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Road accident due to a pancreatic insulinoma: a case report.

Parisi A, Desiderio J, Cirocchi R, Grassi V, Trastulli S, Barberini F, Corsi A, Cacurri A, Renzi C, Anastasio F, Battista F, Pucci G, Noya G, Schillaci G - Medicine (Baltimore) (2015)

Bottom Line: Abdominal computerized tomography and magnetic resonance imaging allowed us to identify and localize the tumor.Insulin-producing tumors may go undetected for a long period due to nonspecific clinical symptoms, and may cause episodes of loss of consciousness with potentially lethal consequences.Robot-assisted procedures can be performed with the same techniques of the traditional surgery, reducing surgical trauma, intraoperative blood loss, and hospital stays.

View Article: PubMed Central - PubMed

Affiliation: From the Unit of Digestive and Liver Surgery (AP, JD, VG, ST, AC), Santa Maria Hospital, Terni; Department of General and Oncologic Surgery (RC, FB, AC, CR, GN), University of Perugia, Perugia; Unit of Internal Medicine (FA, FB, GP, GS), Santa Maria Hospital, Terni; and Department of Medicine (FA, FB, GP, GS), University of Perugia, Perugia, Italy.

ABSTRACT
Insulinoma is a rare pancreatic endocrine tumor, typically sporadic and solitary. Although the Whipple triad, consisting of hypoglycemia, neuroglycopenic symptoms, and symptoms relief with glucose administration, is often present, the diagnosis may be challenging when symptoms are less typical. We report a case of road accident due to an episode of loss of consciousness in a patient with pancreatic insulinoma. In the previous months, the patient had occasionally reported nonspecific symptoms. During hospitalization, endocrine examinations were compatible with an insulin-producing tumor. Abdominal computerized tomography and magnetic resonance imaging allowed us to identify and localize the tumor. The patient underwent a robotic distal pancreatectomy with partial omentectomy and splenectomy. Insulin-producing tumors may go undetected for a long period due to nonspecific clinical symptoms, and may cause episodes of loss of consciousness with potentially lethal consequences. Robot-assisted procedures can be performed with the same techniques of the traditional surgery, reducing surgical trauma, intraoperative blood loss, and hospital stays.

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The dissection of the pancreas.
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Figure 6: The dissection of the pancreas.

Mentions: The patient is in dorsal position with the legs spread. One optical and 3 working robotic trocars are used. A 12 mm extra-port is also placed. It is used by the assistant surgeon in the various surgical phases to introduce the aspirator, mechanical stapler and stitches. Using atraumatic forceps, the stomach is grasped and lifted. A wide opening in the gastrocolic ligament is performed using the Ligasure system. The pancreas is exposed by elevating the stomach and pulling the colon downward with the atraumatic forceps. Once the access in the omental pouch is achieved, the dissection of the splenic artery is performed. The splenic artery is isolated and shown on a loop. Section is performed after placing a hem-o-lok ligation system (Figure 3). The pancreatic isthmus is identified, removed from the portal trunk at the level of the posterior wall, and surrounded by a loop (Figure 4). Section of the pancreas at the level of the isthmus is performed by robotics stapler (Figure 5), and after careful hemostasis the body and tail are dissected using the hook (Figure 6). After dissecting the splenic lower-pole vessels, the spleen is separated from its adhesions with the diaphragm and the stomach. The specimen is positioned in the endo-bag, and a peritoneal lavage is done. Hemostasis is achieved with cautery and compression. A drainage tube is placed in a retrogastric position. The specimen is removed from the abdomen through a 12-mm port (Figure 7). Surgical time was 210 minutes, and the blood loss was 90 mL; no transfusion was performed. Nasogastric tube, urinary catheter, and drainage tube were removed after 24 hours. On the first day, the pain on the Visual Analog Scale (VAS) score was equal to 3, and bowels were open to gas. On the second day, bowel sounds were audible and a liquid diet was started; on the third day, the bowels were open to the feces and a solid diet was started. On the fourth postoperative day, the patient was discharged in good health with proper glucose levels. Histopathological examination of tissues revealed a normal but enlarged spleen of 160 × 135 × 50 mm. In the resected caudal portion of the pancreas, a 14 × 20 mm brownish nodule, apparently capsulated, was present. The omentum included 2 capsulated, brownish red–colored nodules, respectively, 10 and 9 mm in diameter, compatible with accessory spleens. The histological diagnosis was well-differentiated neuroendocrine tumor (NET-G1), limited to the pancreas. No evidence of perineural and angiolymphatic neoplastic infiltration was present. Mitotic index was <1 mitotic figures per 10 high power fields. There was no infiltration of the surgical margins. The immunohistochemical analysis showed chromogranin +, synaptophysin +, NSE +, CD56 +/−, ki-67/MIB1 1%. After 90 days, all symptoms attributable to hypoglycemia disappeared, and plasma glucose and insulin levels were in the normal range.


