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BYPASS-OMA: Hypoglycemic Hyperinsulinemic Nesidioblastosis after Gastric Bypass Surgery-A Case Report and Review of the Literature. Case Rep Endocrinol 2022; 2022:5472304. [PMID: 36588628 PMCID: PMC9800099 DOI: 10.1155/2022/5472304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/18/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
This rare case vignette describes hypoglycemic, hyperinsulinemic nesidioblastosis in a female patient with prior Roux-en-Y gastric bypass. The patient presented with severe symptomatic hypoglycemia resistant to IV dextrose and diazoxide, requiring surgical resection. Traditional imaging found nonspecific findings, and biochemical analysis was inconsistent with insulinoma. A gallium-68 dotatate PET scan was utilized to successfully localize the tumor in the distal pancreas. She underwent laparoscopic resection of the distal pancreatic lesion with resolution of her symptoms and return to euglycemia. The histological evaluation confirmed the diagnosis of nesidioblastosis. Nesidioblastosis is a rare complication of bariatric surgery that may be more clinically relevant with rising prevalence of obesity. Diagnosis with conventional imaging modalities may be challenging; however, the dotatate PET scan may have high utility in detecting lesions. It is essential for clinicians to consider nesidioblastosis in the differential diagnosis of hyperinsulinemic hypoglycemic conditions and recognize there may be a link with increasing rates of bariatric surgery.
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Amaratunga SA, Hussein Tayeb T, Rozenkova K, Kucerova P, Pruhova S, Lebl J. Congenital Hyperinsulinism Caused by Novel Homozygous KATP Channel Gene Variants May Be Linked to Unexplained Neonatal Deaths among Kurdish Consanguineous Families. Horm Res Paediatr 2021; 93:58-65. [PMID: 32203961 DOI: 10.1159/000506476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Neonatal hypoglycemia due to congenital hyperinsulinism (CHI) is a potentially life-threatening condition. Biallelic pathogenic variants in KATP channel subunit genes (ABCC8, KCNJ11), causing severe forms of CHI, are more prevalent in regions with a significant rate of consanguinity and may lead to unexplained neonatal deaths. We hypothesized that KATP channel gene variants are the cause of CHI in three unrelated children from consanguineous Kurdish families with histories of four unexplained neonatal deaths with convulsions. CASES (1) A girl presented on the 6th day of life with recurrent hypoglycemic convulsions (blood glucose 2.05 mmol/L, insulin 58 mIU/L, C-peptide 2,242 pmol/L). (2) A girl with severe developmental delay was diagnosed with CHI at 3 years of age (blood glucose 2.78 mmol/L, insulin 8.1 mIU/L, C-peptide 761 pmol/L) despite a history of recurrent hypoglycemia since neonatal age. (3) A girl presented at 3 weeks of age with convulsions and unconsciousness (blood glucose 2.5 mmol/L, insulin 14.6 mIU/L, C-peptide 523 pmol/L). Coding regions of the ABCC8 and KCNJ11 genes were tested by Sanger sequencing. Potential variants were evaluated using the American College of Medical Genetics standards. Three novel causative homozygous variants were found - p.Trp514Ter in the ABCC8 gene (Pt2), and p.Met1Val (Pt1) and p.Tyr26Ter (Pt3) in the KCNJ11 gene. CONCLUSION CHI caused by KATP channel variants was elucidated in three children, providing a highly probable retrospective diagnosis for their deceased siblings. Future lives can be saved by timely diagnosis of CHI when encountering a neonate with unexplained seizures or other signs of recurrent and/or persistent hypoglycemia.
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Affiliation(s)
- Shenali Anne Amaratunga
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia,
| | - Tara Hussein Tayeb
- Department of Pediatrics, Sulaymani University, College of Medicine, Sulaymani, Iraq
| | - Klara Rozenkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Kucerova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
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Männistö JME, Jääskeläinen J, Otonkoski T, Huopio H. Long-Term Outcome and Treatment in Persistent and Transient Congenital Hyperinsulinism: A Finnish Population-Based Study. J Clin Endocrinol Metab 2021; 106:e1542-e1551. [PMID: 33475139 PMCID: PMC7993590 DOI: 10.1210/clinem/dgab024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT The management of congenital hyperinsulinism (CHI) has improved. OBJECTIVE To examine the treatment and long-term outcome of Finnish patients with persistent and transient CHI (P-CHI and T-CHI). DESIGN A population-based retrospective study of CHI patients treated from 1972 to 2015. PATIENTS 106 patients with P-CHI and 132 patients with T-CHI (in total, 42 diagnosed before and 196 after year 2000) with median follow-up durations of 12.5 and 6.2 years, respectively. MAIN OUTCOME MEASURES Recovery, diabetes, pancreatic exocrine dysfunction, neurodevelopment. RESULTS The overall incidence of CHI (n = 238) was 1:11 300 live births (1972-2015). From 2000 to 2015, the incidence of P-CHI (n = 69) was 1:13 500 and of T-CHI (n = 127) 1:7400 live births. In the 21st century P-CHI group, hyperinsulinemic medication was initiated and normoglycemia achieved faster relative to earlier. Of the 74 medically treated P-CHI patients, 68% had discontinued medication. Thirteen (12%) P-CHI patients had partial pancreatic resection and 19 (18%) underwent near-total pancreatectomy. Of these, 0% and 84% developed diabetes and 23% and 58% had clinical pancreatic exocrine dysfunction, respectively. Mild neurological difficulties (21% vs 16%, respectively) and intellectual disability (9% vs 5%, respectively) were as common in the P-CHI and T-CHI groups. However, the 21st century P-CHI patients had significantly more frequent normal neurodevelopment and significantly more infrequent diabetes and pancreatic exocrine dysfunction compared with those diagnosed earlier. CONCLUSIONS Our results demonstrated improved treatment and long-term outcome in the 21st century P-CHI patients relative to earlier.
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Affiliation(s)
- Jonna M E Männistö
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
- Correspondence: Jonna Männistö, MD, Department of Pediatrics, Kuopio University Hospital, P.O. Box 100, FI-70029 KYS, Kuopio, Finland.
| | - Jarmo Jääskeläinen
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Timo Otonkoski
- Children’s Hospital and Stem Cells and Metabolism Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Huopio
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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Garg PK, Putegnat B, Truong L, Reynolds C, Sanchez I, Nedrelow JK, Uffman J, Lokitz SJ, Nazih R, Garg S, Thornton PS. Visual interpretation, not SUV ratios, is the ideal method to interpret 18F-DOPA PET scans to aid in the cure of patients with focal congenital hyperinsulinism. PLoS One 2020; 15:e0241243. [PMID: 33108363 PMCID: PMC7591017 DOI: 10.1371/journal.pone.0241243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Congenital hyperinsulinism is characterized by abnormal regulation of insulin secretion from the pancreas causing profound hypoketotic hypoglycemia and is the leading cause of persistent hypoglycemia in infants and children. The main objective of this study is to highlight the different mechanisms to interpret the 18F-DOPA PET scans and how this can influence outcomes. MATERIALS AND METHODS After 18F-Fluoro-L-DOPA was injected intravenously into 50 subjects' arm at a dose of 2.96-5.92 MBq/kg, three to four single-bed position PET scans were acquired at 20, 30, 40 and 50-minute post injection. The radiologist interpreted the scans for focal and diffuse hyperinsulinism using a visual interpretation method, as well as determining the Standard Uptake Value ratios with varying cut-offs. RESULTS Visual interpretation had the combination of the best sensitivity and positive prediction values. CONCLUSIONS In patients with focal disease, SUV ratios are not as accurate in identifying the focal lesion as visual inspection, and cases of focal disease may be missed by those relying on SUV ratios, thereby denying the patients a chance of cure. We recommend treating patients with diazoxide-resistant hyperinsulinism in centers with dedicated multidisciplinary team comprising of at least a pediatric endocrinologist with a special interest in hyperinsulinism, a radiologist experienced in interpretation of 18F-Fluoro-L-DOPA PET/CT scans, a histopathologist with experience in frozen section analysis of the pancreas and a pancreatic surgeon experienced in partial pancreatectomies in patients with hyperinsulinism.
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Affiliation(s)
- Pradeep K. Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
- * E-mail:
| | - Burton Putegnat
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Lisa Truong
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Courtney Reynolds
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Irene Sanchez
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | | | - John Uffman
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Stephen J. Lokitz
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Rachid Nazih
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Sudha Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Paul S. Thornton
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
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Abstract
A multidisciplinary approach to patients with congenital hyperinsulinism (HI) can distinguish focal from diffuse HI, localize focal lesions, and permit partial pancreatectomy with cure in almost all focal patients. Surgery does not cure diffuse disease but can help prevent severe hypoglycemia and brain damage. Surgery can be curative for insulinoma and for some cases of atypical HI.
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Affiliation(s)
- N Scott Adzick
- Department of Surgery and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
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Rasmussen AG, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Rasmussen AH, Mortensen MB, Christesen HT. The difficult management of persistent, non-focal congenital hyperinsulinism: A retrospective review from a single, tertiary center. Pediatr Diabetes 2020; 21:441-455. [PMID: 31997554 DOI: 10.1111/pedi.12989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Congenital hyperinsulinism (CHI) is a rare, heterogeneous disease with transient or persistent hypoglycemia. Histologically, focal, diffuse, and atypical forms of CHI exist, and at least 11 disease-causing genes have been identified. METHODS We retrospectively evaluated the treatment and outcome of a cohort of 40 patients with non-focal, persistent CHI admitted to the International Hyperinsulinism Center, Denmark, from January 2000 to May 2017. RESULTS Twenty-two patients (55%) could not be managed with medical monotherapy (diazoxide or octreotide) and six (15%) patients developed severe potential side effects to medication. Surgery was performed in 17 (43%) patients with resection of 66% to 98% of the pancreas. Surgically treated patients had more frequently KATP -channel gene mutations (surgical treatment 12/17 vs conservative treatment 6/23, P = .013), highly severe disease (15/17 vs 13/23, P = .025) and clinical onset <30 days of age (15/17 vs 10/23, P = .004). At last follow-up at median 5.3 (range: 0.3-31.3) years of age, 31/40 (78%) patients still received medical treatment, including 12/17 (71%) after surgery. One patient developed diabetes after a 98% pancreatic resection. Problematic treatment status was seen in 7/40 (18%). Only 8 (20%) had clinical remission (three spontaneous, five after pancreatic surgery). Neurodevelopmental impairment (n = 12, 30%) was marginally associated with disease severity (P = .059). CONCLUSIONS Persistent, non-focal CHI remains difficult to manage. Neurological impairment in 30% suggests a frequent failure of prompt and adequate treatment. A high rate of problematic treatment status at follow-up demonstrates an urgent need for new medical treatment modalities.
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Affiliation(s)
- Amalie G Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Melikian
- Department of Pediatric Endocrinology, Endrocrine Research Center, Moscow, Russia
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Research Center of Endocrine Surgery, Kyiv, Ukraine
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Annett H Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
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Adzick NS, De Leon DD, States LJ, Lord K, Bhatti TR, Becker SA, Stanley CA. Surgical treatment of congenital hyperinsulinism: Results from 500 pancreatectomies in neonates and children. J Pediatr Surg 2019; 54:27-32. [PMID: 30343978 PMCID: PMC6339589 DOI: 10.1016/j.jpedsurg.2018.10.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Congenital Hyperinsulinism (HI) causes severe hypoglycemia in neonates and children. We reviewed our experience with pancreatectomy for the various types of HI. METHODS From 1998 to 2018, 500 patients with HI underwent pancreatectomy: 246 for focal HI, 202 for diffuse HI, 37 for atypical HI (16 for Localized Islet Nuclear Enlargement [LINE], 21 for Beckwith-Wiedemann Syndrome), and 15 for insulinoma. Focal HI neonates were treated with partial pancreatectomy. Patients with diffuse HI who failed medical management underwent near-total (98%) pancreatectomy. Atypical HI patients had pancreatectomies tailored to the PET scan and biopsy findings. RESULTS The vast majority of pancreatectomies for focal HI were < 50%, and many were 2%-10%. 97% of focal HI patients are cured. For diffuse disease patients, 31% were euglycemic, 20% were hyperglycemic, and 49% required treatment for hypoglycemia; the incidence of diabetes increased with long-term follow-up. All 15 insulinoma patients were cured. CONCLUSIONS Our approach to patients with focal HI can distinguish focal from diffuse HI, localize focal lesions, and permit partial pancreatectomy with cure in almost all focal patients. Surgery does not cure diffuse disease but can help prevent severe hypoglycemia and brain damage. Surgery can be curative for insulinoma and for some cases of atypical HI. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- N Scott Adzick
- Department of Surgery and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Diva D De Leon
- Department of Pediatrics and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lisa J States
- Department of Radiology and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Katherine Lord
- Department of Pediatrics and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tricia R Bhatti
- Department of Pathology and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Susan A Becker
- Department of Pediatrics and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Charles A Stanley
- Department of Pediatrics and the Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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van der Steen I, van Albada ME, Mohnike K, Christesen HT, Empting S, Salomon-Estebanez M, Greve Rasmussen A, Verrijn Stuart A, van der Linde AAA, Banerjee I, Boot AM. A Multicenter Experience with Long-Acting Somatostatin Analogues in Patients with Congenital Hyperinsulinism. Horm Res Paediatr 2018; 89:82-89. [PMID: 29241206 DOI: 10.1159/000485184] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/10/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Congenital hyperinsulinism (CHI) is a rare disease characterized by recurrent severe hypoglycemia. In the diffuse form of CHI, pharmacotherapy is the preferred choice of treatment. Long-acting somatostatin analogues have been used in children as off-label medication. However, the efficacy, outcomes, and adverse effect profiles of long-acting somatostatin analogues have not been described in multicentered studies. The aim of this retrospective study is to summarize the experience with long-acting somatostatin analogues in a large group of children with CHI. METHODS Data were obtained retrospectively from 27 patients with CHI who received long-acting somatostatin analogues in 6 different centers in Europe. These included information on glycemic stability, auxology, and adverse effect profile in clinical follow-up assessments. RESULTS Blood glucose control improved in most patients (89%). No life-threatening side effects occurred. Thirteen patients (48%) experienced side effects; in 3 patients (11%), the side effects were the main reason for discontinuation of the treatment. The most frequent side effect was elevated liver enzymes (n = 10, 37%). CONCLUSION Long-acting somatostatin analogues are effective in glycemic control of patients with CHI. However, in 37% of all patients increased liver enzymes were observed. It is important to monitor liver function in all patients receiving long-acting somatostatin analogue therapy.
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Affiliation(s)
- Ivo van der Steen
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mirjam E van Albada
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Klaus Mohnike
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital and Odense Pancreas Center OPAC, Odense University Hospital, Odense, Denmark
| | - Susann Empting
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Maria Salomon-Estebanez
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | - Annemarie Verrijn Stuart
- Department of Pediatric Endocrinology, University Medical Center Utrecht - Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Annelieke A A van der Linde
- Department of Pediatric Endocrinology, Radboud University Medical Center - Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Indraneel Banerjee
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Annemieke M Boot
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Bendix J, Laursen MG, Mortensen MB, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Christesen HT. Intraoperative Ultrasound: A Tool to Support Tissue-Sparing Curative Pancreatic Resection in Focal Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2018; 9:478. [PMID: 30186238 PMCID: PMC6113400 DOI: 10.3389/fendo.2018.00478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Focal congenital hyperinsulinism (CHI) may be cured by resection of the focal, but often non-palpable, pancreatic lesion. The surgical challenge is to minimize removal of normal pancreatic tissue. Aim: To evaluate the results of intraoperative ultrasound-guided, tissue-sparing pancreatic resection in CHI patients at an international expert center. Methods: Retrospective study of CHI patients treated at Odense University Hospital, Denmark, between January 2010 and March 2017. Results: Of 62 consecutive patients with persistent CHI, 24 (39%) had focal CHI by histology after surgery. All patients had a paternal ABCC8 or KCNJ11 mutation and a focal lesion by 18F-DOPA-PET/CT. Intraoperative ultrasound localized the focal lesion in 16/20 patients (sensitivity 0.80), including one ectopic lesion in the duodenal wall. Intraoperative ultrasound showed no focal lesion in 11/11 patients with diffuse CH (specificity 1.0). The positive predictive value for focal histology was 1.0, negative predictive value 0.73. Tissue-sparing pancreatic resection (focal lesion enucleation, local resection of tail or uncinate process) was performed in 67% (n = 16). In 11/12 having tissue-sparing resection and intraoperative ultrasound, the location of the focal lesion was exactly identified. Eight patients had resection of the pancreatic head or head/body, four with Roux-en-Y, three with pancreatico-gastrostomy and one without reconstruction. None had severe complications to surgery. Cure of hypoglycaemia was seen in all patients after one (n = 21) or two (n = 3) pancreatic resections. Conclusion: In focal CHI, tissue-sparing pancreatic resection was possible in 67%. Intraoperative ultrasound was a helpful supplement to the mandatory use of genetics, preoperative 18F-DOPA-PET/CT and intraoperative frozen sections.
