Anesth Analg 2001;93:239-240
© 2001 International Anesthesia Research Society
CASE REPORT
A Successful Monitoring for Intraoperative Calcium Stimulation Test in Complete Resection of Pancreatic Insulinoma
Masashi Nakagawa, MD*,
Fujiko Sasakuma, CT ,
Yoshihiko Kishi, MD*, and
Osamu Ishikawa, MD
Departments of *Anesthesiology, Laboratory Medicine, and Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
Address correspondence and reprint requests to Dr. Nakagawa, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari, Osaka City, 537-8511, Japan. Address e-mail to m.h.naka{at}f4.dion.ne.jp
 |
Abstract
|
|---|
Implications: An intraoperative arterial stimulation, venous sampling method was recently used for resection of insulinoma. In using this technique, some anesthetic concerns complicate the usual management of insulinoma. We suggest methods for solving these problems.
|
Introduction
|
|---|
Twelve percent of those who undergo surgical removal of an insulinoma require reoperations (1). This is because these residual tumors are extremely small (<2 cm in diameter), and 11% are multiple (2). Therefore, it is very important to certify the complete removal of small insulinomas during surgery.
The arterial stimulation venous sampling (ASVS) method, in which insulin secretion is stimulated by calcium gluconate injection from feeding arteries and the immunoreactive insulin (IRI) value of the drainage vein is measured, was developed for localizing functional tumors during angiography (3,4). Recently, the ASVS method has been used for detecting an insulinoma and certifying its complete removal during surgery (5). The following is an example of such a case.
|
Case Report
|
|---|
A 52-yr-old man with Whipple’s triad had a preliminary diagnosis of insulinoma. Before surgery, endoscopic ultrasonogram and a magnetic resonance image detected a 10-mm-diameter tumor in the pancreatic tail, but computed tomography and abdominal ultrasonography could not detect it. During angiography, injection of calcium gluconate into the proximal and distal portion of the splenic artery demonstrated an increase in the IRI value in the hepatic vein blood, but injection from other arteries did not show any increase (Fig. 1). From these data, partial resection of the pancreatic tail was planned.
For preventing hypoglycemia, a 12.5% glucose solution was infused at a rate of 0.2 g · kg-1 · h-1 during the preoperative fasting period. Premedications were not prescribed because they could mask the symptoms of hypoglycemia.
In the operating room, the usual monitoring was used. Anesthesia was induced with propofol IV, and endotracheal intubation was facilitated by the administration of vecuronium, after which an epidural catheter was inserted into the T9-10 interspace. Thereafter, anesthesia was maintained by a continuous infusion of propofol and supplemental epidural injection of local anesthetics.
The blood glucose level was measured every 10 min during anesthesia and was maintained at approximately 100 mg/dL by adjusting an infusion rate of 10% of glucose solution until documentation of complete removal with the ASVS method had been achieved. Then the infusion rate of 10% of glucose solution was adjusted to minimize rebound hyperglycemia.
After partial resection of the pancreatic tail, a catheter was inserted through the umbilical vein for sampling portal venous blood. From the resected edge of the splenic artery, 0.025 mEq/kg of calcium gluconate was injected, and portal venous blood was obtained at 0, 30, 60, 90, and 120 s after injection. The IRI value from these samples demonstrated no abrupt increase, as observed before surgery (Fig. 1). Moreover, to deny the presence of ectopic insulinoma, 0.075 mEq/kg of calcium gluconate was administered systematically from the peripheral vein, and arterial blood was obtained at 0, 30, 60, 90, 120, and 150 s after injection. The IRI value from those samples also demonstrated no abrupt increment (Fig. 1). These findings meant that removal of insulinoma was completed. The patient has had no episodes of hypoglycemia during a 2-yr follow-up.
|
Discussion
|
|---|
Many methods (e.g., blood glucose monitoring, circulating IRI monitoring, and intraoperative ultrasonography) have been used to certify complete removal of insulinoma; however, these tests are sometimes inaccurate (6,7). The ASVS method was first developed for localization of gastrinoma in the Zollinger-Ellison syndrome during angiography (3). This method is also useful for the localization of insulinoma (4,8,9), but there are no reports that describe the anesthetic management for insulinoma removal using the intraoperative ASVS method.
To use the ASVS method for intraoperative documentation, we developed a new, quick radioimmunoassay kit for IRI that uses polyclonal antiinsulin antibody insolubilized with bacterial cell wall particles (10,11). It can measure not only insulin, but also proinsulin and intermediate insulin, by using the polyclonal antibody. Thus, this kit can be used for insulinoma that secretes precursors of insulin. Moreover, it can cover a wide range of insulin levels by adjusting the concentration of particles—that is, this kit can measure an abrupt change in insulin induced by stimulation.