Road accident due to a pancreatic insulinoma: a case report.

Parisi A, Desiderio J, Cirocchi R, Grassi V, Trastulli S, Barberini F, Corsi A, Cacurri A, Renzi C, Anastasio F, Battista F, Pucci G, Noya G, Schillaci G - Medicine (Baltimore) (2015)

The dissection of the pancreas.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554003&req=5

Figure 6: The dissection of the pancreas.
Mentions: The patient is in dorsal position with the legs spread. One optical and 3 working robotic trocars are used. A 12 mm extra-port is also placed. It is used by the assistant surgeon in the various surgical phases to introduce the aspirator, mechanical stapler and stitches. Using atraumatic forceps, the stomach is grasped and lifted. A wide opening in the gastrocolic ligament is performed using the Ligasure system. The pancreas is exposed by elevating the stomach and pulling the colon downward with the atraumatic forceps. Once the access in the omental pouch is achieved, the dissection of the splenic artery is performed. The splenic artery is isolated and shown on a loop. Section is performed after placing a hem-o-lok ligation system (Figure 3). The pancreatic isthmus is identified, removed from the portal trunk at the level of the posterior wall, and surrounded by a loop (Figure 4). Section of the pancreas at the level of the isthmus is performed by robotics stapler (Figure 5), and after careful hemostasis the body and tail are dissected using the hook (Figure 6). After dissecting the splenic lower-pole vessels, the spleen is separated from its adhesions with the diaphragm and the stomach. The specimen is positioned in the endo-bag, and a peritoneal lavage is done. Hemostasis is achieved with cautery and compression. A drainage tube is placed in a retrogastric position. The specimen is removed from the abdomen through a 12-mm port (Figure 7). Surgical time was 210 minutes, and the blood loss was 90 mL; no transfusion was performed. Nasogastric tube, urinary catheter, and drainage tube were removed after 24 hours. On the first day, the pain on the Visual Analog Scale (VAS) score was equal to 3, and bowels were open to gas. On the second day, bowel sounds were audible and a liquid diet was started; on the third day, the bowels were open to the feces and a solid diet was started. On the fourth postoperative day, the patient was discharged in good health with proper glucose levels. Histopathological examination of tissues revealed a normal but enlarged spleen of 160 × 135 × 50 mm. In the resected caudal portion of the pancreas, a 14 × 20 mm brownish nodule, apparently capsulated, was present. The omentum included 2 capsulated, brownish red–colored nodules, respectively, 10 and 9 mm in diameter, compatible with accessory spleens. The histological diagnosis was well-differentiated neuroendocrine tumor (NET-G1), limited to the pancreas. No evidence of perineural and angiolymphatic neoplastic infiltration was present. Mitotic index was <1 mitotic figures per 10 high power fields. There was no infiltration of the surgical margins. The immunohistochemical analysis showed chromogranin +, synaptophysin +, NSE +, CD56 +/−, ki-67/MIB1 1%. After 90 days, all symptoms attributable to hypoglycemia disappeared, and plasma glucose and insulin levels were in the normal range.

Bottom Line: Abdominal computerized tomography and magnetic resonance imaging allowed us to identify and localize the tumor.Insulin-producing tumors may go undetected for a long period due to nonspecific clinical symptoms, and may cause episodes of loss of consciousness with potentially lethal consequences.Robot-assisted procedures can be performed with the same techniques of the traditional surgery, reducing surgical trauma, intraoperative blood loss, and hospital stays.

View Article: PubMed Central - PubMed

Affiliation: From the Unit of Digestive and Liver Surgery (AP, JD, VG, ST, AC), Santa Maria Hospital, Terni; Department of General and Oncologic Surgery (RC, FB, AC, CR, GN), University of Perugia, Perugia; Unit of Internal Medicine (FA, FB, GP, GS), Santa Maria Hospital, Terni; and Department of Medicine (FA, FB, GP, GS), University of Perugia, Perugia, Italy.

ABSTRACT
Insulinoma is a rare pancreatic endocrine tumor, typically sporadic and solitary. Although the Whipple triad, consisting of hypoglycemia, neuroglycopenic symptoms, and symptoms relief with glucose administration, is often present, the diagnosis may be challenging when symptoms are less typical. We report a case of road accident due to an episode of loss of consciousness in a patient with pancreatic insulinoma. In the previous months, the patient had occasionally reported nonspecific symptoms. During hospitalization, endocrine examinations were compatible with an insulin-producing tumor. Abdominal computerized tomography and magnetic resonance imaging allowed us to identify and localize the tumor. The patient underwent a robotic distal pancreatectomy with partial omentectomy and splenectomy. Insulin-producing tumors may go undetected for a long period due to nonspecific clinical symptoms, and may cause episodes of loss of consciousness with potentially lethal consequences. Robot-assisted procedures can be performed with the same techniques of the traditional surgery, reducing surgical trauma, intraoperative blood loss, and hospital stays.

Show MeSH
Related in: MedlinePlus