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Affiliation(s)
- Julie Bendix
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette G. Laursen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael B. Mortensen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Maria Melikian
- Department of Paediatric Endocrinology, Endocrine Research Centre, Moscow, Russia
| | - Evgenia Globa
- Department of Paediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kiev, Ukraine
| | - Sönke Detlefsen
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Henrik T. Christesen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen
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Esposito C, De Lagausie P, Escolino M, Saxena A, Holcomb GW, Settimi A, Becmeur F, van der Zee D. Laparoscopic Resection of Pancreatic Tumors in Children: Results of a Multicentric Survey. J Laparoendosc Adv Surg Tech A 2017; 27:533-538. [DOI: 10.1089/lap.2016.0630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ciro Esposito
- Department of Translational Medical Sciences, Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Pascal De Lagausie
- Department of Translational Medical Sciences, Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
- Department of Pediatric Surgery, Hôpital d'Enfants de La Timone, Marseille, France
| | - Maria Escolino
- Department of Translational Medical Sciences, Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Amulya Saxena
- Department of Pediatric Surgery, Chelsea Children Hospital, London, United Kingdom
| | - George W. Holcomb
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Alessandro Settimi
- Department of Translational Medical Sciences, Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Francois Becmeur
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - David van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
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Welters A, Lerch C, Kummer S, Marquard J, Salgin B, Mayatepek E, Meissner T. Long-term medical treatment in congenital hyperinsulinism: a descriptive analysis in a large cohort of patients from different clinical centers. Orphanet J Rare Dis 2015; 10:150. [PMID: 26608306 PMCID: PMC4660626 DOI: 10.1186/s13023-015-0367-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 11/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to now, only limited data on long-term medical treatment in congenital hyperinsulinism (CHI) is available. Moreover, most of the drugs used in CHI are therefore not approved. We aimed to assemble more objective information on medical treatment in CHI with regard to type and duration, dosage as well as side effects. METHODS We searched MEDLINE (from 1947) and EMBASE (from 1988) using the OVID interface for relevant data to evaluate medical treatment in a large cohort of patients with CHI from different clinical centers. Randomized, controlled trials were not available. We evaluated case reports and case series. No language restrictions were made. RESULTS A total number of 619 patients were medically treated and information regarding conservative treatment was available. Drugs used were diazoxide (in 84% of patients), somatostatin analogues (16%), calcium channel antagonists (4%) and glucagon (1%). Mean dose of diazoxide was 12.5 (±4.3) mg/kg ⋅ d (range 2-60 mg/kg ⋅ d), mean duration of diazoxide treatment until remission was 57 months. Side effects of diazoxide were usually not severe. The causal relation between diazoxide and severe side effects, e.g. heart failure (3.7%) remains doubtful. Mean dose of octreotide was 14.9 (±7.5) μg/kg ⋅ d (range 2.3-50 μg/kg ⋅ d), of lanreotide 67.3 (±39.8) mg ⋅ month (range 10-120 mg ⋅ month). Mean duration of treatment with somatostatin analogues until remission was 49 months. Frequent side effects included tachyphylaxis and mild gastrointestinal symptoms. The risk of persistent growth deceleration was low (<5%). CONCLUSIONS Severe side effects are rare and a causal relation remains disputable. We conclude that long-term conservative treatment of CHI is feasible.
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Affiliation(s)
- Alena Welters
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany.
| | - Christian Lerch
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Duesseldorf University Hospital, Duesseldorf, Germany.,Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover Medical School, Germany
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany.
| | - Jan Marquard
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany.
| | - Burak Salgin
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany. .,Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. .,University Department of Obstetrics & Gynaecology, University of Cambridge, Cambridge, UK.
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany.
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorff, Moorenstrasse 5, Duesseldorf, D-40225, Germany.
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12
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Montravers F, Arnoux JB, Ribeiro MJ, Kerrou K, Nataf V, Galmiche L, Aigrain Y, Bellanné-Chantelot C, Saint-Martin C, Ohnona J, Balogova S, Huchet V, Michaud L, Talbot JN, de Lonlay P. Strengths and limitations of using 18fluorine-fluorodihydroxyphenylalanine PET/CT for congenital hyperinsulinism. Expert Rev Endocrinol Metab 2014; 9:477-485. [PMID: 30736210 DOI: 10.1586/17446651.2014.949240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
18fluorine-fluorodihydroxyphenylalanine (FDOPA) PET/CT is currently the first-line imaging technique to distinguish between focal and diffuse forms of congenital hyperinsulinism (CHI) and to accurately localize focal forms. However, this technique has a number of limitations, mainly the very small size of focal forms or inversely a very large focal form mimicking a diffuse form, and misinterpretation of physiologic uptake masking hot spots or inversely mimicking focal forms. The other limitation is the limited availability of the radiopharmaceutical. FDOPA PET/CT has no recognized competitor to date among the available morphologic and functional imaging techniques. Other potential approaches using specific tracers for positron emission tomography (PET) are discussed, using radiopharmaceuticals specific for β cell mass or targeting somatostatin receptors. These radiopharmaceuticals can be labeled with gallium-68, a PET emitter readily available in PET centers equipped with 68Ge/68Ga generators.
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Affiliation(s)
- Françoise Montravers
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Baptiste Arnoux
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Maria-Joao Ribeiro
- c Service de médecine nucléaire, CHRU, Université François Rabelais, INSERM U930, Tours, France
| | - Khaldoun Kerrou
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Valérie Nataf
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Louise Galmiche
- d Service d'anatomo-pathologie, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Yves Aigrain
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Christine Bellanné-Chantelot
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Cécile Saint-Martin
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jessica Ohnona
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Sona Balogova
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
- f Department of nuclear medicine, Comenius University and St. Elisabeth Institute, Bratislava, Slovakia
| | - Virginie Huchet
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Laure Michaud
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Noël Talbot
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Pascale de Lonlay
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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13
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Subtotal Pancreatectomy for Congenital Hyperinsulinism: Our Experience and Review of Literature. Indian J Surg 2013; 77:778-82. [PMID: 27011456 DOI: 10.1007/s12262-013-0999-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 10/20/2013] [Indexed: 01/24/2023] Open
Abstract
Congenital hyperinsulinism (HI) is characterized by profound hypoglycemia caused by inappropriate insulin secretion. HI is a heterogeneous disorder with at least two histologic lesions and several implicated genes. If HI is caused by a focal lesion, elective surgery is the treatment of choice because it leads to complete recovery without diabetes. On the contrary, near-total pancreatectomy though recommended for diffuse HI, long-term risks of endocrine and exocrine deficiencies are present. Between the years 2006-2011, three patients of HI were referred to and operated by a single surgeon. The preoperative diagnosis was confirmed by recurrent hypoglycemia, inappropriately high insulin levels, and augmented glucose requirements. The medical records of all three patients were reviewed to study their clinical features, medical and surgical treatment, and postoperative outcome (short- and long-term). There were three patients in this series (male/female ratio, 1:2), all presenting in the neonatal age. All patients failed medical treatment, and radiological imaging did not reveal any pancreatic lesion. All patients underwent subtotal (80 %) pancreatectomy. Two patients had diffuse type of HI and one focal HI. One patient had transient hyperglycemia for 3 months, which needed insulin supplementation. No patient has developed recurrent hypoglycemia, malabsorption syndrome, or any neurological sequelae until the last follow-up. Doing subtotal or near-total pancreatectomy in diffuse type of HI still remains controversial as one has a higher risk of recurrent hypoglycemia, while the other has a higher rate of insulin dependent diabetes mellitus. Subtotal (80 %) pancreatectomy may be considered as the primary modality of surgical intervention in diffuse type of HI, especially when the diagnostic facilities are limited or diagnosis is not known after preliminary investigations. This minimizes the chances of postoperative diabetes mellitus, and redo surgery can always be considered if there is recurrent hypoglycemia.
