220例胰岛素瘤诊治分析
赵玉沛 王欣 杨波 肖毅 蔡力行 钟守先 朱预
摘 要 目的：总结胰岛素瘤的诊断和治疗经验。方法：回顾性分析1953年～1999年7月收治的220例胰岛素瘤病例资料。结果：本组患者平均年龄为39岁，平均确诊时间为35个月，来院前误诊率为54%；手术治疗214例，其中良性201例(93.9%), 恶性12例(5.6%)；肿瘤直径<2cm的占78%; 90.7%肿瘤为单发，多发占9.3%；位于胰头钩部者37.1%，胰体部者26.1%，胰尾部36.1%,胰腺外0.7%；95.5%患者具有Whipple三联症，89%的患者IRI/G>0.3；术前B超、CT、MRI定位诊断阳性率不高，血管造影和PTPC阳性率分别为62.8%和88%，对术中切除肿瘤帮助较大。胰岛素瘤大部分均可行肿瘤单纯摘除，患者血糖可恢复正常；术后主要并发症为胰瘘和胰腺炎。结论：胰岛素瘤是最常见的胰腺内分泌肿瘤，加强对本病的认识，减少误诊，对取得良好的治疗效果具有重要意义。
, 百拇医药
关键词：胰岛素瘤 诊断 治疗
Insulinoma accounts for 70%-80% of islet cell tumors in the pancreas. Its incidence rate is about four per million population each year.[1] Wilder et al in 1927 first described the relation between hyperinsulinism and functional islet cell tumor. Graham in 1929 first treated an islet cell adenoma surgically. “Whipple′s triad” was considered the main standard for the diagnosis of insulinoma. Many such patients with mental disorder or confusion were misdiagnosed because of the inadequacy of experience in this field.At that time,the difficulty in localizing the tumor in some patients made the detection of the tumor impossible.
, 百拇医药
We retrospectively analyze the clinical and diagnostic features as well as surgical treatment of 220 patients with insulinoma in our hospital from 1953 to 1999.
METHODS
Patients
Of 230 patients with insulinoma admitted to our hospital from 1953 to 1999, 220 had detailed clinical record. They were 131 men and 89 women, aged from 10 to 72 years(average 39 years). Six of the 220 patients who had not been operated on for different reasons were not confirmed to have benign or malignant tumor. Of the 214 patients, 201(93.9%) had benign tumor and 12(5.6%) malignant tumor. The remaining one was suspicious of having malignant tumor because of multiple low density shadows in the brain revealed by CT before operation but biopsy failed to make a clear diagnosis. 176 patients were cured by initial operation, the rest 44(20%) underwent reoperation because of multiple or occult insulinomas. Pathologically, islet cell hyperplasia was noted in 11 of the 214 patients.
, 百拇医药
Surgical procedures
Enucleation of insulinoma, partial resection with surrounding normal pancreas and distal pancreatectomy with splenectomy are the main surgical procedures.
RESULTS
Symptoms
210 (95.5%) of the 220 patients had typical Whipple′s triad. Obesity was common in these patients due to frequent eating. Mental disorders or confusion was also seen because of frequent damage to the brain by hypoglycemia.
, 百拇医药
Size of insulinoma
The diameter of the largest tumor resected was 11cm and that of the smallest 0.1cm. The diameter of insulinoma was larger than 2cm in 49 patients(22%), between 1-2cm in 153(70%)， and less than 1cm in 18(8%). 291 tumors were resected from the 220 patients. 194 patients (90.7%) had single tumor and 20 (9.3%) multiple tumors, 2 or 3 of which were seen in most patients. One patient had 21 tumors which were removed by two operations.
, 百拇医药
Diagnosis
The earliest diagnosis was 1 month after the onset of symptoms and the latest 12 years (mean 35 months). One patient with psychiatric symptoms was diagnosed one year after the onset of the first symptom, but he refused operation for 19 years. 119 patients(54%) were misdiagnosed as having epilepsy, hypoglycemia, insanity, Addison′s disease, anaemia, hysteria, and menopause syndrome before admission.
The serum glucose level was below 50mg/dL in 95% patients when hypoglycemia attacked and the lowest was 4 mg/dL. One patient experienced hypoglycemia with a serum glucose level of 56mg/dL and some patients with a serum glucose level less than 50mg/dL had no symptom. In 69.4% of the patients, the serum insulin level was above 25 μU/ml. The ratio of insulin to glucose in 102 patients was below 0.3 at the attack of hypoglycemia or during fasting (11 patients) and above 0.3(91). It was between 0.31-18.8, which was consistent with the diagnostic criteria for insulinoma.[2]
, 百拇医药
Localization of tumors
In this group, insulinomas evenly distributed throughout the pancreas (37.1% head, 26.1% body, and 36.1% tail).Two patients had tumors outside the pancreas: one in the colon mesentery and the other in the fossa of the spleen.Seventy-three patients were subjected to B-ultrasound examination before operation with a positive rate of 31.5% (23/73). Among them, 42 (57.5%) with a negative result of B-ultrasound were found to have insulinoma during operation, and 8 (11%) a wrong localization of tumors. Negative B-ultrasound results were frequently seen in tumors with a diameter less than 2cm or of 2.5-3.0cm.
, 百拇医药
Fifty-eight of the 220 patients underwent PTPC with a positive rate of 88%. In 1 patient with malignant insulinoma metastasized to the liver, the serum glucose level did not elevate after distal pancreatectomy. Intraoperative PTPC found that the ratio of insulin to glucose was three times higher than the preoperative ratio, suggesting the remnant of the tumors. Four patients showed positive results after ASVS.
CT showed positive results in 23.2% of the patients, negative results in 62.3%, and wrong localization in 14.5%. In 3 patients who had received enhanced CT, 2 showed positive results. In 5 patients underwent MRI,only 1 had the tumor detected.
, 百拇医药
In all examinations, angiography showed a highest positive rate of 62.8%. Its negative rate was 20.9%, and wrong localization rate 16.7%. Intraoperative puncture in doubtful focus showed a positive rate of 90%. Intraoperative ultrasonography for 2 patients showed positive results in one and negative results in the other.
Glucose level monitoring
Monitoring of intraoperative glucose level is very important in estimating whether the tumors were totally removed or not. The response of the serum glucose level (more than one time the level before tumor excision or up to 100mg/dL) assures that no tumors remain. In our group, 52.6% of patients had the glucose response in 30 minutes after tumor removal, 77.7% within 1 hour, and only few after 2 hours.
, 百拇医药
90% of the 214 patients had postoperative high blood glucose level; the duration varied from 3 days to 18 days (mean 1 week). The blood glucose level was between 100mg/dL and 200mg/dL.
Postoperative complications
The main complications were pancreatic fistulae and pancreatitis. In our group, 33.8% of patients had the fistulae regardless of the location of the tumor(50% head, 50% body and tail). Pancreatitis had a lower occurrence(13.1%). The incidences of pancreatic fistulae and pancreatitis were 31.8% and 19.3% in simple enucleation of insulinoma and 54.5% and 27.3% in distal pancreatectomy respectively.
, http://www.100md.com
DISCUSSION
Localizing methods
85.7% of the patients in our group had preoperative localization of tumors. Because the diameters of 78% tumors were less than 2cm, B-ultrasound, CT and MRI showed a low positive rate and were helpful only to those patients with liver metastasis or relatively larger tumors. Angiography, however, showed a higher positive rate in detecting insulinoma that was well-vascularized. Milana[2]reported that its positive rate was 46.7%, but in our group it was 62.8%. Special attention should be paid to those patients with multiple tumors or who had removal of insulinoma previously. PTPC, an invasive and complicated examination, is still effective for diagnosis or differential diagnosis of the tumor. Since the application of PTPC in our hospital in 1981, insulinoma has been ruled out in 5 patients with a low level of insulin in the splenic vein and portal vein.In recent years, new techniques such as EUS, ASVS have been used in detecting insulinoma. High sensitivity and less injury are their merits and could improve the accuracy in localizing insulinoma.
