[Surgery of insulinoma]

Pre-operative imaging of insulinomas should always be considered, but, if diagnosis is certain, negative imaging studies should never preclude laparotomy. A pre-operative medical trial with Diazoxide is mandatory to check its efficiency and thus allow better therapy at the end of a fruitless exploration, avoiding unnecessary blind pancreatic resection. And even sometimes, its efficiency may lead to discard surgery in a frail elderly patient or in the special patient with multiple tumors and the MEN I syndrome. State-of-the-art surgical exploration requires careful intra-operative monitoring of blood glucose--possibly with biostator--allowing control of completeness of the procedure. Intra-operative localization of the inciting tumor requires full pancreatic mobilization, careful palpation, intra-operative echography and sometimes insulin staged portal sampling with quick intra-operative assay. Insulinomas are very rarely ectopic, but they are multiple in 10% of cases, three out of four such cases in a MEN I setting. Any type of pancreatic resection can be used for tumour removal, but the more conservative one, i.e, enucleation should be elicited, especially in the head. Ultrasonic dissection is a useful tool. Left pancreatic resection should aim to spare the spleen. Completeness of tumor removal is assessed by the hyperglycemic rebound--sometimes delayed till 40 minutes--, a dramatic plasma insulin decrease and possibly change in biostator output. Blind pancreatic resection should be given up. Surgery of liver metastases is of anecdotal interest. Chemotherapy and SMS-analogs can provide long-term palliation.(ABSTRACT TRUNCATED AT 250 WORDS)