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14
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Blomberg BA, Moghbel MC, Saboury B, Stanley CA, Alavi A. The value of radiologic interventions and (18)F-DOPA PET in diagnosing and localizing focal congenital hyperinsulinism: systematic review and meta-analysis. Mol Imaging Biol 2013; 15:97-105. [PMID: 22752652 PMCID: PMC3553406 DOI: 10.1007/s11307-012-0572-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to quantify the diagnostic performance of pancreatic venous sampling (PVS), selective pancreatic arterial calcium stimulation with hepatic venous sampling (ASVS), and (18)F-DOPA positron emission tomography (PET) in diagnosing and localizing focal congenital hyperinsulinism (CHI). PROCEDURES This systematic review and meta-analysis was conducted according to the PRISMA statement. PubMed, EMBASE, SCOPUS and Web of Science electronic databases were systematically searched from their inception to November 1, 2011. Using predefined inclusion and exclusion criteria, two blinded reviewers selected articles. Critical appraisal ranked the retrieved articles according to relevance and validity by means of the QUADAS-2 criteria. Pooled data of homogeneous study results estimated the sensitivity, specificity, likelihood ratios and diagnostic odds ratio (DOR). RESULTS (18)F-DOPA PET was superior in distinguishing focal from diffuse CHI (summary DOR, 73.2) compared to PVS (summary DOR, 23.5) and ASVS (summary DOR, 4.3). Furthermore, it localized focal CHI in the pancreas more accurately than PVS and ASVS (pooled accuracy, 0.82 vs. 0.76, and 0.64, respectively). Important limitations comprised the inclusion of studies with small sample sizes, high probability of bias and heterogeneity among their results. Studies with small sample sizes and high probability of bias tended to overestimate the diagnostic accuracy. CONCLUSIONS This systematic review and meta-analysis found evidence for the superiority of (18)F-DOPA PET in diagnosing and localizing focal CHI in patients requiring surgery for this disease.
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Affiliation(s)
- Björn A. Blomberg
- Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA USA
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA USA
- University Medical Center Utrecht, Utrecht University School of Medicine, Utrecht, The Netherlands
| | - Mateen C. Moghbel
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Babak Saboury
- Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA USA
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Charles A. Stanley
- Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA USA
- Division of Endocrinology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Abass Alavi
- Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA USA
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA USA
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15
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Nollevaux MC, Rahier J, Marchandise J, Thurion P, Godecharles S, Van den Steen G, Jamart J, Sempoux C, Jacquemin P, Guiot Y. Characterization of β-cell plasticity mechanisms induced in mice by a transient source of exogenous insulin. Am J Physiol Endocrinol Metab 2013; 304:E711-23. [PMID: 23403947 PMCID: PMC3625751 DOI: 10.1152/ajpendo.00304.2012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
β-Cell plasticity governs the adjustment of β-cell mass and function to ensure normoglycemia. The study of how β-cell mass is controlled and the identification of alternative sources of β-cells are active fields of research. β-Cell plasticity has been implicated in numerous physiological and pathological conditions. We developed a mice model in which we induced major β-cell mass atrophy by implanting insulin pellets (IPI) for 7 or 10 days. The implants were then removed (IPR) to observe the timing and characteristics of β-cell regeneration in parallel to changes in glycemia. Following IPR, the endocrine mass was reduced by 60% at day 7 and by 75% at day 10, and transient hyperglycemia was observed, which resolved within 1 wk. Five days after IPR, enhanced β-cell proliferation and an increased frequency of small islets were observed in 7-day IPI mice. β-Cell mass was fully restored after an additional 2 days. For the 10-day IPI group, β-cell and endocrine mass were no longer significantly different from those of the control group at 2 wk post-IPR. Furthermore, real-time quantitative PCR analysis of endocrine structures isolated by laser capture microdissection indicated sequentially enhanced expression of the pancreatic transcription factors β(2)/NeuroD and Pdx-1 post-IPR. Thus, our data suggest this mouse model of β-cell plasticity not only relies on replication but also involves enhanced cell differentiation plasticity.
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Affiliation(s)
- M-C Nollevaux
- Service d’Anatomie Pathologique, CHU Mont-Godinne, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Yvoir, Brussels, Belgium.
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16
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Faletra F, Athanasakis E, Morgan A, Biarnés X, Fornasier F, Parini R, Furlan F, Boiani A, Maiorana A, Dionisi-Vici C, Giordano L, Burlina A, Ventura A, Gasparini P. Congenital hyperinsulinism: clinical and molecular analysis of a large Italian cohort. Gene 2013; 521:160-5. [PMID: 23506826 DOI: 10.1016/j.gene.2013.03.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/07/2013] [Indexed: 11/15/2022]
Abstract
Congenital hyperinsulinism (CHI) is a genetic disorder characterized by profound hypoglycemia related to an inappropriate insulin secretion. It is a heterogeneous disease classified into two major subgroups: "channelopathies" due to defects in ATP-sensitive potassium channel, encoded by ABCC8 and KCNJ11 genes, and "metabolopathies" caused by mutation of several genes (GLUD1, GCK, HADH, SLC16A1, HNF4A and HNF1A) and involved in different metabolic pathways. To elucidate the genetic etiology of CHI in the Italian population, we conducted an extensive sequencing analysis of the CHI-related genes in a large cohort of 36 patients: Twenty-nine suffering from classic hyperinsulinism (HI) and seven from hyperinsulinism-hyperammonemia (HI/HA). Seventeen mutations have been found in fifteen HI patients and five mutations in five HI/HA patients. Our data confirm the major role of ATP-sensitive potassium channel in the pathogenesis of Italian cases (~70%) while the remaining percentage should be attributed to other. A better knowledge of molecular basis of CHI would lead to improve strategies for genetic screening and prenatal diagnosis. Moreover, genetic analysis might also help to distinguish the two histopathological forms of CHI, which would lead to a clear improvement in the treatment and in genetic counseling.
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Affiliation(s)
- Flavio Faletra
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.
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17
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Near-total pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy (nesidioblastosis). ANNALS OF PEDIATRIC SURGERY 2012. [DOI: 10.1097/01.xps.0000412949.98148.cf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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18
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Arnoux JB, Verkarre V, Saint-Martin C, Montravers F, Brassier A, Valayannopoulos V, Brunelle F, Fournet JC, Robert JJ, Aigrain Y, Bellanné-Chantelot C, de Lonlay P. Congenital hyperinsulinism: current trends in diagnosis and therapy. Orphanet J Rare Dis 2011; 6:63. [PMID: 21967988 PMCID: PMC3199232 DOI: 10.1186/1750-1172-6-63] [Citation(s) in RCA: 173] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 10/03/2011] [Indexed: 01/25/2023] Open
Abstract
Congenital hyperinsulinism (HI) is an inappropriate insulin secretion by the pancreatic β-cells secondary to various genetic disorders. The incidence is estimated at 1/50, 000 live births, but it may be as high as 1/2, 500 in countries with substantial consanguinity. Recurrent episodes of hyperinsulinemic hypoglycemia may expose to high risk of brain damage. Hypoglycemias are diagnosed because of seizures, a faint, or any other neurological symptom, in the neonatal period or later, usually within the first two years of life. After the neonatal period, the patient can present the typical clinical features of a hypoglycemia: pallor, sweat and tachycardia. HI is a heterogeneous disorder with two main clinically indistinguishable histopathological lesions: diffuse and focal. Atypical lesions are under characterization. Recessive ABCC8 mutations (encoding SUR1, subunit of a potassium channel) and, more rarely, recessive KCNJ11 (encoding Kir6.2, subunit of the same potassium channel) mutations, are responsible for most severe diazoxide-unresponsive HI. Focal HI, also diazoxide-unresponsive, is due to the combination of a paternally-inherited ABCC8 or KCNJ11 mutation and a paternal isodisomy of the 11p15 region, which is specific to the islets cells within the focal lesion. Genetics and 18F-fluoro-L-DOPA positron emission tomography (PET) help to diagnose diffuse or focal forms of HI. Hypoglycemias must be rapidly and intensively treated to prevent severe and irreversible brain damage. This includes a glucose load and/or a glucagon injection, at the time of hypoglycemia, to correct it. Then a treatment to prevent the recurrence of hypoglycemia must be set, which may include frequent and glucose-enriched feeding, diazoxide and octreotide. When medical and dietary therapies are ineffective, or when a focal HI is suspected, surgical treatment is required. Focal HI may be definitively cured when the partial pancreatectomy removes the whole lesion. By contrast, the long-term outcome of diffuse HI after subtotal pancreatectomy is characterized by a high risk of diabetes, but the time of its onset is hardly predictable.
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Affiliation(s)
- Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme de l'Enfant et l'Adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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Capito C, de Lonlay P, Verkarre V, Jaubert F, Rahier J, Nihoul-Fékété C, Aigrain Y. The surgical management of atypical forms of congenital hyperinsulinism. Semin Pediatr Surg 2011; 20:54-5. [PMID: 21186006 DOI: 10.1053/j.sempedsurg.2010.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Beyond the 2 classical forms of congenital hyperinsulinism, focal and diffuse, we report our experience on the surgical treatment of atypical forms. We define 2 subtypes among these atypical forms of hyperinsulinism: in case of a giant focal form the surgical strategy is the same as in focal forms. In case of hyperinsulinism caused by a mosaic, our experience suggests the benefit of a limited resection from the tail to the body of the pancreas.
