From the Guidelines
The primary treatment for exophytic or peripheral insulinomas is enucleation, which can be performed laparoscopically for localized solitary tumors within the body and tail of the pancreas, as stated in the most recent guideline 1. When deciding between insulinoma enucleation and partial pancreatic resection, several factors should be considered, including tumor size, location, and relationship to the pancreatic duct.
- Enucleation is preferred for small, solitary, benign-appearing insulinomas located at least 2-3 mm away from the main pancreatic duct and superficially situated within the pancreas, as it preserves pancreatic tissue and function while reducing the risk of postoperative diabetes and exocrine insufficiency.
- Partial pancreatic resection (distal pancreatectomy, pancreaticoduodenectomy, or central pancreatectomy) is indicated for larger tumors, those deeply embedded in the pancreatic parenchyma, tumors close to or involving the main pancreatic duct, multiple insulinomas, suspected malignancy, or when located in the pancreatic neck or proximal body where enucleation risks ductal injury. The most recent study 1 suggests that distal pancreatectomy can be performed laparoscopically, and may be associated with shorter hospital stays. Preoperative localization with CT, MRI, endoscopic ultrasound, and intraoperative ultrasound is essential for surgical planning, and the surgeon should always confirm complete removal by monitoring intraoperative blood glucose levels, which should normalize after successful tumor removal, as supported by the guideline 1. Enucleation is the preferred treatment for benign insulinomas, and partial pancreatic resection should be considered when enucleation is not possible due to tumor location or invasion, as recommended by the guideline 1.
From the Research
Insulinoma Enucleation vs Partial Pancreatic Resection
- Insulinoma enucleation is the preferred surgical management for small, likely benign insulinomas, as it spares pancreatic parenchyma and minimizes morbidity 2.
- Laparoscopic enucleation is a minimally invasive approach that can reduce the morbidity of pancreatic surgery for patients with insulinomas, and is ideal for tumors located in the pancreatic body or tail 2, 3.
- For tumors located in the head of the pancreas, a novel technique of needle-guided laparoscopic enucleation can be used, which involves inserting an 18-G needle into the pancreatic lesion under laparoscopic sonographic guidance 4.
- In cases where the tumor is deep-seated or adjacent to critical vascular structures, a laparoscopic distal pancreatectomy with a focus on vascular and splenic preservation can be performed 5.
- The selection of the optimal surgical technique must be individualized for each patient, taking into account the size, location, and characteristics of the tumor, as well as the patient's overall health and surgical expertise available 3.
- Laparoscopic intraoperative ultrasound is a crucial tool for accurate intraoperative localization of the lesion in the pancreatic region, and can facilitate safe enucleation of small insulinomas 2, 4, 3, 6.