, 百拇医药
Intraoperative palpation is very important when preoperative localization fails. For an experienced surgeon, the success rate of explorative operation was above 90%; together with intraoperative ultrasonography，the success rate could come up to 100%.[3] In 67 patients with insulinomas, 56 (83.6%) were subjected to preoperative localization, combined intraoperative ultrasonography and palpation, with a successful operative rate of 89%.[2] In our group, 85.7% patients had preoperative localization, with a successful rate of 92.4%. For those patients with negative preoperative localization or intraoperative palpation, fine needle puncture at suspicious focus and immediate cytological examination were helpful. Compared to frozen slice, this method showed the same accuracy but lower occurrence of pancreatic fistulae. If the tumor was not identified by these methods, segmented resection from the tail of the pancreas by monitoring blood glucose level was suggested. In addition, measuring the insulin level of blood samples from the splenic vein in different sites were also helpful. Intraoperative insulin measurement by radioimmunity can also judge whether the tumor is resected totally or not.[4]
, 百拇医药
Surgical procedures
The choice of surgical procedure depends on the intraoperative situation. It is better to perform distal pancreatectomy in the patients with multiple tumors. Because the diameter of 90% insulinomas is less than 2cm and their border is clear, simple enucleation is preferable. Partial resection including surrouding normal pancreas is not acceptable because of the injury to the nearby pancreatic duct or blood vessels. Extensive pancreatectomy should be considered in the patients with malignant tumor. For inoperable patients or those with liver metastasis, hepatic artery embolization, chemotherapy and somatostatin could be adopted.
, 百拇医药
Occult insulinoma
Some of such tumors can not be found during operation for two reasons. First, the tumor is very small, hiding in the head and tail of the pancreas or in the hilus of the spleen or outside the pancreas. Second, it is nesidioblastosis. In our group, the incidence of insulinoma was similar in the head, body and tail of the pancreas, hence the success rate of blind distal pancreatectomy was very low when the tumor was not found. Segmented resection from the tail of the pancreas while monitoring blood glucose level could be done. 90% or 95% of the pancreas could be resected, but total pancreatectomy was not accepted. If the tumor was not found by these methods, the best choice was to finish the operation. To measure the insulin level of blood sample from the portal and splenic vein, the operation was helpful for localization and reoperation.
, 百拇医药
Pancreatic wound
To prevent fistulae of the pancreas, we followed the following principles: (1) thorough haemostasis of wound and ligation of the severed large pancreatic duct (if possible,intravenous secretion could make pancreatic juice secret and is helpful to find the ruptured large pancreatic duct); (2) covering wound surface with omentum and smooth suturing; (3) well drainage
Problems in reoperation
, http://www.100md.com
Twenty patients were admitted to our hospital because failed operation in other medical center. The failure was due to: (1) small tumors in the head of the pancreas; (2) blind distal pancreatectomy; (3) multiple tumors: no blood glucose level monitoring and meticulous exploration; (4) nesidioblastosis; (5) malignant insulinomas; and (6) ectopic insulinomas. In these patients, whether elevated insulin level or high insulin peak could be found by PTPC is important for reoperation. Nesidioblastosis or malignant tumors usually have a high insulin level and high peak insulin, which indicate the location of the tumor. In our group, a 0.2cm-tumor was found in one patient by measuring the high peak of insulin level in the tail of the pancreas. In another patient, multiple tumors were resected according to the two peaks of PTPC.
, 百拇医药
Malignant insulinoma
The incidence of malignant insulinoma was as low as 5.6% in our group compared with 10% reported by Milana.[2] The diagnosis of malignant tumor is mainly dependent on whether liver metastasis, lymph node metastasis and local invasion occur. It is very important to remove the primary focus, metastatic lymph node and metastatic tumors in the surface of the liver. Since Whipple procedure has become a relatively safer operation in some hospitals, it is recommended, combined with postoperative hepatic artery embolization, for those patients with malignant tumors in the head of the pancreas. One patient after repeated hepatic artery embolization after operation survived for 8 years.[5]Other methods such as frozen therapy with B-ultrasound guiding and hot coagulation under laparoscopy were also helpful. In addition, strepozotocin, 5-FU, adriacin and interferon could be used. The effect of combined use of medicines was better than that of single medicine. No obvious side effect was observed after use of diazoxide in most patients apart from palpitation, nausea and discomfort in the gastrointestinal tract in some patients. Sandostadin, dilantin and chemotherapeutic drugs were also used before operation, but the effect could not be identified.
