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Arterial calcium stimulation with hepatic venous sampling predicts the localization and size of the insulinoma as well as postoperative weight loss.

We have read with great interest the manuscript ‘Surgery in overweight patients with insulinoma: effects on weight loss.’ and decided to share our experiences in patients with insulinoma regarding prediction of tumor size and postoperative weight loss. Contemporary management of insulinoma is possible only with appropriate laboratory testing of hypoglycemic symptoms and exact preoperative localization with aim to minimize unsuccessful pancreatic surgical resection. The aim of our analysis was to explore whether some anamnestic or laboratory data during 72- hour fasting test and/or arterial calcium stimulation with hepatic venous sampling (ASVS) of patients with insulinoma and inconclusive localization techniques could predict not only localization but also the size of the tumor. The next question was whether postoperatively established maximum diameter of tumor size could predict future weight loss. We retrospectively analyzed data of 11 patents (5 male, 6 female) diagnosed at the Department of Endocrinology, Internal Medicine Clinic, University Hospital Centre Zagreb, Croatia form 2007 and 2017 and followed for at least 6 months. Those patients had established diagnosis of endogenous hyperinsulinism, though noninvasive localization techniques (US, abdominal CT, or MRI) were inconclusive. One patient that developed tumor recurrence and was diagnosed with multiple endocrine neoplasia type 1 was excluded form analysis as well as the one that rejected surgical procedure and was later treated with diazoxide. Median age of the patients was 55 years (45-60), median body mass index (BMI) 25, 8 kg/m2 (21, 3-40, 3). Half of the patients claimed to gain weight before the diagnosis of insulinoma. Hypoglycemia was confirmed with standard 72- hour fasting test protocol, mean of lowest glucose level during the test was 1, 7 mmol/l (1, 0-2, 1) without adequate insulin suppression. All patients underwent ASVS ; standard pancreatic arteriography was performed and followed by selective catheterization of the gastroduodenal, splenic, and superior mesenteric arteries. An injection of calcium gluconate at a dose of 0.025 mEq/Kg body weight was applied in every artery and blood samples were obtained from the hepatic vein 10 minutes before the calcium injection and 30, 60, 90, and 120 seconds after. Median of peek insulin level during ASVS was 410 mU/L (128-2195). Peek insulin level following ASVS exactly pointed to the tumor feeding artery ; in 6 patients it was splenic, in three patients gastroduodenal and in two patients superior mesenteric artery. Two patients had enucleation of the tumor form the body of the pancreas, 4 distal pancreatectomy with splenectomy, in one patient pancreaticoduodenectomy was performed, in two pancreatic head resection and two patients underwent enucleation of the tumor from uncinate process. There was no operative mortality, all patients had a benign type of tumor. One patient developed postoperatively pancreatitis with pseudocyst formation, and one got hospital-acquired pneumonia. Complete symptom resolution was achieved in all cases. None of the patients had long term endocrine pancreatic insufficiency, i.e. diabetes mellitus. Median tumor size was 1, 7 cm (0, 8- 2, 5). Median weight loss of all patients shown as percentage of initial weight after 6± 2 and after 18 ± 4 months following the surgery were 10, 5% and 13 % retrospectively. We found a moderate positive correlation among lowest glucose level during the 72- hour fasting test and tumor size (r =0, 45) as well among peek insulin level during ASVS and tumor size (r=0, 49). Following the surgery we divided patient in two subgroups ; those with tumors smaller than 1, 5 cm (4 patient with median tumor size of 1, 4 cm, range 0, 8 -1, 5) and those with tumor larger than 1, 5 cm (8 patient with median tumor size of 1, 8 cm, range 1, 6-2, 2). 2 confirms statistical difference (P = 0.05) in patients who did or didn’t gain weight before the surgery and had tumor smaller or larger than 1, 5 cm. Patients with tumor larger than 1, 5 cm after 6± 2 and 18 ± 4 months lost 17 % and 19% of their initial body weight retrospectively. Those with tumor smaller than 1, 5 cm after 6± 2 and 18 ± 4 months lost 8% and 16% of their initial body weight retrospectively. In short, accurate preoperative localization of insulinoma and presumption of its size is key information for surgeon with the aim of pancreatic sparing surgery and preservation of healthy pancreatic parenchyma. We found that weight gain before the surgery, lover glucose level during the 72- hour fasting test and higher peek insulin level during ASVS could predict the size of insulinoma. Such information can help planning the extent of the surgical procedure. Following the surgery, size of the tumor itself, predicts short and long term weight loss rate.

Arterial calcium stimulation ; Insulinoma ; Weight loss

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