrey B
authors.initials: GB
authors.lastname: Thompson
authors.forename: David R
authors.initials: DR
authors.lastname: Farley
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kendrick
authors.forename: John F
authors.initials: JF
authors.lastname: Service
authors.forename: Adrian
authors.initials: A
authors.lastname: Vella
authors.forename: Clive S
authors.initials: CS
authors.lastname: Grant
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D016063:Blood Loss, Surgical / Q000503:physiopathology; D015331:Cohort Studies; D016208:Databases, Factual; D003952:Diagnostic Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007340:Insulinoma / Q000175:diagnosis / Q000601:surgery*; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010149:Postoperative Pain / Q000503:physiopathology; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000175:diagnosis / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome