title: Impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation with hepatic venous sampling for preoperative localization of occult insulinoma.
abstract: BACKGROUND
  To determine the impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation (SACST) with hepatic venous sampling for preoperative localization of occult insulinoma.
  
  
  METHODS
  An institutional review board-approved retrospective review was undertaken of 42 patients with surgically confirmed, occult insulinoma who underwent SACST from January 1996 to March 2014. Location of the insulinoma was predicted initially based on the biochemical results of SACST alone according to Doppman's criteria. Pancreatic arteriograms were reviewed blinded to the biochemical results and the regional perfusion of each artery assessed. The anatomic and perfusion data were combined with the biochemical results to make a second prediction and compared with the surgical findings.
  
  
  RESULTS
  The biochemical results were positive in 1, 2, and 3 arterial distributions in 73.8%, 21.4%, and 4.8% of patients, respectively. The celiac trunk and superior mesenteric artery (SMA) anatomy were aberrant in 38.1% and 35.7% of patients, respectively. Clinically significant variations included dorsal pancreatic artery replaced to SMA (21.4%) and celiac stenosis (4.8%). Significant variation and overlap in regional pancreatic perfusion was observed, particularly for the SMA. Sensitivity for insulinoma localization was 54.8% (diagnostic arteriography), 73.8% (biochemical data), 88.1% (biochemical, anatomic, perfusion data), and 92.8% (arteriographic, biochemical, anatomic, perfusion data).
  
  
  CONCLUSIONS
  Careful review of the pancreatic arterial anatomy and regional perfusion is critical for correct interpretation of the biochemical results of SACST and improves the sensitivity of localization for occult insulinoma, particularly in the presence of pancreatic arterial variants or overlap in regional perfusion.
authors: College of Medicine, Mayo Clinic, Rochester, MN. Electronic address: thompson.scott@mayo.edu.
authors: Scott M
authors: SM
authors: Thompson
authors: College of Medicine, Mayo Clinic, Rochester, MN.
authors: Adrian
authors: A
authors: Vella
authors: College of Medicine, Mayo Clinic, Rochester, MN.
authors: F John
authors: FJ
authors: Service
authors: College of Medicine, Mayo Clinic, Rochester, MN.
authors: Clive S
authors: CS
authors: Grant
authors: College of Medicine, Mayo Clinic, Rochester, MN.
authors: Geoffrey B
authors: GB
authors: Thompson
authors: College of Medicine, Mayo Clinic, Rochester, MN.
authors: James C
authors: JC
authors: Andrews
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000792:Angiography; D001158:Arteries / Q000002:abnormalities; D002118:Calcium / Q000378:metabolism; D005260:Female; D006503:Hepatic Veins / Q000000981:diagnostic imaging; D006801:Humans; D007328:Insulin / Q000097:blood / Q000378:metabolism; D000078790:Insulin Secretion; D007340:Insulinoma / Q000097:blood* / Q000000981:diagnostic imaging / Q000378:metabolism / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000098:blood supply* / Q000000981:diagnostic imaging / Q000378:metabolism / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000097:blood* / Q000000981:diagnostic imaging / Q000378:metabolism / Q000601:surgery; D011300:Preoperative Care; D012039:Regional Blood Flow; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D007328:Insulin; D002118:Calcium