This study will determine if laparoscopy can be used successfully to find and remove
insulinomas (insulin-secreting tumors of the pancreas). These tumors are very small and
often difficult to locate with magnetic resonance imaging (MRI), computed tomography (CT) or
ultrasound. Invasive procedures, such as arteriograms (X-ray imaging using a contrast agent
injected into the bloodstream through a catheter) and venous sampling are more successful
but involve more patient discomfort and greater risk. This study will test whether
laparoscopy can be used to replace some or all of these tests, as well as more extensive
Patients 11 years of age and older with low blood sugar (hypoglycemia) probably caused by an
insulinoma may be eligible for this study. Candidates will have their hypoglycemia confirmed
(with tests done under NIH protocol 91-DK-0066: Diagnosis and Treatment of Hypoglycemia) and
will have CT imaging of the abdomen and MRI and ultrasound tests of the liver and pancreas.
Patients whose tumors are not found by these studies will undergo arteriography of the
pancreas and hepatic (liver) venous sampling.
Patients will then have laparoscopy. This surgical procedure uses a laparoscope-a tube-like
device with special cameras and an ultrasound probe attached through which the surgeon can
see and operate inside the abdomen. Laparoscopy is commonly done to remove the gallbladder
and is also used to remove portions of the pancreas. For the current procedure, the surgeon
makes small incisions in the abdomen, inserts tubes, fills the abdomen with gas, and
proceeds to explore and operate on the pancreas. The surgeon will try to locate the tumor
with the laparoscope. If the tumor is found, the location will be verified by the imaging
study results. If it cannot be located by laparoscopy, the results of the imaging studies
will be disclosed to enable removal. If the tumor cannot be successfully removed using the
laparoscope, standard surgery will then be performed. If the tumor cannot be found though
laparoscopy, imaging studies, or traditional surgery, the operation will be concluded
without removing any of the pancreas. Medical treatment will be initiated and re-evaluation
will be recommended after 6 months.
Patients with the clinical diagnosis of hypoglycemia secondary to a putative insulin
secreting pancreatic neuroendocrine tumor require accurate localization of the tumor and
definitive surgical resection. Non-invasive pre-operative imaging studies such as CT, MRI
and ultrasound often fail to accurately localize the lesion prior to surgery. Invasive
imaging such as arteriogram and selective arterial stimulation are a major improvement, but
may not be needed in all patients. This trial will evaluate the ability of laparoscopic
exploration with intraoperative ultrasound to localize the insulinoma and allow for its
resection with a single procedure.
Patients with a history of symptomatic hypoglycemia due to insulin or proinsulin secretion
presumed to be from an insulinoma.
Age greater than or equal to 11 years.
Patients must be willing to return to NIH for follow-up.
Patients (or their parents or guardians) must be able to sign informed consent.
Patients with a history of Multiple Endocrine Neoplasia type 1 (MEN1) or Von-Hipple-Lindau
(VHL) syndrome or any history of a familial neuroendocrine tumor syndrome.
pregnancy or breast-feeding. A negative pregnancy test (urine or serum) is required prior
Known allergy to contrast agents and contraindications to or failure of pretreatment with
prednisone, diphenhydramine, and cimetidine per standard procedure to prevent such
Evidence of metastatic disease by CT, MRI or US.
Platelet count less than 50,000.
Medical condition which would preclude surgery including moderate to severe chronic lung
disease that may be worsened by gas insufflation of the abdomen.