, 百拇医药
Rebounded high blood glucose level
The high blood glucose level after operation does nothing good to the recovery of patient but increases the opportunity of complications. In recent years, insulin has been used regularly in our hospital to control the blood glucose after operation and help the recovery of islet cell function.
Postoperative complications Pancreatitis and fistulae of the pancreas are the common complications. The most severe complication is severe acute pancreatitis because of the injury to the blood vessel or pancreatic duct at specrfic tumor site (behind the head) or the extensive resection of the pancreas. In the early stage of our treatment, 2 patients died from this complication. Hence tender exploration should be emphasized. Cimetidine or losec should be routinely applied to prevent fistulae after operation and to reduce the secretion of pancreatic juice. The regular use of sandostadin after operation is also benefitial.
, http://www.100md.com
作者单位：赵玉沛 中国协和医科大学 北京协和医院外科，北京100730，中国
王 欣 中国协和医科大学 北京协和医院外科，北京100730，中国
杨 波 中国协和医科大学 北京协和医院外科，北京100730，中国
肖 毅 中国协和医科大学 北京协和医院外科，北京100730，中国
蔡力行 中国协和医科大学 北京协和医院外科，北京100730，中国
钟守先 中国协和医科大学 北京协和医院外科，北京100730，中国
朱 预 中国协和医科大学 北京协和医院外科，北京100730，中国
REFERENCES
, 百拇医药
[1]Service FJ, McMahon MM, O′Brien PC,et al. Functioning insulinoma: incidence, recurrence, and long term survival of patients: a 60 year study. Mayo Clin Proc，1991，66:711-719.
[2]Milana PB, John HK, John S, et al. Insulinoma-Experience from 1950 to 1995. West J Med， 1998，169:98-104.
[3]Norton JA, Shawker TH, Doppman JL, et al. Localization and surgical treatment of occult insulinomas. Ann Surg, 1990，212:615.
[4]Charles P, Francois P, Bruno C, et al. Intraoperative insulin measurement during surgical management of insulinomas. World J Surg,1998, 22:1218-1224.
[5]Modlin IM, Lewis JJ, Ahlman H, et al. Management of unresectable malignant endocrine tumor of the pancreas, 1993,176:507., 百拇医药
摘 要 目的：总结胰岛素瘤的诊断和治疗经验。方法：回顾性分析1953年～1999年7月收治的220例胰岛素瘤病例资料。结果：本组患者平均年龄为39岁，平均确诊时间为35个月，来院前误诊率为54%；手术治疗214例，其中良性201例(93.9%), 恶性12例(5.6%)；肿瘤直径<2cm的占78%; 90.7%肿瘤为单发，多发占9.3%；位于胰头钩部者37.1%，胰体部者26.1%，胰尾部36.1%,胰腺外0.7%；95.5%患者具有Whipple三联症，89%的患者IRI/G>0.3；术前B超、CT、MRI定位诊断阳性率不高，血管造影和PTPC阳性率分别为62.8%和88%，对术中切除肿瘤帮助较大。胰岛素瘤大部分均可行肿瘤单纯摘除，患者血糖可恢复正常；术后主要并发症为胰瘘和胰腺炎。结论：胰岛素瘤是最常见的胰腺内分泌肿瘤，加强对本病的认识，减少误诊，对取得良好的治疗效果具有重要意义。
, 百拇医药
关键词：胰岛素瘤 诊断 治疗
Insulinoma accounts for 70%-80% of islet cell tumors in the pancreas. Its incidence rate is about four per million population each year.[1] Wilder et al in 1927 first described the relation between hyperinsulinism and functional islet cell tumor. Graham in 1929 first treated an islet cell adenoma surgically. “Whipple′s triad” was considered the main standard for the diagnosis of insulinoma. Many such patients with mental disorder or confusion were misdiagnosed because of the inadequacy of experience in this field.At that time,the difficulty in localizing the tumor in some patients made the detection of the tumor impossible.
