胰岛素瘤的术前及术中超声定位

目的:探讨术前及术中超声在胰岛素瘤定位诊断中的价值.方法:对4例胰岛素瘤患者的术前B型超声检查B超及术中B超、计算机断层摄影(CT)、核磁共振成像术(MRI)和数字减影血管造影(DSA)定位治疗进行分析.结果:术前B超,CT,MRI和DSA对胰岛素瘤的定位诊断准确率分别为40%,100%,40%,20%和60%,术中超声(IOUS)定位诊断准确率为100%.结论:术中超声对胰岛素瘤的定位诊断率高,并可显示肿瘤的毗邻关系.有助于术中选择合适的手术方式.     

胰岛素瘤62例诊治体会

目的总结胰岛素瘤的诊治经验,评估胰岛素瘤的多种定位诊断技术.方法回顾性分析两院1970年～2001年来收治的62例胰岛素瘤的临床资料.结果 CT、MRI、术前B超、SAOG及IOUS诊断胰岛素瘤的敏感性分别为46.4%、70.0%、75.6%、75.9%和100%;手术治疗60例,其中实施肿瘤剜除术41例,胰体尾切除术14例,胰十二指肠切除术3例,楔形切除术1例,姑息手术1例,总手术切除率98.3%;全组无手术死亡,肿瘤切除术后病人随访无低血糖发作;术后并发症包括胰瘘5例、胰腺假性囊肿2例.结论术前B超和SAOG、术中详尽扪诊联合IOUS可基本上取得胰岛素瘤较为满意的定位诊断;根据胰岛素瘤的大小、部位、数目及性质采取适宜的手术方式是获得良好疗效的关键.     

胰岛素瘤的定位诊断及外科治疗方法探讨

目的 探讨胰岛素瘤的定位诊断及外科治疗方法。方法 对确诊的18例胰岛素瘤患者的临床资料进行回顾性分析。结果 术前B超、CT和选择性动脉造影检查的阳性率分别为46％(7／15)、54%(7/13)和75％(6／8)，术中B超检查的阳性率为100％(5／5)。18例中行肿瘤剜除术11例，胰体尾切除术7例。结论 胰岛素瘤的术前定位诊断比较困难，术中探查和术中B超检查准确性很高；手术切除是胰岛素瘤惟一可靠的治疗方法。     

胰岛素瘤62例诊治体会

目的：总结胰岛素瘤的诊治经验，评估胰岛素瘤的多种定位诊断技术。方法：回顾性分析两院1970年-2001年来收治的62例胰岛素瘤的临床资料。结果：CT、MRI、术前B超、SAOG及IOUS诊断胰岛素瘤的敏感性分别为46.4%、70.0%、75.6%、75.9和100%；手术治疗60例，其中实施肿瘤剜除术41例，胰体尾切除术14例，胰十二指肠切除术3例，楔形切除术1例，姑息手术1例，总手术切除率98.3%；全组无手术死亡，肿瘤切除术后病人随访无低血糖发作；术后并发症包括胰瘘5例、胰腺假性囊肿2例。结论：术前B超和SAOG、术中详尽扪诊联合IOUS可基本上取得胰岛素瘤较为满意的定位诊断；根据胰岛素瘤的大小、部位、数目及性质采取适宜的手术方式是获得良好疗效的关键。     

胰岛素瘤的定位诊断方法

对41例胰岛素瘤患者的临床资料作回顾性分析,发现术前B超、CT、MRI、选择性动脉造影（AS）检查定位诊断的阳性率分别为45%（18/40）、62.5%（20/32）、66.7%（10/15）、80%（8/10）,术中B超检查为100% （15/15）。认为胰岛素瘤的术前定位诊断较为困难,手术探查加术中B超检查是定位诊断的最佳方法。     

功能性胰岛素瘤的外科临床诊疗分析

目的 探讨功能性胰岛素瘤的外科诊疗方法.方法 回顾性分析1990年1月至2006年12月有明显临床症状的,经手术治疗、病理证实的36例功能性胰岛素瘤患者的临床资料.结果 在功能性胰岛素瘤患者中良性胰岛素瘤病例最多见,共27例,占全部病例的75%;恶性胰岛素瘤6例,胰岛细胞增殖症2例.在B超、CT、MRI、内镜超声等影像学检查中,术中B超阳性发现和定位准确率均为92.3%.所有病例均行手术治疗,7例行胰十二指肠切除术,17例行胰体尾切除术,12例行单纯瘤体摘除术,术后症状改善明显,复发率低.结论 术中B超是诊断和定位胰岛素瘤最有效的诊断方法,手术规范切除是治疗功能性胰岛素瘤的有效方法,其预后良好.     

