Are Preoperative Localization Tests Beneficial

There is no question that preoperative localization tests are essential for all reoperative cases of insulinoma. However, for the initial operation of an insulinoma, some differences of opinion exist. Some investigators shun most preoperative testing and rely almost exclusively on IOUS with careful palpation.40,43 Others, however, favor administering a battery of preoperative localization tests before the initial operation. In a national study of German institutions, it was shown that when no invasive preoperative localization studies were used, 7.4% of all insulinomas were undetected at operation. However, when invasive testing was employed, the negative laparotomy rate dropped to 3.7%.23 It should be remembered that there is a learning curve associated with the use of IOUS, and thus in many centers the use of currently available localization studies does aid in curative surgery for small, occult insulinomas. In general, we start with trans-gastric ultrasonography and proceed to calcium-stimulated arteriography if the former study is negative.

FIGURE 79-11. Intraoperative sonogram. A, Insulinoma of the tail of the pancreas. The arrows designate the insulinoma, which is hypoechogenic compared with the surrounding pancreas. B, A hypoechoic tumor (T) of the pancreas is visualized by intraoperative ultrasonography. Note that the pancreatic duct (arrow) and its proximity to the tumor are clearly shown. (A, From Kaplan EL, Arganini M, Kang S-J. Diagnosis and treatment of hypoglycemic disorders. Surg Clin North Am 1987;67:395-410. B, From Zeiger MA, Shawker TH, Norton JA. Use of intraoperative ultrasonography to localize islet tumors. World J Surg 1993;17:448.)

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