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Glucagonoma: anaesthetic management.

Glucagonoma are rare slow-growing tumours of the pancreatic alpha cells that cause hypersecretion of glucagon with an incidence estimated to be one in 20 million people per annum. Patients typically present with a clinical syndrome of necrolytic migratory erythema, diabetes mellitus and weight loss with nutritional depletion (1). Surgical resection of both the primary and metastatic lesions can lead to complete cure and resolution of symptoms. While manipulation of the tumour can be associated with large peaks of glucagon, there have been no previous reports that this has caused perioperative problems (2,3). We describe a case where we encountered both blood sugar and myocardial changes during the perioperative period.

A 49-year-old female presented for elective laparotomy and removal of a glucagoma (central pancreatectomy and roux-en-y pancreaticojejunostomy) and wide local excision of liver lesions. Her preoperative examination was essentially normal aside from a resting tachycardia of 110 beats per minute. Routine blood tests and chest X-ray were unremarkable. Her fasting blood sugar level (BSL) was 5.6 mmol/l.

The patient was anaesthetised with a general anaesthetic and a thoracic epidural. We checked the BSL every hour. The first BSL was 4.5 mmol/l, rising to 9.5 mmol/l after the first hour of the operation, when a low dose of insulin (2 IU/hour) was started. The BSL was responsive to this and was soon discontinued. Around the time of the tumour manipulation, the BSL fell to 3.1 and then to 2.8 mmol/l, which required treatment with 10 ml 50% dextrose and 10% dextrose infusion (see Table 1).

Throughout her anaesthetic, she had a persistent tachycardia that did not change with boluses of metoprolol 1 mg IV (5 mg in total). The question was raised whether she had an undiagnosed underlying cardiomyopathy.

The patient required an ongoing dextrose infusion overnight but the BSL remained stable thereafter. She made a good recovery and was discharged home two weeks after the operation. The histology showed a well-differentiated endocrine tumour of uncertain malignant potential. The liver lesions showed focal nodular hyperplasia.

There have been only two other reports specifically pertaining to the anaesthetic management of this condition (2,3). Both described no cardiovascular or metabolic abnormalities during anaesthesia despite showing large peaks of glucagon during tumour manipulation. Glucagon levels during these cases fell to normal limits within 24 hours postoperatively.

Glucagonomas become independent secretory tumours and a lack of equilibrium can occur between insulin and glucagon production (4). We found that the BSL fell during the tumour manipulation, which required glucose infusions intraoperatively and for many hours after the operation. Our management strategy was to regularly check the BSL and institute treatment according. Previous case reports suggest that pre-emptive routine administration of glucose can lead to undesirable hyperglycaemia (3). The utility of preoperative somatostatin analogues must also be considered to stabilise BSL. Also, it is difficult to predict what role epidural analgesia would have to play in glucose homeostasis as attenuation of both the stress response and the increase in BSL can occur (5).

Glucagon is an inotropic agent and chronically elevated glucagon levels have been associated with dilated cardiomyopathy. One case report describes a 54-year-old patient presenting with congestive heart failure and tachycardia (6). Echocardiography showed left ventricular hypertrophy and an ejection fraction of only 15%. This patient was treated with carvedilol 12.5 mg, but tachycardia persisted. Glucagonoma was confirmed and resolution of chronic tachycardia and rash occurred after resection.

In managing patients with glucagonoma, we advocate a preoperative echocardiogram to exclude or confirm cardiomyopathy, especially in those patients that have unexplained tachycardia or congestive heart failure. Further optimisation of their cardiac function may be indicated. Heightened awareness of intraoperative glucose instability, particularly at time of tumour manipulation, including regular monitoring of blood glucose levels and treatment with dextrose or insulin as required, is also recommended. If tumour resection is successful, then the BSL should stabilise within 24 hours and resolution of diabetes may occur.



(1.) Wermers RA, Fatourechi V, Wynne AG, Kvols LK, Lloyd RV. The glucagonoma syndrome. Clinical and pathologic features in 21 patients. Medicine (Baltimore) 1996; 75:53-63.

(2.) Nicoll JM, Catling SJ. Anaesthetic management of glucagonoma. Anaesthesia 1985; 40:152-157.

(3.) Boskovski NA, Chapin JW, Becker GL, Edney JA, Sanders WC, Wolpert LA. Anaesthesia for glucagonoma resection. J Clin Anaesth 1991; 3:48-52.

(4.) Fanelli CG, Porcellati F, Rossetti P, Bolli GB. Glucagon: the effects of its excess and deficiency on insulin action. Nutr Metab Cardiovasc Dis 2006; 16 (Suppl 1):S28-34.

(5.) Kouraklis G, Glinavou A, Raftopoulos L, Alevisou V, Lagos G, Karatzas G. Epidural analgesia attenuates the systemic stress response to upper abdominal surgery: a randomized trial. Int Surg 2000; 85:353-357.

(6.) Chang-Chretien K, Chew JT, Judge DP. Reversible dilated cardiomyopathy associated with glucagonoma. Heart 2004; 90:e44.



Dunedin, New Zealand

Intraoperative blood glucose levels and institution of insulin
and dextrose treatments in response to changes in levels. Note
that tumour manipulation occurred between 300 and 360 minutes.

Time Glucose Insulin Dextrose Dextrose
(mins) (mmol/l) (IU/h) 50% (ml 10%
 bolus) (ml/h)

0 4.4 -- -- --
30 5.2 -- -- --
60 9.4 2 -- --
120 8.9 1 -- --
180 6.3 0 -- --
240 5.0 -- -- --
300 3.1 -- 10 --
315 4.4 -- -- --
360 2.4 -- 10 50
375 3.7 -- -- 50
420 4.0 -- -- 50
480 5.0 -- -- 50
510 6.1 -- -- 50
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Article Details
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Title Annotation:Correspondence
Author:Gin, V.C.; Zacharias, M.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8NEWZ
Date:Mar 1, 2009
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