术中超声检查在胰岛素瘤定位诊断中的应用

目的探讨术中超声（IOUS）检查在胰岛素瘤定位诊断中的的应用价值。方法对15例已经作出定性诊断的胰岛素瘤患者进行IOUS检查。结果 15例胰岛素瘤患者IOUS检查均作出定位诊断。结论 IOUS检查可对胰岛素瘤作出准确的定位诊断,同时显示肿瘤和周围器官的关系,有助于手术方式的选择,并可指导准确切除肿瘤,减少并发症。     

功能性胰岛素瘤的外科临床诊疗分析

目的探讨功能性胰岛素瘤的外科诊疗方法。方法回顾性分析1990年1月至2006年12月有明显临床症状的,经手术治疗、病理证实的36例功能性胰岛素瘤患者的临床资料。结果在功能性胰岛素瘤患者中良性胰岛素瘤病例最多见,共27例,占全部病例的75%;恶性胰岛素瘤6例,胰岛细胞增殖症2例。在B超、CT、MRI、内镜超声等影像学检查中,术中B超阳性发现和定位准确率均为92.3%。所有病例均行手术治疗,7例行胰十二指肠切除术,17例行胰体尾切除术,12例行单纯瘤体摘除术,术后症状改善明显,复发率低。结论术中B超是诊断和定位胰岛素瘤最有效的诊断方法,手术规范切除是治疗功能性胰岛素瘤的有效方法,其预后良好。     

胰岛素瘤的诊断和治疗

目的 总结胰岛素瘤的诊断和治疗经验,以期提高手术成功率和改善预后.方法 回顾性分析1966年至2007年收治的138例胰岛素瘤患者的临床资料.结果 全组病例均有不同程度的低血糖症状和Whipple三联征表现;64例有不同程度的精神神经症状,12例术后血糖恢复正常,但仍遗留精神神经症状.检测空腹血胰岛素88例,胰岛素释放指数均>0.3.术前B超检查75例,检出肿瘤8例;腹部CT 68例,检出17例;腹部MRI检查10例,检出5例;术中B超44例,检出肿瘤43例,另1例病理证实为胰岛细胞增生症.135例行手术治疗,其中肿瘤摘除术88例,胰体尾切除44例,胰十二指肠切除2例,活检1例.132例术后血糖恢复正常.术后血糖反跳性升高110例,多于术后2周内恢复正常;术后胰瘘20例,急性胰腺炎32例.结论 根据whipple三联征和胰岛素释放指数对胰岛素瘤作出定性诊断.手术探查联合术中B超是简单有效的定位诊断方法.手术是治愈胰岛素瘤的惟一方法.术中B超引导下切除肿瘤可有效避免主胰管和血管的损伤,降低手术并发症.     

低频小探头超声内镜对胰腺内分泌肿瘤术前定位诊断的价值

目的 评价低频小探头超声内镜检查(LFMPS)在胰腺内分泌肿瘤术前定位诊断中的临床价值。方法 2000年6月至2002年6月期间21例临床拟诊为胰腺内分泌肿瘤的患者术前行腹部 B超、螺旋 CT、磁共振(MRI)及 LFMPS探查(Fujinon 7.5 MHz低频小探头超声及超声系统),检查结果与外科术中定位和病理结果对照,评估LFMPS对胰腺内分泌肿瘤的术前定位诊断价值。结果21例患者中17例经外科手术及术后病理证实为内分泌肿瘤,4例未手术。其中胰岛素瘤16例(头部9例、体部 3例、尾部4例),胰腺外血管活性肠肽瘤1例,检出病灶的平均直径 2.02 cm。LFMPS确诊14例(82.4％),B超确诊9例(52.9％),螺旋CT确诊15例(88.2％),MRI确诊12例(70.6％),其中LFMPS对位于胰腺头、体部肿瘤以及直径<1cm病灶的确诊率优于其他常规影像方法。结论LFMPS对胰腺内分泌肿瘤的术前定位诊断准确率较高,且与肿瘤的位置与大小有关。     

Insulinoma: Diagnosis and surgical treatment. Retrospective analysis of 31 cases.

