2019, Number 3
Gastric linitis in lymphoma. Utility of the endoscopic ultrasound in the diagnostic
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Language: English/Spanish [Versi?n en espa?ol]
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Page: 202-207
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ABSTRACT
Introduction: The prevalence of gastric cancer in Mexico has increased in recent years, with a predominance in men. The risk factors are alcohol, tobacco and Helicobacter pylori infection, considering in our population as of moderate risk. Although adenocarcinoma continues to predominate as the most frequent gastric malignancy, a non-negligible percentage of 7-8% according to WHO is occupied by non-Hodgkin's lymphoma (extranodal) and leiomyosarcomas. The appropriate diagnostic approach and differentiation is crucial between adenocarcinoma and lymphoma, since this depends on prognosis and treatment. Case report: A case of a 79 year old man with asthenia, malignant hypercalcemia with an incidental finding of gastric thickening by tomography, in which endoscopic ultrasound was performed for the diagnosis of gastric lymphoma of diffuse variety (Ann Arbor modified II2). Literature review: Endoscopic ultrasound is considered a tool for the diagnosis of gastric carcinoma in all its variants, mainly where the disease is in deep layers. Conclusion: Endoscopic ultrasound is the method that leads us to obtain high diagnostic accuracy in gastric lymphoma allowing the biopsies of total wall thickness for the cell block to perform differential diagnosis always with immunohistochemistry.INTRODUCTION
Insulinomas are neuroendocrine neoplasms that originate in the beta cells of pancreatic islets characterized by increased production of insulin. They are rare tumors.1 The clinical diagnosis is based on Whipple's triad. The most frequent location of insulinomas is in the head and neck of the pancreas. The highest sensitivity for localization of insulinomas is an endoscopic ultrasound of 86.6 to 92.3%.2
The surgical approach to insulinoma depends on the size, proximity to the pancreatic duct, and the splenic vessels. Surgical resection is the treatment of choice with a cure rate in more than 90% of patients.3 Enucleation is indicated in benign small superficial tumors ≤ 3 cm in diameter, located farther than 2 mm from the pancreatic duct. Insulinomas of these characteristics are excellent candidates for laparoscopic resection.4
Laparoscopic approach is infrequent because of the deep location of the pancreas, the technical difficulty, and the need for experienced surgeons. Currently, the safety and efficacy of laparoscopic pancreatic resection have been described as reliable.
PRESENTATION OF THE CASE
A 51-year-old woman with no significant family history. She started her condition three years before her hospital admission with intermittent episodes of diaphoresis and palpitations. On arrival, she reported an oppressive frontal headache and had a capillary glycemia of 28 mg/dl. Her symptoms improved after ingestion of glucose-rich food. She was admitted because of a seizure. Her thorax was found with no alterations, her abdomen with abundant adipose panniculus, soft, non-painful, peristalsis present and normal, and the rest of the examination also without pathological data. Her laboratory studies showed glycosylated hemoglobin of 4.5%, negative blood sulfonylureas, glucose 37 mg, insulin 64.1 IU/ml, C-peptide 8.36 ng/ml, TSH 1.8 IU/ml, T4L 1.11 ng/dl. A contrast-enhanced CT scan of the abdomen was reported normal. Magnetic resonance imaging (MRI) showed a nodular lesion between the head and body of the pancreas of 2.0 × 1.8 × 1.6 cm, which did not produce obstruction. Endoscopic ultrasound (Figure 1) corroborated the superficial location of the tumor, distant more than 2 mm from the splenic vessels and the pancreatic duct. Given its size and location, a laparoscopic enucleation was done. Pneumoperitoneum was produced, ports placed in the umbilicus (10 mm), another one for the hepatic retractor in the right anterior axillary line (10 mm), two left and one right port (5 mm). After dissection of the gastrocolic omentum, the stomach retracted upwards and the tumor was detected between the body and tail of the pancreas (Figure 2). Enucleation was done with a harmonic scalpel and the tumor was removed from the abdominal cavity using a bag through the assistant's port.
The glucose concentration elevated after removal of the tumor and insulin administration by infusion pump was started. Ports were removed under direct vision, the skin was closed in planes with Vicryl 0-0. A closed Jackson-Pratt drain was placed. Cephalexin 500 mg was given every eight hours for three days. The patient was discharged on the seventh day. She tolerated her diet and her glucose was within normal parameters. The drain was removed after 14 days without complications. The histopathological diagnosis was insulinoma.
DISCUSSION
Laparoscopic enucleation of insulinoma is a safe and effective option, with a short hospital stay and rapid patient recovery. It is indicated in cases of single benign insulinoma smaller than 2 cm and in malignant insulinomas that do not require pancreatic reconstruction.5 Transoperative ultrasonography is the most effective technique to confirm the pancreatic anatomy and decide the surgical technique.3 The main reason for converting to open surgery is the inability to locate the tumor, with a conversion rate of 20 to 33% of cases.4
Blood loss is significantly lower when resection is performed laparoscopically.5 Morbidity with the laparoscopic approach (32%) is lower than with laparotomy (40.5%).5 Surgical time does not vary significantly between the two, p > 0.71.6 Gastrointestinal function recovery time was lower with laparoscopy p < 0.0001 compared to hospital stay between 4 to 7 days in patients who underwent laparotomy p < 0.00001.5 The percentage of complications is higher with laparoscopy, 27% vs 15% laparotomy.7 Pancreatic fistula is the main complication in pancreatic resections with an incidence of more than 27%. The frequency is equal for both approaches.8 Factors favoring the formation of a pancreatic fistula are body mass index greater than 27, extensive pancreatic resection ≥ 8 cm, and a blood volume loss ≥ 150 ml.9 Mortality in laparotomy is 3.7%, there are no data yet for laparoscopy. Recurrence of insulinomas is rare and long-term survival is 100% at five years and 96% at 10 years.10
CONCLUSION
Surgical resection of insulinomas by laparoscopy is an appropriate technique in patients with tumors whose location and size allow it. The success of surgery will depend on an adequate preoperative study by the different imaging studies and patient characteristics. The difference in surgical time is not significantly greater with the laparoscopic approach.
REFERENCES
AFFILIATIONS
1 General Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.
2 2nd-year Resident in General Surgery. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.
3 Liver, Pancreas and Biliary Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.
4 Transplant Surgeon. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.
5 Head of the General Surgery Department. Department of General Surgery. Hospital Universitario "Dr. José Eleuterio González". Monterrey, Nuevo León, México.
Ethical considerations and responsibility: Data privacy. In accordance with the protocols established at the authors\' work center, the authors declare that they have followed the protocols on patient data privacy and preserved their anonymity.
The informed consent of the patient referred to in the article is in the possession of the author.
Funding: No financial support was received for this study.
Conflict of interest: The authors declare that there is no conflict of interest.
CORRESPONDENCE
Dr. Alberto González-Quezada. E-mail: agonzalezuanl@gmail.comReceived: 03/03/2017. Accepted: 13/05/2019