Insulinoma: treatment

Radical treatment of insulinoma is a surgical method. The operation is refrained usually when the patient himself refuses or if there are serious accompanying somatic manifestations. The best method of anesthesia, ensuring the safety of the patient and the maximum convenience of the surgeon, is endotracheal anesthesia with muscle relaxants. The choice of access to the tumor focus is determined by the data of topical diagnosis. When localizing insulinoma in the head or body of the pancreas, it is convenient to use a median laparotomy. If the tumor is detected in the tail, especially in the distal region, then it is advisable to use an extraperitoneal lumbotomy access to the left. With negative or questionable data, topical diagnosis requires a broad overview of the entire pancreas. This goal is fully met by transverse subcostal laparotomy. Insulinoma is equally found in any part of the pancreas. The tumor can be removed by enucleation, excision or resection of the pancreas. It is rare to resort to pancreatoduodenal resection or pancreatectomy. In the postoperative period, the main actions should be aimed at the prevention and treatment of pancreatitis. To do this, protease inhibitors such as trasylol, gordoks, contrikal are used. To suppress the excretory activity of the pancreas, 5-fluorouracil, somatostatin is successfully used. For the same purposes, it is desirable to have a 5-7-day fast with complete parenteral nutrition. During 4-6 days after the operation transient hyperglycemia may occur, which in rare cases needs correction with insulin preparations. In the late period after the removal of the tumor, diabetes mellitus develops rarely. Among the complications of operations for insulinoma, pancreatitis, pancreatic necrosis and pancreatic fistula are traditional. Sometimes there are late bleedings from fistula.

Relapse of the disease is about 3%, postoperative lethality - from 5 to 12%. X-ray and radiotherapy with beta-cell neoplasms is ineffective.

Conservative treatment of insulinoma includes, first, the arrest and prevention of hypoglycemia, and, secondly, should be aimed at the actual tumor process. The first is achieved by the use of various hyperglycemic agents, as well as more frequent feeding of the patient. The traditional hyperglycemic agents include adrenaline and norepinephrine, glucagonol, glucocorticoids. However, the short-term effect and the parenteral mode of application of most of them are extremely inconvenient for permanent use. As for glucocorticoids, the positive effect of the latter is usually achieved at doses that cause cushingoid manifestations. In some patients, stabilization of the level of glycemia is possible with the help of such drugs as diphenylhydantoin (diphenin) at a dose of 400 mg / day, but the greatest recognition has now been received by the drug diazoxide (proglikem, hyperstat). The hyperglycemic effect of this non-diuretic benzothiazide is based on the inhibition of the secretion of insulin 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 shown to all inoperable and incurable patients in the event of patient's refusal from surgical treatment, as well as unsuccessful attempts to detect a tumor on the operation. The drug due to the expressed hypoglycemic effect is able to maintain a normal level of glycemia for years, however, due to a decrease in the excretion of sodium and water, its use in almost all patients leads to edematic 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 insulins, streptozotocin was the most widely recognized. Its action is based on the selective destruction of islet cells of the pancreas. A single dose of streptozotocin administered to rats, dogs or monkeys is sufficient to produce persistent diabetes. About 60% of patients are more or less sensitive to the drug. Objective decrease in the size of the tumor and its metastases was noted in half of the patients. The drug is administered intravenously infusion. Recommended doses vary: daily - up to 2 g, course - up to 30 g, frequency of application - from daily to weekly. These or other side effects from the use of streptozotocin are observed in almost all patients. This is nausea, vomiting, nephro- and hepatotoxicity, hypochromic anemia, diarrhea.

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

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]