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Affiliation(s)
- Carmen Capito
- Department of Pediatric Surgery, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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20
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Zani A, Nah SA, Ron O, Totonelli G, Ismail D, Smith VV, Ashworth M, Blankenstein O, Mohnike W, De Coppi P, Eaton S, Hussain K, Pierro A. The predictive value of preoperative fluorine-18-L-3,4-dihydroxyphenylalanine positron emission tomography-computed tomography scans in children with congenital hyperinsulinism of infancy. J Pediatr Surg 2011; 46:204-8. [PMID: 21238668 DOI: 10.1016/j.jpedsurg.2010.09.093] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 09/30/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND/PURPOSE In congenital hyperinsulinism (CHI) of infancy, the use of preoperative fluorine-18-L-3,4-dihydroxyphenylalanine-positron emission tomography-computed tomography ((18)F-DOPA-PET-CT) scan has recently been reported. The aim of this study was to evaluate the accuracy of this technique in discriminating between diffuse and focal CHI and the anatomical localization of focal lesions. METHODS Between 2006 and 2010, (18)F-DOPA-PET scan was performed in 19 children with CHI (median age, 2 months; range, 1-12 months) who were not responding to medical therapy and underwent laparoscopic or open surgery. The findings of (18)F-DOPA-PET scan were correlated with histology. RESULTS In 5 children, (18)F-DOPA-PET scan showed diffuse pancreatic uptake, confirmed at histology and supporting the genetic suspicion of diffuse disease. In 14 children, (18)F-DOPA-PET scan indicated focal pancreatic uptake, which corresponded to histology. However, in 5 patients (36%), (18)F-DOPA-PET scan was inaccurate in defining the location of the lesion (n = 3), size of the lesion (n = 1), or both location and size (n = 1), leading to an inaccurate pancreatic resection. CONCLUSIONS Fluorine-18-L-3,4-dihydroxyphenylalanine-positron emission tomography-computed tomography scan discriminates between diffuse and focal forms of CHI. In focal forms, (18)F-DOPA-PET scan is useful in 2/3 of patients in defining the site and dimension of the focal lesion. Intraoperative histologic confirmation of complete focal lesion resection is needed.
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Affiliation(s)
- Augusto Zani
- Department of Paediatric Surgery, Institute of Child Health and Great Ormond Street Hospital for Children, Great Ormond Street, London, United Kingdom
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21
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Arnoux JB, de Lonlay P, Ribeiro MJ, Hussain K, Blankenstein O, Mohnike K, Valayannopoulos V, Robert JJ, Rahier J, Sempoux C, Bellanné C, Verkarre V, Aigrain Y, Jaubert F, Brunelle F, Nihoul-Fékété C. Congenital hyperinsulinism. Early Hum Dev 2010; 86:287-94. [PMID: 20550977 DOI: 10.1016/j.earlhumdev.2010.05.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 05/05/2010] [Indexed: 10/19/2022]
Abstract
Congenital hyperinsulinism (CHI or HI) is a condition leading to recurrent hypoglycemia due to an inappropriate insulin secretion by the pancreatic islet beta cells. HI has two main characteristics: a high glucose requirement to correct hypoglycemia and a responsiveness of hypoglycemia to exogenous glucagon. HI is usually isolated but may be rarely part of a genetic syndrome (e.g. Beckwith-Wiedemann syndrome, Sotos syndrome etc.). The severity of HI is evaluated by the glucose administration rate required to maintain normal glycemia and the responsiveness to medical treatment. Neonatal onset HI is usually severe while late onset and syndromic HI are generally responsive to a medical treatment. Glycemia must be maintained within normal ranges to avoid brain damages, initially with glucose administration and glucagon infusion then, once the diagnosis is set, with specific HI treatment. Oral diazoxide is a first line treatment. In case of unresponsiveness to this treatment, somatostatin analogues and calcium antagonists may be added, and further investigations are required for the putative histological diagnosis: pancreatic (18)F-fluoro-L-DOPA PET-CT and molecular analysis. Indeed, focal forms consist of a focal adenomatous hyperplasia of islet cells, and will be cured after a partial pancreatectomy. Diffuse HI involves all the pancreatic beta cells of the whole pancreas. Diffuse HI resistant to medical treatment (octreotide, diazoxide, calcium antagonists and continuous feeding) may require subtotal pancreatectomy which post-operative outcome is unpredictable. The genetics of focal islet-cells hyperplasia associates a paternally inherited mutation of the ABCC8 or the KCNJ11 genes, with a loss of the maternal allele specifically in the hyperplasic islet cells. The genetics of diffuse isolated HI is heterogeneous and may be recessively inherited (ABCC8 and KCNJ11) or dominantly inherited (ABCC8, KCNJ11, GCK, GLUD1, SLC16A1, HNF4A and HADH). Syndromic HI are always diffuse form and the genetics depend on the syndrome. Except for HI due to potassium channel defect (ABCC8 and KCNJ11), most of these HI are sensitive to diazoxide. The main points sum up the management of HI: i) prevention of brain damages by normalizing glycemia and ii) screening for focal HI as they may be definitively cured after a limited pancreatectomy.
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22
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Liem NT, Son TN, Hoan NT. Laparoscopic Near-Total Pancreatectomy for Persistent Hyperinsulinemic Hypoglycemia of Infancy: Report of Two Cases. J Laparoendosc Adv Surg Tech A 2010; 20:115-7. [DOI: 10.1089/lap.2008.0316] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nguyen T. Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Tran N. Son
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Nguyen T. Hoan
- Department of Endocrinology, Metabolism, and Genetics, National Hospital of Pediatrics, Hanoi, Vietnam
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23
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Abstract
Congenital hyperinsulinism is the principle cause of hypoglycemia during infancy but successful treatment is difficult and persistent hypoglycemia carries the risk of neurologic damage. Focal and diffuse abnormalities are the common forms of hyperinsulinism. Identification and localization of focal hyperinsulinism can be cured by partial pancreatectomy. It has been shown that affected pancreatic areas utilize LDOPA in a higher rate than normal pancreatic tissue and, thus, labeling L-DOPA with fluorine-18 (FDOPA) allows functional mapping of hyperinsulinism using PET. This article presents a fundamental overview of the genetics background, pathology, management, and the role of FDOPA-PET imaging in hyperinsulinism.
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Barthlen W, Blankenstein O, Mau H, Koch M, Höhne C, Mohnike W, Eberhard T, Fuechtner F, Lorenz-Depiereux B, Mohnike K. Evaluation of [18F]fluoro-L-DOPA positron emission tomography-computed tomography for surgery in focal congenital hyperinsulinism. J Clin Endocrinol Metab 2008; 93:869-75. [PMID: 18073294 DOI: 10.1210/jc.2007-2036] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT In congenital hyperinsulinism (CHI), the identification and precise localization of a focal lesion is essential for successful surgery. OBJECTIVE Our objective was to evaluate the predictive value and accuracy of integrated [18F]fluoro-L-DOPA ([18F]FDOPA) positron emission tomography (PET)-computed tomography (CT) for the surgical therapy of CHI. DESIGN This was an observational study. SETTING The study was performed in the Department of Pediatric Surgery at a university hospital. PATIENTS From February 2005 to September 2007, 10 children with the clinical signs of CHI and an increased radiotracer uptake in a circumscribed area of the pancreas in the [18F]FDOPA PET-CT were evaluated. INTERVENTIONS Guided by the [18F]FDOPA PET-CT report, all children underwent partial pancreatic resection, in two cases twice. MAIN OUTCOME MEASURES Correlation of the anatomical findings at surgery with the report of the [18F]FDOPA PET-CT, and the results of surgery and clinical outcome were determined. RESULTS In nine children the intraoperative situation corresponded exactly to the description of the [18F]FDOPA PET-CT. A limited resection of the pancreas was curative in eight cases at the first surgery, in one case at the second intervention. We observed no diabetes mellitus or exocrine insufficiency in the follow up so far. In one child, hypoglycemia persisted even after two partial resections of the pancreatic head. Histological analysis finally revealed an atypical intermediate form of CHI. CONCLUSIONS The integrated [18F]FDOPA PET-CT is accurate to localize the lesion in focal CHI and is a valuable tool to guide the surgeon in limited pancreatic resection.
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Affiliation(s)
- Winfried Barthlen
- Clinic for Pediatric Surgery, Institute for Pathology, Charité University Medicine Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Mittelallee 8, D-13353 Berlin, Germany.
