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DISCUSSION

DISCUSSION. Anatomy. Pancreas: head, uncinate process, neck, body, tail Pancreatic duct ( Wirsung ): joins the CBD at ampulla of Vater  enters 2 nd part of duodenum at duodenal papillae Accessory duct ( Santorini ): opens into the duodenum. Anatomy. Pancreatic gland: Lobulated

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DISCUSSION

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  1. DISCUSSION

  2. Anatomy • Pancreas: head, uncinate process, neck, body, tail • Pancreatic duct (Wirsung): joins the CBD at ampulla of Vater enters 2nd part of duodenum at duodenal papillae • Accessory duct (Santorini): opens into the duodenum

  3. Anatomy • Pancreatic gland: • Lobulated • Digestive hormones • Islets of Langerhans: • α cells secrete glucagon(increase Glucose in blood) • β cells secrete insulin (decrease Glucose in blood) • δ cells secrete somatostatin and Gastrin (regulates/stops α and β cells) • PP cells secrete pancreatic polypeptide

  4. Insulinoma • low frequency, insulinoma (a tumorof pancreatic β-cells) is the most common type of pancreatic endocrine tumors. • annual incidence of 1 to 4 per million • insulinomasare sporadic, small (90% ≤2 cm), solitary (90%) and benign (>90%) • At presentation, 50% of patients are over 50 years • Median duration of symptoms of 18 months. • Insulinoma has a female preponderance of 59% and, at diagnosis a 5% rate of malignancy • About 8% of insulinoma patients are diagnosed with multiple endocrine neoplasia type 1 (MEN-1) Insulinoma - An Atypical Presentation: Case Report and Literature Review Rassauoli, Lai, Sargeant (University of Toronto Medical Journal) volume 82, number 1, December 2004

  5. Insulinoma - An Atypical Presentation: Case Report and Literature Review Rassauoli, Lai, Sargeant (University of Toronto Medical Journal) volume 82, number 1, December 2004

  6. INSULINOMA • endocrine tumor of the pancreas derived from beta cells that ectopically secretes insulin, which results in hypoglycemia. • 40–50 years. • Small; 90% are < 2 cm • not multiple (90%) • 5–15% are malignant • distributed throughout the head, body, and tail

  7. NEUROGLYCEMIC SYMPTOMS • The most common clinical symptoms • confusion, headache, disorientation, visual difficulties, irrational behavior, or even coma. • sweating, tremor, and palpitations

  8. Fast up to 72 h with serum glucose, C-peptide, and insulin measurements every 4–8 h <40 mg/dL

  9. CRITERIA FOR DIAGNOSIS • Insulin level >6 µU/mL; blood glucose is <40 mg/dL • Elevated C-peptide and serum proinsulinlevel • Insulin/glucose ratio >0.3 • Decreased plasma B-hydroxybutyratelevel

  10. EXOGENOUS INSULIN • (N) Proinsulinlevels • ↓ C-peptide levels • (+) Antibodies to insulin • Sulfonylurea

  11. DIAGNOSTIC TECHNIQUES • CT scanning • Endoscopic ultrasound • Arteriography with catheterization of small arterial branches of the celiac system combined with calcium injections

  12. DIFFERENTIALS • Reactive hypoglycaemia • Functional hypoglycaemia with Gastrectomy • Adrenal Insufficiency • Hypopituitarism • Hepatic Insufficiency • Manchausensyndrome (insulin self-injections) • Nonislet cell tumor causing hypoglycaemia • Surreptitious administration of insulin or OHAs

  13. MANAGEMENT

  14. CONSERVATIVE MANAGEMENT • Intake of small frequent meals that are rich in carbohydrates • Strenuous exercise should be avoided • Medical treatment • Diazoxide - nondiureticbenzothiadiazine - stimulate b-cell adrenergic receptors decreasing insulin release - standard dose: 150-450mg daily, often divided into doses every 8 hours - side effects: sodium and water retention, hirsutism

  15. SURGICAL MANAGEMENT Surgical resection - treatment of choice • Enucleationof the insulinoma - performed in patients who have a solitary tumor that is not encroaching on the pancreatic duct • Distal pancreatectomy - performed en-bloc along with resection of the spleen - makes the operation short and easy - tumors are often present in the tail and body of the pancreas

  16. SURGICAL MANAGEMENT • Whipple procedure (pancreaticoduodenectomy) - may be required if the tumor is in close proximity to major ductal structures • Warshaw'stechnique - spleen may be preserved by maintaining the integrity of the short gastric vessels and the left gastro-epiploic vessels

  17. SURGICAL MANAGEMENT Complications: pancreatic fistula persistent hyperinsulinism bile leak and prolonged gastric ileus injury to the spleen

  18. SURGICAL MANAGEMENT • New Techniques Cryoablation Laparoscopic pancreatic surgery

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