BACKGROUND : Insulinomas are rare tumors that are usually benign, single and curable by simple surgical excision. They can present problems in diagnosis and localization. STUDY DESIGN: Retrospective analysis of patients with insulinoma managed during a 13-year period (1992-2005) at a tertiary-level institution. RESULTS: 31 patients (mean age 38.4 [SD 13.3] years; 16 men) presented with hypoglycemic symptoms for 4.6 (5.5) years. In 22 (71%) patients, the lesion was successfully localized pre-operatively. Of various pre-operative localization techniques, CT angiography (5/6; 83%), intra-arterial digital subtraction angiography (11/17; 65%), dual-phase CT (8/14; 57%) and conventional MRI (4/13; 31%) had high rates of successful tumor localization. Intra-operative palpation and ultrasonography also had localization success rates (22/30 [76%] and 11/12 [92%], respectively); each identified one lesion that the other procedure did not localize. Of the 30 patients who underwent surgery, 28 had solitary tumor. CONCLUSION: Pre-operative investigations to localize insulinoma are helpful despite the availability of intra-operative ultrasound. Dual-phase CT should be the non-invasive investigation of first choice.     

Intra-operative procedures to localize endocrine tumours of the pancreas and duodenum

Somatostatin receptor scintigraphy is the best imaging method to identify the presence of neuroendocrine gastroenteropancreatic tumours. Nevertheless, a well structured surgical approach incorporating specific intra-operative methods can localize those tumours that cannot be readily detected by this imaging technique. In the case of gastrinoma, standard palpation allows duodenal tumour detection in approximately 60% of cases, endoscopic transillumination, in more than 80%. Furthermore, adding duodenotomy, 95-97% duodenal tumours can be localized. Intraoperative ultrasound, instead, does not add much to standard palpation in duodenal gastrinoma localization. For insulinoma detection, among the intra-operative methods, inspection gives the poorest results, identifying the lesion in only 20% of cases. Palpation offers better results, localizing 60-80% of insulinomas. The introduction of intra-operative ultrasound has revolutionized the ability to find pancreatic insulinoma, allowing the surgeon to identify the insulinoma in nearly every patient.     

Endogenous hyperinsulinemic hypoglycemia: diagnostic strategies, predictive features of malignancy and long-term survival

Diagnostic strategies, malignancy predictors and long-term survival were retrospectively evaluated in patients with hyperinsulinemic hypoglycemia (64 insulinomas). Lower median glycemia was 30 (range 20-53) mg/dl [1.6 (1.1-2.9) mmol/l] with concurrent insulin of 48 (13.2-217) microU/ml and 15 (2-46) microU/ml measured by radioimmunoassay (RIA) and immunofluorimetric assay (IFMA), respectively. All patients with insulinomas had a positive prolonged fast within 48 h. Sensitivity of localization methods was: ultrasonography (US) 23%, computed tomography (CT) 28%, magnetic resonance imaging (MRI) 65%, endoscopic US 75%, arteriography 38%, portal venous sampling 67%, selective arterial calcium stimulation 67%, intraoperative US 94% and palpation 92%. Nine patients (14%) had malignant insulinomas. Age at diagnosis (mean+/-SD, 53.8+/-19 vs 39.4+/-16.3 yr; p=0.03), insulin (1372+/-730 vs 785+/-659% (percentage of the method's diagnostic cut-off; 6 and 3 microU/ml for RIA and IFMA, respectively; p=0.007) and C-peptide levels (9.8+/-2.9 vs 3.9+/-2.8 ng/ml (3.2+/-0.9 vs 1.3+/-0.9 nmol/l; p=0.006), and tumor size (6.2+/-4.1 vs 1.5+/-0.6 cm; p=0.0002) were increased in malignant insulinomas. C-peptide level above 6.1 ng/ml (2.0 nmol/l) had a 100% sensitivity and 96% specificity, and tumor size above 2.6 cm yielded a sensitivity of 88% and specificity of 100% in predicting malignancy. Survival of patients with malignant insulinomas was significantly impaired (16 vs 100% at 5 yr; p=0.0000001). The diagnosis of insulinoma can be made within 48 h of fasting. The association between intraoperative US and palpation evidenced the tumor in 95% of the patients. C-peptide and tumor size were reliable malignancy predictors.     