, 百拇医药
We retrospectively analyze the clinical and diagnostic features as well as surgical treatment of 220 patients with insulinoma in our hospital from 1953 to 1999.
METHODS
Patients
Of 230 patients with insulinoma admitted to our hospital from 1953 to 1999, 220 had detailed clinical record. They were 131 men and 89 women, aged from 10 to 72 years(average 39 years). Six of the 220 patients who had not been operated on for different reasons were not confirmed to have benign or malignant tumor. Of the 214 patients, 201(93.9%) had benign tumor and 12(5.6%) malignant tumor. The remaining one was suspicious of having malignant tumor because of multiple low density shadows in the brain revealed by CT before operation but biopsy failed to make a clear diagnosis. 176 patients were cured by initial operation, the rest 44(20%) underwent reoperation because of multiple or occult insulinomas. Pathologically, islet cell hyperplasia was noted in 11 of the 214 patients.
, 百拇医药
Surgical procedures
Enucleation of insulinoma, partial resection with surrounding normal pancreas and distal pancreatectomy with splenectomy are the main surgical procedures.
RESULTS
Symptoms
210 (95.5%) of the 220 patients had typical Whipple′s triad. Obesity was common in these patients due to frequent eating. Mental disorders or confusion was also seen because of frequent damage to the brain by hypoglycemia.
, 百拇医药
Size of insulinoma
The diameter of the largest tumor resected was 11cm and that of the smallest 0.1cm. The diameter of insulinoma was larger than 2cm in 49 patients(22%), between 1-2cm in 153(70%)， and less than 1cm in 18(8%). 291 tumors were resected from the 220 patients. 194 patients (90.7%) had single tumor and 20 (9.3%) multiple tumors, 2 or 3 of which were seen in most patients. One patient had 21 tumors which were removed by two operations.
, 百拇医药
Diagnosis
The earliest diagnosis was 1 month after the onset of symptoms and the latest 12 years (mean 35 months). One patient with psychiatric symptoms was diagnosed one year after the onset of the first symptom, but he refused operation for 19 years. 119 patients(54%) were misdiagnosed as having epilepsy, hypoglycemia, insanity, Addison′s disease, anaemia, hysteria, and menopause syndrome before admission.
The serum glucose level was below 50mg/dL in 95% patients when hypoglycemia attacked and the lowest was 4 mg/dL. One patient experienced hypoglycemia with a serum glucose level of 56mg/dL and some patients with a serum glucose level less than 50mg/dL had no symptom. In 69.4% of the patients, the serum insulin level was above 25 μU/ml. The ratio of insulin to glucose in 102 patients was below 0.3 at the attack of hypoglycemia or during fasting (11 patients) and above 0.3(91). It was between 0.31-18.8, which was consistent with the diagnostic criteria for insulinoma.[2]
, 百拇医药
Localization of tumors
In this group, insulinomas evenly distributed throughout the pancreas (37.1% head, 26.1% body, and 36.1% tail).Two patients had tumors outside the pancreas: one in the colon mesentery and the other in the fossa of the spleen.Seventy-three patients were subjected to B-ultrasound examination before operation with a positive rate of 31.5% (23/73). Among them, 42 (57.5%) with a negative result of B-ultrasound were found to have insulinoma during operation, and 8 (11%) a wrong localization of tumors. Negative B-ultrasound results were frequently seen in tumors with a diameter less than 2cm or of 2.5-3.0cm.
, 百拇医药
Fifty-eight of the 220 patients underwent PTPC with a positive rate of 88%. In 1 patient with malignant insulinoma metastasized to the liver, the serum glucose level did not elevate after distal pancreatectomy. Intraoperative PTPC found that the ratio of insulin to glucose was three times higher than the preoperative ratio, suggesting the remnant of the tumors. Four patients showed positive results after ASVS.
CT showed positive results in 23.2% of the patients, negative results in 62.3%, and wrong localization in 14.5%. In 3 patients who had received enhanced CT, 2 showed positive results. In 5 patients underwent MRI,only 1 had the tumor detected.
