Insulinoma - Treatment

Radical treatment of insulinoma is a surgical method. Surgery is usually avoided if the patient refuses or if there are severe concomitant somatic manifestations. The best method of anesthesia, ensuring patient safety and maximum comfort for the surgeon, is endotracheal anesthesia with muscle relaxants. The choice of access to the tumor focus is determined by the data of topical diagnostics. When insulinoma is localized in the head or body of the pancreas, it is convenient to use a midline laparotomy. If the tumor is detected in the tail, especially in the distal part, it is advisable to use an extraperitoneal lumbotomy approach on the left. In case of negative or questionable data of topical diagnostics, a wide view of the entire pancreas is necessary. Transverse subcostal laparotomy fully meets this goal. Insulinoma is equally detected in any part of the pancreas. The tumor can be removed by enucleation, excision or resection of the pancreas. Pancreatoduodenal resection or pancreatectomy is rarely necessary. In the postoperative period, the main actions should be aimed at preventing and treating pancreatitis. For this purpose, protease inhibitors such as trasylol, gordox, contrical are used. 5-fluorouracil and somatostatin are successfully used to suppress the excretory activity of the pancreas. For the same purposes, a 5-7-day fast with adequate parenteral nutrition is desirable. Transient hyperglycemia may be observed for 4-6 days after surgery, which in rare cases requires correction with insulin preparations.Diabetes mellitus rarely develops in the late stages after tumor removal. Among the complications of operations for insulinoma, pancreatitis, pancreatic necrosis and fistulas of the pancreas are traditional. Sometimes late bleeding from fistulas is observed.

Recurrence of the disease is about 3%, postoperative mortality is from 5 to 12%. X-ray and radiotherapy for beta-cell neoplasms are ineffective.

Conservative treatment of insulinoma includes, firstly, relief and prevention of hypoglycemia, and, secondly, it should be aimed at the tumor process itself. The first is achieved by using various hyperglycemic agents, as well as more frequent feeding of the patient. Traditional hyperglycemic agents include adrenaline and noradrenaline, glucagon, glucocorticoids. However, the short-term effect and parenteral route of administration of most of them are extremely inconvenient for continuous use. As for glucocorticoids, the positive effect of the latter is usually achieved at doses that cause Cushingoid manifestations. In some patients, stabilization of glycemia levels is possible with drugs such as diphenylhydantoin (diphenin) at a dose of 400 mg / day, but the drug diazoxide (proglycem, hyperstat) has received the greatest recognition at present. The hyperglycemic effect of this non-diuretic benzothiazide is based on inhibition of insulin secretion from tumor cells. The recommended dose ranges from 100 to 600 mg/day in 3-4 doses (capsules of 50 and 100 mg). Diazoxide is indicated for all inoperable and incurable patients in case of the patient's refusal of surgical treatment, as well as in cases of unsuccessful attempts to detect a tumor during surgery. Due to its pronounced hypoglycemic effect, the drug is capable of maintaining normal glycemia levels for years, however, due to a decrease in sodium and water excretion, its use in almost all patients leads to edema syndrome, so the use of this drug is possible only in combination with diuretics.

Among the chemotherapeutic drugs successfully used in patients with malignant metastatic insulinomas, streptozotocin has received the greatest recognition. Its action is based on the selective destruction of pancreatic islet cells. A single dose of streptozotocin administered to rats, dogs or monkeys is sufficient to produce persistent diabetes mellitus. About 60% of patients are sensitive to the drug to one degree or another. An objective decrease in the size of the tumor and its metastases was noted in half of the patients. The drug is administered intravenously by infusion. The recommended doses vary: daily - up to 2 g, course - up to 30 g, frequency of use - from daily to weekly. Some or other side effects from the use of streptozotocin are noted in almost all patients. These are nausea, vomiting, nephro- and hepatotoxicity, hypochromic anemia, diarrhea.

The frequency of complications largely depends on the daily and course dose. In cases of tumor insensitivity to streptozotocin, adriamycin can be used.

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