胰岛素瘤术前定位价值的探讨

目的：探讨胰岛素瘤的术前定位价值。方法：比较分析1985－2001年我院普外科收治的33例手术治疗胰岛素瘤患的各种检查定位方法，结果：各种检查的准确性如下：超声15％，普通CT33．3％，SCT62．5％，高场MR61．1％，选择性动脉造影46．1％，术中探查93．9％，术中超声91．7％，术中超声＋探查为100％。结论：术前定位检查的价值有限。     

Role of EUS in the preoperative localization of insulinomas compared with spiral CT

BACKGROUND: Preoperative radiologic localization of insulinomas often fails because of the small size of these tumors. Endoscopic ultrasound (EUS) can localize insulinomas in up to 80% of the cases. The aim of this study was to compare EUS and computed tomography (CT) diagnostic accuracy for insulinomas. METHODS: We reviewed medical records from 12 patients (10 women) with a biochemical diagnosis of hypoglycemia and hyperinsulinism from 1 university hospital and 1 community hospital. A diagnosis of insulinoma was ultimately made in all cases and before surgery the patients underwent abdominal US, spiral CT and EUS in an attempt to precisely localize the tumor. Surgery was considered the standard for tumor localization. RESULTS: Ten tumors were benign (83.3%) and 2 were malignant (16.7%). The overall sensitivity of EUS in identifying insulinomas was 83.3% compared with 16.7% for CT. Tumors not detected by EUS had a mean size of 0.75 cm. EUS-guided fine-needle aspiration was possible in only 3 patients, with a positive cytologic diagnosis in 2 (66.6%). Tumors located in the head and body of the pancreas were identified by EUS in all patients, but those located in the tail were diagnosed in only 50% of the cases. CONCLUSIONS: EUS is superior to spiral CT and should replace it for the detection of pancreatic insulinomas. EUS identification depends on the site and size of the tumor.     

Endoscopic ultrasound is highly accurate and directs management in patients with neuroendocrine tumors of the pancreas

Preoperative localization of pancreatic neuroendocrine tumors with traditional imaging fails in 40-60% of patients. Endoscopic ultrasound (EUS) is highly sensitive in the detection of these tumors. Previous reports included relatively few patients or required the collaboration of multiple centers. We report the results of EUS evaluation of 82 patients with pancreatic neuroendocrine tumors. METHODS: We prospectively used EUS early in the diagnostic evaluation of patients with biochemical or clinical evidence of neuroendocrine tumors. Patients had surgical confirmation of tumor localization or clinical follow-up of >1 yr. RESULTS: Eighty-two patients underwent 91 examinations (cases). Thirty patients had multiple endocrine neoplasia syndrome type 1. One hundred pancreatic tumors were visualized by EUS in 54 different patients. The remaining 28 patients had no pancreatic tumor or an extrapancreatic tumor. Surgical/pathological confirmation was obtained in 75 patients. The mean tumor diameter was 1.51 cm and 71% of the tumors were < or =2.0 cm in diameter. Of the 54 explorations with surgical confirmation of a pancreatic tumor, EUS correctly localized the tumor in 50 patients (93%). Twenty-nine insulinomas, 18 gastrinomas, as well as one glucagonoma, one carcinoid tumor, and one somatostatinoma were localized. The most common site for tumor localization was the pancreatic head (46 patients). Most tumors were hypoechoic, homogenous, and had distinct margins. EUS of the pancreas was correctly negative in 20 of 21 patients (specificity, 95%). EUS was more accurate than angiography with or without stimulation testing (secretin for gastrinoma, calcium for insulinoma), transcutaneous ultrasound, and CT in those patients undergoing further imaging procedures. EUS was not reliable in localizing extrapancreatic tumors. CONCLUSIONS: In this series, the largest single center experience reported to date, EUS had an overall sensitivity and accuracy of 93% for pancreatic neuroendocrine tumors. Our results support the use of EUS as a primary diagnostic modality in the evaluation and management of patients with neuroendocrine tumors of the pancreas.     