, 百拇医药
In all examinations, angiography showed a highest positive rate of 62.8%. Its negative rate was 20.9%, and wrong localization rate 16.7%. Intraoperative puncture in doubtful focus showed a positive rate of 90%. Intraoperative ultrasonography for 2 patients showed positive results in one and negative results in the other.
Glucose level monitoring
Monitoring of intraoperative glucose level is very important in estimating whether the tumors were totally removed or not. The response of the serum glucose level (more than one time the level before tumor excision or up to 100mg/dL) assures that no tumors remain. In our group, 52.6% of patients had the glucose response in 30 minutes after tumor removal, 77.7% within 1 hour, and only few after 2 hours.
, 百拇医药
90% of the 214 patients had postoperative high blood glucose level; the duration varied from 3 days to 18 days (mean 1 week). The blood glucose level was between 100mg/dL and 200mg/dL.
Postoperative complications
The main complications were pancreatic fistulae and pancreatitis. In our group, 33.8% of patients had the fistulae regardless of the location of the tumor(50% head, 50% body and tail). Pancreatitis had a lower occurrence(13.1%). The incidences of pancreatic fistulae and pancreatitis were 31.8% and 19.3% in simple enucleation of insulinoma and 54.5% and 27.3% in distal pancreatectomy respectively.
, http://www.100md.com
DISCUSSION
Localizing methods
85.7% of the patients in our group had preoperative localization of tumors. Because the diameters of 78% tumors were less than 2cm, B-ultrasound, CT and MRI showed a low positive rate and were helpful only to those patients with liver metastasis or relatively larger tumors. Angiography, however, showed a higher positive rate in detecting insulinoma that was well-vascularized. Milana[2]reported that its positive rate was 46.7%, but in our group it was 62.8%. Special attention should be paid to those patients with multiple tumors or who had removal of insulinoma previously. PTPC, an invasive and complicated examination, is still effective for diagnosis or differential diagnosis of the tumor. Since the application of PTPC in our hospital in 1981, insulinoma has been ruled out in 5 patients with a low level of insulin in the splenic vein and portal vein.In recent years, new techniques such as EUS, ASVS have been used in detecting insulinoma. High sensitivity and less injury are their merits and could improve the accuracy in localizing insulinoma.
, 百拇医药
Intraoperative palpation is very important when preoperative localization fails. For an experienced surgeon, the success rate of explorative operation was above 90%; together with intraoperative ultrasonography，the success rate could come up to 100%.[3] In 67 patients with insulinomas, 56 (83.6%) were subjected to preoperative localization, combined intraoperative ultrasonography and palpation, with a successful operative rate of 89%.[2] In our group, 85.7% patients had preoperative localization, with a successful rate of 92.4%. For those patients with negative preoperative localization or intraoperative palpation, fine needle puncture at suspicious focus and immediate cytological examination were helpful. Compared to frozen slice, this method showed the same accuracy but lower occurrence of pancreatic fistulae. If the tumor was not identified by these methods, segmented resection from the tail of the pancreas by monitoring blood glucose level was suggested. In addition, measuring the insulin level of blood samples from the splenic vein in different sites were also helpful. Intraoperative insulin measurement by radioimmunity can also judge whether the tumor is resected totally or not.[4]
, 百拇医药
Surgical procedures
The choice of surgical procedure depends on the intraoperative situation. It is better to perform distal pancreatectomy in the patients with multiple tumors. Because the diameter of 90% insulinomas is less than 2cm and their border is clear, simple enucleation is preferable. Partial resection including surrouding normal pancreas is not acceptable because of the injury to the nearby pancreatic duct or blood vessels. Extensive pancreatectomy should be considered in the patients with malignant tumor. For inoperable patients or those with liver metastasis, hepatic artery embolization, chemotherapy and somatostatin could be adopted.
