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Invited Critique
December 1, 2007

Laparoscopic Enucleation of Insulinomas—Invited Critique

Arch Surg. 2007;142(12):1205. doi:10.1001/archsurg.142.12.1205

Sweet and colleagues provide a benchmark series of laparoscopic enucleation of pancreatic insulinomas. Insulinomas are the most common functional neuroendocrine pancreatic tumors; most are solitary and benign. Focusing on laparoscopic enucleation of these lesions is reasonable.

The authors report successful preoperative CT localization in only 5 of 9 patients, supplemented by EUS and successful in 2 of 3 patients with nondiagnostic CT scans. These data mirror other findings, with the caveat that EUS is heavily operator dependent and may reveal false-positive or false-negative results.1 The authors' description of laparoscopic intraoperative ultrasonography (used in 6 of 9 patients) as being of principal value to confirm CT findings and to demonstrate the relationship of the lesion to pancreatic duct and vascular anatomy may underrate the usefulness of intraoperative ultrasonography. Given that preoperative noninvasive imaging localizes only 50% to 55% of lesions, laparoscopic intraoperative ultrasonography may be a key operative localization tool to reduce conversion rates due to failure to identify the target lesion. Grover et al2 reported successful laparoscopic intraoperative ultrasonography in localizing 12 of 14 insulinomas (86%). A reasonable localization algorithm would be CT imaging, followed by laparoscopy with intraoperative ultrasonography if positive, and if negative, followed by EUS or calcium-stimulated venous sampling, or even directly to laparoscopy with intraoperative ultrasonography.

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