Endoscopic ultrasonography and somatostatin receptor scintigraphy in the preoperative localisation of insulinomas and gastrinomas.

BACKGROUND: Endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS) can detect a high percentage of gastroenteropancreatic neuroendocrine tumours especially in the upper gastrointestinal tract. The ability of these procedures to localise primary tumour lesions and metastases of gastrinomas and insulinomas was evaluated in comparison with transabdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). PATIENTS AND METHODS: In a prospective trial, patients with gastrinomas (n = 10) and insulinomas (n = 10) diagnosed by clinical signs and laboratory tests were assessed by EUS, SRS, US, CT and MRI. RESULTS: In 10 patients with gastrinoma and 10 patients with insulinoma, a total of 14 separate primary tumour lesions were histologically confirmed for each of the tumour entities. The mean diameter was 2.1 cm for gastrinomas and 1.5 cm for insulinomas. All insulinomas and nine gastrinoma lesions were located in the pancreas. Three gastrinomas were found in the duodenal wall, one in a periduodenal lymph node, and one in the liver, For gastrinomas, sensitivities were 79% with EUS, 86% with SRS and 29% with CT, US, and MRI. For insulinomas, sensitivities were 93% with EUS, 14% with SRS, 21% with CT and 7% with US and MRI. CONCLUSIONS: EUS is of high value for localising primary lesions of both tumour entities. SRS is a very sensitive procedure for diagnosing of gastrinomas but not insulinomas. CT, US and MRI are primarily useful for visualising metastases.     

Assessment of selective arterial calcium stimulation and hepatic venous sampling to localize insulin-secreting tumours

OBJECTIVE: Non-invasive localization modalities such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) often fail to localize insulinomas smaller than 2 cm in diameter. Recent studies have shown that the selective arterial stimulation and hepatic venous sampling (ASVS) technique using intra-arterial calcium as the insulin secretagogue facilitates the regionalization of such occult insulinomas. This study assesses the sensitivity of ASVS in localizing insulin-secreting tumours. SUBJECTS AND METHODS: Eleven consecutive patients (8 women), aged 29-82 years, were studied over the past 4 years at our hospital. Hyperinsulinaemic hypoglycaemia due to an insulin-secreting tumour was proven in all patients. Calcium gluconate (0.025 mEq/kg body weight) was injected directly into the arteries supplying the pancreas and the liver. Insulin levels were measured in samples taken from the right hepatic vein before and 30, 60 and 120 s after each injection. The ASVS technique was performed in all 11 patients; the results were compared with the surgical findings in 10 patients and the autopsy findings in 1 case. The ASVS results were also compared with the findings of other, previously performed imaging modalities. RESULTS: ASVS correctly localized 4 insulin-secreting tumours to the head, 3 to the body, 1 to the tail, 2 to the tail or body of the pancreas and 1 to the liver. Thus, the sensitivity was 100% (11/11) whereas other localization techniques were less sensitive: 7/11 tumours were detected by angiography, 4/8 by endosonography, 3/8 by CT and 1/6 by MRI. Insulinomas (confirmed by histological examination), sized 4-25 mm, were found in 10 patients. All were cured by selective surgery and remained free of hypoglycaemia over the next 1-4 years of follow-up. An insulin-secreting neuroendocrine tumour in the liver was documented in 1 case at autopsy. CONCLUSIONS: Arterial stimulation and hepatic venous sampling is a very sensitive technique for preoperative localization of insulin-producing tumours. It can help to plan minimally invasive surgery and to select an appropriate strategy for patients suffering from malignant tumours in others.