, 百拇医药
Occult insulinoma
Some of such tumors can not be found during operation for two reasons. First, the tumor is very small, hiding in the head and tail of the pancreas or in the hilus of the spleen or outside the pancreas. Second, it is nesidioblastosis. In our group, the incidence of insulinoma was similar in the head, body and tail of the pancreas, hence the success rate of blind distal pancreatectomy was very low when the tumor was not found. Segmented resection from the tail of the pancreas while monitoring blood glucose level could be done. 90% or 95% of the pancreas could be resected, but total pancreatectomy was not accepted. If the tumor was not found by these methods, the best choice was to finish the operation. To measure the insulin level of blood sample from the portal and splenic vein, the operation was helpful for localization and reoperation.
, 百拇医药
Pancreatic wound
To prevent fistulae of the pancreas, we followed the following principles: (1) thorough haemostasis of wound and ligation of the severed large pancreatic duct (if possible,intravenous secretion could make pancreatic juice secret and is helpful to find the ruptured large pancreatic duct); (2) covering wound surface with omentum and smooth suturing; (3) well drainage
Problems in reoperation
, http://www.100md.com
Twenty patients were admitted to our hospital because failed operation in other medical center. The failure was due to: (1) small tumors in the head of the pancreas; (2) blind distal pancreatectomy; (3) multiple tumors: no blood glucose level monitoring and meticulous exploration; (4) nesidioblastosis; (5) malignant insulinomas; and (6) ectopic insulinomas. In these patients, whether elevated insulin level or high insulin peak could be found by PTPC is important for reoperation. Nesidioblastosis or malignant tumors usually have a high insulin level and high peak insulin, which indicate the location of the tumor. In our group, a 0.2cm-tumor was found in one patient by measuring the high peak of insulin level in the tail of the pancreas. In another patient, multiple tumors were resected according to the two peaks of PTPC.
, 百拇医药
Malignant insulinoma
The incidence of malignant insulinoma was as low as 5.6% in our group compared with 10% reported by Milana.[2] The diagnosis of malignant tumor is mainly dependent on whether liver metastasis, lymph node metastasis and local invasion occur. It is very important to remove the primary focus, metastatic lymph node and metastatic tumors in the surface of the liver. Since Whipple procedure has become a relatively safer operation in some hospitals, it is recommended, combined with postoperative hepatic artery embolization, for those patients with malignant tumors in the head of the pancreas. One patient after repeated hepatic artery embolization after operation survived for 8 years.[5]Other methods such as frozen therapy with B-ultrasound guiding and hot coagulation under laparoscopy were also helpful. In addition, strepozotocin, 5-FU, adriacin and interferon could be used. The effect of combined use of medicines was better than that of single medicine. No obvious side effect was observed after use of diazoxide in most patients apart from palpitation, nausea and discomfort in the gastrointestinal tract in some patients. Sandostadin, dilantin and chemotherapeutic drugs were also used before operation, but the effect could not be identified.
, 百拇医药
Rebounded high blood glucose level
The high blood glucose level after operation does nothing good to the recovery of patient but increases the opportunity of complications. In recent years, insulin has been used regularly in our hospital to control the blood glucose after operation and help the recovery of islet cell function.
Postoperative complications Pancreatitis and fistulae of the pancreas are the common complications. The most severe complication is severe acute pancreatitis because of the injury to the blood vessel or pancreatic duct at specrfic tumor site (behind the head) or the extensive resection of the pancreas. In the early stage of our treatment, 2 patients died from this complication. Hence tender exploration should be emphasized. Cimetidine or losec should be routinely applied to prevent fistulae after operation and to reduce the secretion of pancreatic juice. The regular use of sandostadin after operation is also benefitial.
, http://www.100md.com
作者单位：赵玉沛 中国协和医科大学 北京协和医院外科，北京100730，中国
王 欣 中国协和医科大学 北京协和医院外科，北京100730，中国
杨 波 中国协和医科大学 北京协和医院外科，北京100730，中国
肖 毅 中国协和医科大学 北京协和医院外科，北京100730，中国
蔡力行 中国协和医科大学 北京协和医院外科，北京100730，中国
钟守先 中国协和医科大学 北京协和医院外科，北京100730，中国
朱 预 中国协和医科大学 北京协和医院外科，北京100730，中国
REFERENCES
, 百拇医药
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