What are the surgical options for the treatment of insulinoma?

Updated: May 31, 2020
  • Author: Zonera Ashraf Ali, MBBS; Chief Editor: Neetu Radhakrishnan, MD  more...
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Answer

If an open procedure is selected, fully expose the pancreas, including a wide Kocher maneuver to allow complete bimanual palpation.

Compared with open procedures, laparoscopy has been found to permit equivalent oncologic resection, along with decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. [53] A large study from Spain showed laparoscopic surgery to be safe and effective in benign and malignant tumor resection. [8]

Laparoscopic enucleation techniques, also in combination with preservation of the spleen for distal pancreatic tumors, have been described. [54] Because of the small likelihood that a tumor that presents without metastatic spread is malignant, insulinomas may be removed by enucleation. [55] Care should be taken to achieve total tumor capsule removal to prevent tumor recurrence.

If enucleation is not possible, a larger pancreatic resection including pancreaticoduodenectomy may be necessary. This should only rarely be required. When metastatic insulinoma is found on a patient's initial presentation, the organ spread is to liver and sometimes to bone.

Other surgical considerations are as follows:

  • Avoid total pancreatectomy because of its high morbidity and mortality rates.

  • Major resections, such as the Whipple procedure, may become necessary when the tumor is found in the pancreatic head and local excision is not possible.

  • Resect all gross disease when multiple tumors or metastases are present.

  • If insulinoma is associated with type 1 multiple endocrine neoplasia (MEN 1), the management strategy is modified because tumors are often multiple, diffusely spread in the pancreas, and of small size. Definite cure by surgery is rare.

  • Subtotal pancreatectomy with enucleation of tumors from the pancreatic head and uncinate processus often is recommended over simple enucleation because of frequent multiple tumors in MEN 1.

  • Intraoperative serum insulin measurements have been employed to ensure complete tumor removal. This may be important, particularly in patients with MEN 1 who harbor multiple insulinomas.


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