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25
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Abstract
Hyperinsulinemic hypoglycemia (HH) in children requiring surgery is rare. Early HH can be the result of focal or diffuse pancreatic pathology. A number of genetic abnormalities in early HH have been identified, but in the majority of patients no abnormality is found. The sporadic focal and diffuse forms as well the autosomal recessive form are particularly therapy-resistant and demand for early surgery. Preoperative discrimination between focal and diffuse disease in early HH is difficult. 18 F DOPA PET in combination with CT is promising as is laparoscopic exploration of the pancreas. Frozen section biopsy analysis has not been uniformly beneficial. If macroscopically no focal lesion is found, limited laparoscopic distal pancreatectomy provides tissue for definitive pathologic examination. Subsequent near total laparoscopic spleen-saving pancreatectomy surgery is not particularly difficult. Later HH may occur in the context of the MEN-1 syndrome and is then multifocal in nature. In MEN-1 patients, a distal spleen-saving pancreatectomy with enucleation of lesions in the head seems justified. Insulin-producing lesions in non-MEN-1 patients should be enucleated. There should always be a suspicion of malignancy. Also, in older children, surgery for hyperinsulinism should be performed laparoscopically.
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Affiliation(s)
- Klaas N M A Bax
- Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Oliveira CF, Falcão MC. Prognóstico da hipoglicemia hiperinsulinêmica persistente da infância: uma revisão sistemática. REVISTA PAULISTA DE PEDIATRIA 2007. [DOI: 10.1590/s0103-05822007000300013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO: Descrever o prognóstico de crianças com hipoglicemia hiperinsulinêmica persistente da infância, submetidos ou não à pancreatectomia. FONTES DE DADOS: Foram selecionados, por meio das bases de dados Medline e Ovid, estudos publicados nos últimos dez anos contendo o termo "hyperinsulinemic hypoglycemia". A partir desta seleção, foram analisados os artigos que realizaram estudos observacionais sobre o prognóstico da hipoglicemia hiperinsulinêmica persistente da infância (zero a dez anos), para a revisão sistemática. SÍNTESE DOS DADOS: Foram identificadas 269 publicações, das quais 13 continham informações sobre prognóstico das crianças com hipoglicemia hiperinsulinêmica persistente da infância, incluindo oito artigos referentes a pacientes submetidos à pancreatectomia. O principal determinante do prognóstico é o quadro neurológico. Nos estudos apresentados, a incidência de retardo do desenvolvimento neurológico variou de 10 a 70%, dependendo da casuística e da idade de aparecimento dos sintomas. Entre as crianças submetidas à pancreatectomia para controle da hipoglicemia, o principal fator que influenciou o prognóstico em longo prazo foi a característica e a extensão da lesão pancreática. As lesões focais acarretam significativamente menos complicações que as difusas. A incidência de diabetes melito após a pancreatectomia parcial ou subtotal variou de 25 a 100% dos pacientes, de acordo com a casuística avaliada. CONCLUSÕES: O momento de aparecimento dos sintomas influi diretamente sobre a gravidade do quadro neurológico e, consequentemente, sobre o prognóstico. Nos pacientes submetidos à pancreatectomia, a característica da lesão determina maiores ou menores conseqüências.
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Bremer AA, Nobuhara KK, Gitelman SE. Congenital hyperinsulinism in an infant caused by a macroscopic insulin-producing lesion. J Pediatr Endocrinol Metab 2007; 20:437-40. [PMID: 17451083 DOI: 10.1515/jpem.2007.20.3.437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Congenital hyperinsulinism is the most common cause of persistent neonatal hypoglycemia. Severe congenital hyperinsulinism is most often due to inactivating mutations in either the ABCC8 or KCNJ11 genes, which encode the SUR1 and Kir6.2 proteins, respectively--the two components of the ATP-sensitive K+ (KATP) channel; neonatal hypoglycemia due to macroscopic insulin-producing pancreatic lesions or adenomas are extremely rare. KATP channel hyperinsulinism is classified as diffuse or focal, the latter being associated with paternally-derived mutations of ABCC8 or KCNJ11 and somatic loss of heterozygosity of the maternal alleles. KATP channelopathies usually produce microscopic intra-pancreatic lesions and are typically unresponsive to drug therapy, requiring > 95% pancreatectomy for diffuse disease and occasionally more limited pancreatic resection for focal disease; macroscopic pancreatic lesions and adenomas are focally excised. We describe a 1 month-old infant with severe congenital hyperinsulinism who had a macroscopic insulin-producing pancreatic lesion successfully treated with focal lesion enucleation.
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Affiliation(s)
- Andrew A Bremer
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco 94143-0434, USA.
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Berrocal T, Luque AA, Pinilla I, Lassaletta L. Pancreatic regeneration after near-total pancreatectomy in children with nesidioblastosis. Pediatr Radiol 2005; 35:1066-70. [PMID: 16003534 DOI: 10.1007/s00247-005-1537-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Accepted: 05/23/2005] [Indexed: 01/10/2023]
Abstract
BACKGROUND Nesidioblastosis is often resistant to medical therapy and requires near-total pancreatectomy. There is little information on the postoperative imaging findings of these patients. OBJECTIVE To demonstrate by US the late imaging findings in these patients. MATERIALS AND METHODS Children diagnosed with nesidioblastosis and who had undergone 90-95% pancreatectomy received preoperative, immediate-postoperative (within 10 days of surgery) and long-term annual US examinations. In the preoperative study, three anterior-posterior (AP) measurements were obtained of the head, body and tail of the pancreas. In the postoperative and long-term follow-up US, AP and transverse measurements of the pancreatic remnant were obtained. Pancreatic echogenicity was also assessed. The results were compared with normal pancreatic dimensions as a function of age. Glucose metabolism and pancreatic enzymes were also analysed. RESULTS The study group comprised 22 patients (aged 9 days to 2 years). The pancreas was normal in all preoperative US examinations. The first postoperative examination showed, in all patients, a remnant of the pancreatic head measuring 8-13 mm. The last follow-up US was similar to the first postoperative study in 6 patients, and 12 showed complete pancreatic regeneration (normal size, echogenicity and function), and 4 had incomplete regeneration with head and body normal in size, but lack of a pancreatic tail. All patients were asymptomatic and showed normal laboratory tests. CONCLUSIONS US measurements indicated normal age-dependent growth after near-total resection in 54% of patients. The function and echogenicity of the regenerated pancreas indicate that the increase in organ size was due to normal pancreatic tissue.
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Affiliation(s)
- Teresa Berrocal
- Department of Radiology, Division of Paediatric Radiology, University Hospital La Paz, Paseo Castellana 261, Madrid 28046, Spain.
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Abstract
Hereditary origin of a tumor helps toward early discovery of its mutated gene; for example, it supports the compilation of a DNA panel from index cases to identify that gene by finding mutations in it. The gene for a hereditary tumor may contribute also to common tumors. For some syndromes, such as hereditary paraganglioma, several genes can cause a similar syndrome. For other syndromes, such as multiple endocrine neoplasia 2, one gene supports variants of a syndrome. Onset usually begins earlier and in more locations with hereditary than sporadic tumors. Mono- or oligoclonal ("clonal") tumor usually implies a postnatal delay, albeit less delay than for sporadic tumor, to onset and potential for cancer. Hormone excess from a polyclonal tissue shows onset at birth and no benefit from subtotal ablation of the secreting organ. Genes can cause neoplasms through stepwise loss of function, gain of function, or combinations of these. Polyclonal hormonal excess reflects abnormal gene dosage or effect, such as activation or haploinsufficiency. Polyclonal hyperplasia can cause the main endpoint of clinical expression in some syndromes or can be a precursor to clonal progression in others. Gene discovery is usually the first step toward clarifying the molecule and pathway mutated in a syndrome. Most mutated pathways in hormone excess states are only partly understood. The bases for tissue specificity of hormone excess syndromes are usually uncertain. In a few syndromes, tissue selectivity arises from mutation in the open reading frame of a regulatory gene (CASR, TSHR) with selective expression driven by its promoter. Polyclonal excess of a hormone is usually from a defect in the sensor system for an extracellular ligand (e.g., calcium, glucose, TSH). The final connections of any of these polyclonal or clonal pathways to hormone secretion have not been identified. In many cases, monoclonal proliferation causes hormone excess, probably as a secondary consequence of accumulation of cells with coincidental hormone-secretory ability.
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Affiliation(s)
- Stephen J Marx
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases/NIH, Building 10, Room 9C-101, 10 Center Drive, MSC 1802, Bethesda, MD 20892-1802, USA.
