[Surgical treatment and outcome in insulinoma]

In the therapy of organic hyperinsulinism, interest is mainly focussed on the surgical removal of the hyperactive tissue. In spite of these progresses, the surgical treatment is not devoid of problems. These comprise the primary untraceable insulinoma, multiple insulinomas, nesidioblastosis and reoperation. The development of laparoscopic surgery leads to new opportunities the rating of which must be defined. Solitary adenomas are causal for primary hyperinsulinism in 80% to 90% of cases. Intraoperative 87.5% of the tumors are palpable and 83% are detectable by ultrasound. By combination of both methods it is possible to remove 97% of the solitary tumors. Occult adenomas, which cannot be represented by preoperative imaging diagnostics are detectable through intraoperative methods in over 80% of cases by palpation or ultrasound respectively. By combination of both methods, 97% of these occult adenomas can be removed. This reliability of the intraoperative detection makes the preoperative localizing diagnostics unnecessary if no MEN-syndrome is present. If a MEN-syndrome is present, multiple adenomas are common. In 60% of cases multiple adenomas are responsible for the persistency of the syndrome after an unsuccessful primary operation. Therefore a preoperative localizing diagnostics is advisable in case of a MEN-syndrome. Multiple adenomas are treated by left-pancreatic resection with enucleation of remaining adenomas in the pancreatic head region. In case of an untraceable adenoma, the possibility of the rare nesidioblastosis should be considered. This rare occurrence can be detected by fresh frozen sectioning. The resection of 75% to 80% of the pancreas is recommended. The attempt of a laparoscopic removal of solitary adenomas may be indicated, taking into account all contraindications. The preliminary requisite for this is an experienced center in endocrine surgery as well as an experienced laparoscopic surgeon. Contraindications for the laparoscopic procedure are: a tumor localized in the head of the pancreas or in the dorsal parts of the organ, multiple adenomas and nesidioblastosis. In case of occult adenomas, laparoscopic therapy is problematic, as they are also difficult to detect intraoperatively through laparoscopy. The incidence of postoperative complications is still high with 30% and a mortality of 2%. Most often pancreatic fistulas (10%) and septic complications were seen.