Results after operative treatment of organic hyperinsulinism

In the therapy of organic hyperinsulinism, interest is mainly focussed on t he surgical removal of the hyperactive tissue. In spite of these progresses , the surgical treatment is not devoid of problems. These comprise the prim ary untraceable insulinoma, multiple insulinomas, nesidioblastosis and reop eration. The development of laparoscopic surgery leads to new opportunities the rating of which must be defined. Solitary adenomas are causal for prim ary hyperinsulinism in 80 % to 90 % of cases. Intraoperative 87.5 % of the tumors are palpable and 83 % are detectable by ultrasound. By combination o f both methods it is possible to remove 97 % of the solitary tumors. Occult adenomas, which cannot be represented by preoperative imaging diagnostics are detectable through intraoperative methods in over 80 % of cases by palp ation or ultrasound respectively. By combination of both methods, 97 % of t hese occult adenomas can be removed. This reliability of the intraoperative detection makes the preoperative localizing diagnostics unnecessary if no MEN-syndrome is present. If a MEN-syndrome is present, multiple adenomas ar e common. In 60 % of cases multiple adenomas are responsible for the persis tency of the syndrome after an unsuccessful primary operation. Therefore a preoperative localizing diagnostics is advisable in case of a MEN-syndrome. Multiple adenomas are treated by left-pancreatic resection with enucleatio n of remaining adenomas in the pancreatic head region. In case of an untrac eable adenoma, the possibility of the rare nesidioblastosis should be consi dered. This rare occurrence can be detected by fresh frozen sectioning. The resection of 75 % to 80 % of the pancreas is recommended. The attempt of a laparoscopic removal of solitary adenomas may be indicated, taking into ac count all contraindications. The preliminary requisite for this is an exper ienced center in endocrine surgery as well as an experienced laparoscopic s urgeon. Contraindications for the laparoscopic procedure are: a tumor local ized in the head of the pancreas or in the dorsal parts of the organ, multi ple adenomas and nesidioblastosis. In case of occult adenomas, laparoscopic therapy is problematic, as they are also difficult to detect intraoperativ ely through laparoscopy. The incidence of postoperative complications is st ill high with 30 % and a mortality of 2 %. Most often pancreatic fistulas ( 10 %) and septic complications were seen.