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Giurgea I, Ulinski T, Touati G, Sempoux C, Mochel F, Brunelle F, Saudubray JM, Fekete C, de Lonlay P. Factitious hyperinsulinism leading to pancreatectomy: severe forms of Munchausen syndrome by proxy. Pediatrics 2005; 116:e145-8. [PMID: 15995015 DOI: 10.1542/peds.2004-2331] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clinical history and inappropriate insulin secretion during hypoglycemic episodes permit the diagnosis of hyperinsulinism. We report 2 cases of factitious hyperinsulinism leading to partial pancreatectomy. Case 1 was an 8-year-old girl who presented with severe hypoglycemia and elevated insulin and C-peptide levels. Catheterization of pancreatic veins was performed to localize the excess insulin secretion. Insulinoma was suspected, and partial pancreatectomy was performed. Ten days after surgery, severe hypoglycemia recurred with severely elevated plasma insulin levels (x100) but very low C-peptide plasma levels, suggesting factitious hyperinsulinemia. Hypoglycemic episodes before surgery were provoked by oral sulfonamides; postoperative episodes were caused by parenteral insulin. Falsified prescriptions for sulfonamides and insulin by the mother, a nurse, were found. Case 2 was a 6-month-old girl who presented with seizures and hypoglycemia but had a symptom-free interval of many months afterward. At 2 years of age, repeated hypoglycemic seizures and elevated insulin plasma levels suggested congenital hyperinsulinism. C-peptide plasma level, measured once, was normal, but blood sampling was performed 15 minutes after a hypoglycemic episode. Partial pancreatectomy was performed. Two weeks after surgery, hypoglycemic seizures recurred, and the patient was admitted for pancreatic vein catheterization. This investigation was performed during hypoglycemia and revealed high insulin levels and undetectable C-peptide levels, suggesting factitious hypoglycemia. Insulin/C-peptide ratio analysis is crucial to assess factitious hypoglycemia, although sulfonamide-induced hypoglycemia is not thereby detected. One percent (2 of 250) of all cases of hyperinsulinemic hypoglycemia in our unit have been identified as Munchausen syndrome by proxy. Atypical disease history should raise the question of factitious hypoglycemia.
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Affiliation(s)
- Irina Giurgea
- Department of Metabolic Disorders, Hôpital Necker Enfants Malades, 75015 Paris, France.
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Stringer MD, Davison SM, McClean P, Rajwal S, Puntis JWL, Sheridan M, Ramsden W, Woodley H. Multidisciplinary management of surgical disorders of the pancreas in childhood. J Pediatr Gastroenterol Nutr 2005; 40:363-7. [PMID: 15735494 DOI: 10.1097/01.mpg.0000153007.38363.37] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe the frequency and range of pancreatic disorders in children requiring surgical intervention and to highlight the importance of multidisciplinary management. METHODS An audit of all children under 17 years of age referred with surgical disorders of the pancreas or pancreatitis to a regional pediatric gastroenterology unit in the United Kingdom during a 10-year period. A retrospective chart review of clinical features, pathology and outcome was undertaken. RESULTS Surgical intervention was required for the following pancreatic disorders: persistent hyperinsulinemic hypoglycemia of infancy (n = 4), pancreatic tumors (n = 5), pancreaticobiliary malunion (n = 12), pancreatic trauma (n = 6) and pancreatitis (n = 10). The indications for surgery in acute pancreatitis were a persistent pseudocyst (n = 1) and treatment of an underlying cause of pancreatitis (n = 4); in chronic pancreatitis, surgery was used to treat symptomatic pancreatic duct strictures (n = 4). One child died of a progressive lymphoma but all others who underwent surgery are alive and well. All 33 children with acute pancreatitis, including four with pancreatic necrosis, survived. CONCLUSIONS Surgery for pancreatic disorders in children is rarely required but may be necessary a) for definitive management of primary pancreatic pathology, b) to treat sequelae of acute or chronic pancreatitis and c) to treat an underlying cause of pancreatitis. There is a broad spectrum of potential pathologies. These patients are best managed by a multidisciplinary team approach.
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Affiliation(s)
- Mark D Stringer
- Children's Liver and Gastrointestinal Unit and Department of Paediatric Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Lindley KJ, Dunne MJ. Contemporary strategies in the diagnosis and management of neonatal hyperinsulinaemic hypoglycaemia. Early Hum Dev 2005; 81:61-72. [PMID: 15707716 DOI: 10.1016/j.earlhumdev.2004.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Congenital hyperinsulinism (CHI) is a genetically and phenotypically diverse syndrome. Key management issues involve early diagnosis by ensuring that appropriate samples are taken at the point of hypoglycaemia, prevention of recurrent hypoglycaemia, and detailed characterisation of the clinical, biochemical, and genetic features of each case. Infants with persistent diazoxide resistant CHI require evaluation at specialist referral centres equipped to differentiate those with focal (fo-HI) and diffuse (di-HI) pancreatic disease. Fo-HI is treated with selective pancreatic resection but di-HI is treated by surgery only if intensive medical management regimes are not efficacious.
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Affiliation(s)
- Keith J Lindley
- London Centre for Pancreatic Disease in Childhood, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.
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De Vroede M, Bax NMA, Brusgaard K, Dunne MJ, Groenendaal F. Laparoscopic diagnosis and cure of hyperinsulinism in two cases of focal adenomatous hyperplasia in infancy. Pediatrics 2004; 114:e520-2. [PMID: 15466080 DOI: 10.1542/peds.2003-1180-l] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Persistent hyperinsulinemic hypoglycemia of infancy or congenital hyperinsulinism of the neonate is a rare condition that may cause severe neurologic damage if the disease is unrecognized or inadequately treated. Current treatment aims to restore normal blood glucose levels by providing a carbohydrate-enriched diet and drugs that inhibit insulin secretion. If medical treatment fails, then surgery is required. Because congenital hyperinsulinism may be caused either by diffuse involvement of pancreatic beta-cells or by a focal cluster of abnormal beta-cells, the extent of pancreatectomy varies. We report on 2 patients with a focal form of the disease for whom diagnosis was made with laparoscopy. Laparoscopic enucleation of the lesion was curative.
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Affiliation(s)
- Monique De Vroede
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands.
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Suchi M, Thornton PS, Adzick NS, MacMullen C, Ganguly A, Stanley CA, Ruchelli ED. Congenital Hyperinsulinism. Am J Surg Pathol 2004; 28:1326-35. [PMID: 15371948 DOI: 10.1097/01.pas.0000138000.61897.32] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Most cases of congenital hyperinsulinism (HI) manifest as either a diffuse or focal form. Diffuse HI is characterized by the presence of enlarged islet cell nuclei, defined as those occupying an area 3 times larger than the surrounding nuclei, throughout the pancreas, and usually requires near total pancreatectomy. Focal HI contains, within an otherwise normal pancreas with islet cell nuclei of normal size, a focus of adenomatous hyperplasia characterized by endocrine cell overgrowth occupying more than 40% of a given area. This form of HI is amenable to partial pancreatectomy. The current study assesses whether intraoperative frozen section evaluation can distinguish the 2 forms and guide the extent of pancreatectomy. By frozen section analysis, diffuse HI is diagnosed when enlarged islet cell nuclei are present in random intraoperative biopsies from the head, body, and tail of the pancreas. Focal HI is suggested when random biopsies contain no large islet cell nuclei, prompting a further search for a focal lesion. Fifty-two HI patients who underwent pancreatectomy from October 1, 1998 to September 30, 2002 were reviewed. On permanent sections, 18 were classified as diffuse HI, 30 had focal HI, and 4 could not be categorized as either. Among 18 diffuse HI patients, 17 were correctly diagnosed by frozen section; all underwent near total pancreatectomy. One case was interpreted as not belonging to typical diffuse or focal HI; however, the permanent sections showed diffuse HI. Twenty-six of 30 focal HI cases were correctly diagnosed by frozen section. The remaining 4 focal HI cases posed diagnostic difficulties on frozen sections because of one the following reasons: 1) presence of equivocally large islet cell nuclei or rare truly large islet cell nuclei in areas nonadjacent to the focal lesion, and 2) large and/or ill defined focus of adenomatous hyperplasia. Twenty-one of 30 focal HI patients eventually had 10% to 93% (mean, 41.8%) of their pancreas resected. In addition to cases typical for diffuse and focal HI, there were 4 other cases whose pancreata did not fit well with either category. These pancreata showed islet cell nuclear enlargement, as characteristically seen in diffuse HI, but only in confined areas of the pancreas. Examination of routinely processed tissue confirmed frozen section findings in all 4 cases. Intraoperative frozen section evaluation, therefore, can assume an essential role in identifying patients with focal HI to limit the extent of pancreatectomy. However, a small number of cases with unusual histology warrant caution when performing frozen section evaluation.