It is very important to prevent hypoglycemia perioperatively. Hyperglycemia should also be avoided when using the ASVS method because insulin secretion from ß islet cells is stimulated by high blood glucose levels. To keep the blood glucose level at approximately 100 mg/dL, we measured blood glucose concentrations every 10 minutes and adjusted the infusion rate of 10% of glucose solution. This maneuver provided a favorable level of blood glucose concentration.
The ASVS method for insulinoma has the potential risk of severe hypoglycemia because of hyperinsulinemia induced by the calcium stimulation (12). In our patient, the blood glucose level was kept at approximately 100 mg/dL during the ASVS method. Maintaining this blood glucose level might have increased the risk of hypoglycemia. Thus, closer monitoring of his blood glucose level was essential for anesthetic management during this period.
We experienced three cases of insulinoma when using the ASVS method, including this case. All cases could be managed safely by the frequent measurement of blood glucose concentration and adjustment of the glucose infusion rates. We strongly recommend using this maneuver when ASVS is planned for surgical removal of insulinoma.
|
References
|
|---|
-
Thompson GB, Service FJ, van Heerden JA, et al. Reoperative insulinomas, 1927–1992: an institutional experience. Surgery 1992; 114: 1196–206.
-
Ishii H, Ito T, Moriya S, et al. Insulinoma: a statistical review of 443 cases in Japan. Nippon Rinsho 1993; 51: 199–206.
-
Imamura M, Minematsu S, Suzuki T, et al. Usefulness of selective arterial secretin injection test for localization of gastrinoma in the Zollinger-Ellison syndrome. Ann Surg 1987; 205: 230–9.[Web of Science][Medline]
-
Doppman JL, Millar DL, Chang R, et al. Insulinomas: localization with selective intraarterial injection of calcium. Radiology 1991; 178: 237–41.[Abstract/Free Full Text]
-
Aoki T, Sakon M, Ohzato H, et al. Evaluation of preoperative and intraoperative arterial stimulation and venous sampling for diagnosis and surgical resection of insulinoma. Surgery 1999; 126: 968–73.[Web of Science][Medline]
-
Tutt GO, Edis AJ, Service FJ, van Heerden JA. Plasma glucose monitoring during operation for insulinoma: a critical reappraisal. Surgery 1980; 88: 351–6.[Web of Science][Medline]
-
Correnti S, Liverani A, Antonini G, et al. Intraoperative ultrasonography for pancreatic insulinoma. Hepatogastroenterology 1996; 43: 207–11.[Medline]
-
Hayashi T, Honda H, Yasumori K, et al. Selective intra-arterial injection of calcium for localization of insulinoma: proposed new criteria. Nippon Igaku Hoshasen Gakkai Zasshi 1995; 55: 957–60.[Medline]
-
Teichmann RK, Spelsberg F, Heberer G. Intraoperative biochemical localization of insulinomas by radioimmunoassay. Am J Surg 1982; 143: 113–5.[Web of Science][Medline]
-
Sasakuma F, Hasegawa K, Ishikawa O, et al. Quick radioimmunoassay for plasma immunoreactive insulin (IRI): application for localizing occult insulinoma during operation. Rinsho Byori 1990; 38: 1267–72.[Medline]
-
Shimizu T, Sasakuma F, Hasegawa K, et al. Comparison of two enzyme immunoassays for IRI using mono- and polyclonal antibody: influence of antibody specificity on IRI values in insulinoma patients. Tonyobyo 1993; 36: 825–7.
-
O’Shea D, Rohrer-Theurs AW, Lynn JA, et al. Localization of insulinomas by selective intraarterial calcium injection. J Clin Endocrinol Metab 1996; 81: 1623–7.[Abstract]
Accepted for publication February 28, 2001.
|
Top
Abstract
Introduction
), the distal portion of the splenic artery (•), the proper hepatic artery (
), the gastroduodenal artery (
, and the superior mesenteric artery (
) in preoperative superselective angiography are shown. Only the IRI values after Ca stimulation from both portions of the splenic arteries presented abrupt increases. IRI values of portal vein blood samples after Ca stimulation from the resection edge of the splenic artery (
and IRI values of the radial artery after Ca stimulation from the peripheral vein (x) during surgery are also shown. No abrupt preoperative increases in the angiography were observed.