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Affiliation(s)
- Mariko Suchi
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, 5203 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Mehta SS, Gittes GK. The impact of advances in developmental biology on the management of neonatal surgical anomalies. Semin Perinatol 2004; 28:152-63. [PMID: 15283095 DOI: 10.1053/j.semperi.2004.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While advances in the clinical management of various congenital anomalies in pediatric surgery have led to new and exciting therapeutic modalities, our understanding of the mechanisms responsible for these defects lags far behind. In a new era of developmental biology, the prospect of unlocking some of these mysteries has become a real possibility. Advances in gene sequencing has allowed us to create new phenotypes that closely mimic those seen in patients, and has created a setting where we are now better able to understand and develop new therapeutic interventions. Here we discuss the implications of some of the molecular mechanisms underlying various congenital anomalies encountered in pediatric surgery, and how continued research will impact the future of these disease processes.
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Affiliation(s)
- Sheilendra S Mehta
- Division of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Adzick NS, Thornton PS, Stanley CA, Kaye RD, Ruchelli E. A multidisciplinary approach to the focal form of congenital hyperinsulinism leads to successful treatment by partial pancreatectomy. J Pediatr Surg 2004; 39:270-5. [PMID: 15017536 DOI: 10.1016/j.jpedsurg.2003.11.019] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/PURPOSE Congenital hyperinsulinism (HI) causes severe hypoglycemia in neonates and infants. Recessive mutations of the beta-cell K(ATP) channel genes cause diffuse HI, whereas loss of heterozygosity together with inheritance of a paternal mutation cause focal adenomatous HI. Although these 2 forms of HI are clinically identical, focal HI can be cured surgically. The authors reviewed their experience with partial pancreatectomy for focal HI. METHODS From December 1998 to January 2003, 38 patients (ages 2 weeks to 14 months; median age, 10 weeks) were treated with partial pancreatectomy for focal HI. Before surgery, patients had localization studies using selective arterial calcium stimulation with venous sampling or transhepatic portal venous sampling. At operation, the focal lesion was found using the preoperative localization data and multiple pancreatic biopsies with frozen section analysis, followed by partial pancreatectomy. A complete response at follow-up was defined as no requirement for glycemic medications, no continuous tube feedings, and no diabetes mellitus. RESULTS Nineteen pancreatic focal lesions were in the head; 15 were in the neck, body, or tail; and 4 had more extensive involvement. Lesions that required substantial resection of the pancreatic head underwent Roux-en-Y pancreaticojejunostomy to preserve the normal body and tail. Lesions of the body or tail were usually treated with partial distal pancreatectomy. Ninety-two percent (35 of 38) of patients had a complete response to surgery. Three patients have required glycemic medications. No patient is diabetic. Surgical complications included additional resection for residual disease (3), small bowel obstruction requiring laparotomy and enterolysis (2), and chylous ascites (3) that resolved with medical management. CONCLUSIONS A multidisciplinary approach to patients with the focal form of congenital hyperinsulinism can distinguish focal from diffuse disease, localize focal lesions, and permit partial pancreatectomy with cure in most patients.
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Affiliation(s)
- N Scott Adzick
- Department of Surgery, and The Center for Hyperinsulinism, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Cosgrove KE, Shepherd RM, Fernandez EM, Natarajan A, Lindley KJ, Aynsley-Green A, Dunne MJ. Genetics and pathophysiology of hyperinsulinism in infancy. HORMONE RESEARCH 2004; 61:270-88. [PMID: 14981344 DOI: 10.1159/000076933] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 01/15/2003] [Indexed: 11/19/2022]
Abstract
Hyperinsulinism in infancy (HI) is a condition of neonates and early childhood. For many years the pathophysiology of this potentially lethal disorder was unknown. Advances in the genetics, histopathology and molecular physiology of this disease have now provided insights into the causes of beta-cell dysfunction and revealed levels of diversity far in excess of our previous knowledge. These include defects in ion channel subunit genes and mutations in several enzymes associated with beta-cell metabolism and anaplerosis. In most cases, beta-cell pathophysiology leads to an alteration in the function of ATP-sensitive K(+) channels. This can manifest as 'channelopathies' of K(ATP) channels through gene defects in ABCC8 and KCNJ11 (Ch.11p15); or as a result of 'metabolopathies' through defects in the genes encoding glucokinase (GCK, Ch.7p15-p13), glutamate dehydrogenase (GLUD1, Ch.10q23.3) and short-chain L-3-hydroxyacyl-CoA dehydrogenase (HADHSC, Ch.4q22-q26). This review focuses upon the relationship between the causes of HI and therapeutic options.
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Affiliation(s)
- Karen E Cosgrove
- School of Biological Sciences, Stopford Building, University of Manchester, Manchester, UK
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Dunne MJ, Cosgrove KE, Shepherd RM, Aynsley-Green A, Lindley KJ. Hyperinsulinism in Infancy: From Basic Science to Clinical Disease. Physiol Rev 2004; 84:239-75. [PMID: 14715916 DOI: 10.1152/physrev.00022.2003] [Citation(s) in RCA: 184] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Dunne, Mark J., Karen E. Cosgrove, Ruth M. Shepherd, Albert Aynsley-Green, and Keith J. Lindley. Hyperinsulinism in Infancy: From Basic Science to Clinical Disease. Physiol Rev 84: 239–275, 2004; 10.1152/physrev.00022.2003.—Ion channelopathies have now been described in many well-characterized cell types including neurons, myocytes, epithelial cells, and endocrine cells. However, in only a few cases has the relationship between altered ion channel function, cell biology, and clinical disease been defined. Hyperinsulinism in infancy (HI) is a rare, potentially lethal condition of the newborn and early childhood. The causes of HI are varied and numerous, but in almost all cases they share a common target protein, the ATP-sensitive K+channel. From gene defects in ion channel subunits to defects in β-cell metabolism and anaplerosis, this review describes the relationship between pathogenesis and clinical medicine. Until recently, HI was generally considered an orphan disease, but as parallel defects in ion channels, enzymes, and metabolic pathways also give rise to diabetes and impaired insulin release, the HI paradigm has wider implications for more common disorders of the endocrine pancreas and the molecular physiology of ion transport.
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Affiliation(s)
- Mark J Dunne
- Research Division of Physiology and Pharmacology, The School of Biological Sciences, University of Manchester, Manchester, United Kingdom.
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Abstract
Hyperinsulinism (HI) is the commonest cause of persistent or recurrent hypoglycaemia in childhood. HI is genetically and phenotypically diverse. Key management issues involve early diagnosis by insuring that appropriate investigations are undertaken at the point of hypoglycaemia, prevention of recurrent hypoglycaemia and clinical, biochemical and genetic characterisation of the HI syndrome. Children with persistent diazoxide resistant HI require investigation at specialist centres to differentiate those with a generalised disorder of the pancreas (diffuse HI; di-HI) from those with localised abnormalities within the pancreas (focal HI; fo-HI). Fo-HI may be managed by selective pancreatic resection of the focal abnormality. Di-HI is only managed by surgery if combination drug therapies are unable to prevent hypoglycaemia. Pancreatic beta-cell dysfunction persists following subtotal pancreatectomy of di-HI.
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Affiliation(s)
- Keith J Lindley
- The Institute of Child Health, University College London, London, UK.
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41
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McAndrew HF, Smith V, Spitz L. Surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy. J Pediatr Surg 2003; 38:13-6; discussion 13-6. [PMID: 12592610 DOI: 10.1053/jpsu.2003.50001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to review the surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI). METHODS A retrospective review was conducted of patients undergoing pancreatectomy for PHHI in one institution over the past 13 years. RESULTS The records of 48 patients were reviewed; the age at operation ranged from 10 days to 30 months (median, 8 weeks). Weight at operation ranged from 1.97 to 11.4 kg (median, 5.2 kg). There were no deaths. Intraoperative complications comprised bleeding in 7, (major in 2), splenic injury in one, bile duct injury in 2 (1 oversewn, 1 choledochoduodenostomy), and 1 small bowel injury. Postoperatively, 5 children underwent choledochoduodenostomy: 2 for biliary leak and 3 for delayed bile duct stricture. Other postoperative complications included wound infection (n = 3), prolonged ileus (n = 1) and adhesion obstruction (n = 1), and wound leakage (n = 1). Renal failure developed in one child owing to acute tubular necrosis. Nine patients required further pancreatic resection because of continued hypoglycaemia. Three patients continued to require medication for hyperinsulinism despite surgery, 20 required insulin, and 13 required pancreatic enzyme replacement at the time of the last review. CONCLUSIONS Pancreatectomy resulted in resolution of hyperinsulinism in 45 of 48 patients. Sixteen patients required no further surgery or medication. Pancreatectomy for PHHI may be associated with major intra and postoperative morbidity.
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Affiliation(s)
- H Fiona McAndrew
- Department of Surgery, Great Ormond Street Hospital for Children, London, England
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