胰岛素瘤的诊断与治疗（附38例临床分析）

目的 总结胰岛素瘤的诊断和治疗经验.方法 收集我院1988年10月至2008年10月收治的38例胰岛素瘤的临床资料,对其临床表现、诊断和治疗方法 进行回顾性分析.结果 全组38例患者均表现Whipple三联征.术前定位检查发现胰岛素瘤阳性率分别为:经腹超声 78.95%,CT 54.17%,MRI 33.33%,EUS 100.00%,DSA 40.00%.术中B超联合扪诊检查阳性率90.00%.其中34例患者在我院接受手术治疗37次,包括胰岛素瘤局部摘除术28次,胰体尾 (或胰尾)切除术5次,胰体尾 (或胰尾)加脾切除3次.术后病理证实单发良性肿瘤32例,多发1例,有恶性倾向1例.肿瘤完全切除的患者术后低血糖症状消失.术后胰瘘5例,均经非手术治疗痊愈.结论 Whipple三联征和反应性胰岛素/血糖＞0.3是定性诊断的主要依据,术前诊断阳性率较高的是EUS、经腹超声和CT,术中扪诊联合术中超声是最有效的肿瘤定位手段,肿瘤摘除术仍为胰岛素瘤的主要术式.     

无创性检查在胰岛素瘤定位诊断中的价值

目的 探讨无创性检查方法在胰岛素瘤定位诊断中的价值.方法 回顾性分析北京协和医院2005年1月至2008年11月手术治疗的88例胰岛索瘤患者的临床资料.其中男性40例,女性48例;年龄15～74岁,平均46.5岁.结果 B超、增强CT、多排螺旋CT胰腺灌注、磁共振成像、奥曲肽显像、超声内镜、腹腔镜超声和术中超声的诊断阳性率分别为19.3%(17/88)、52.4%(11/21)、95.5%(64/67)、1/6、30.0%(6/20)、83.9%(26/31)、8/8和5/5.其中8例多发胰岛素瘤患者共切除肿瘤31个,多排螺旋CT胰腺灌注、术中超声的定位诊断准确率分别为48.4%(15/31)和100%(14/14).结论 目前胰岛素瘤的术前定位诊断已进入无创检查时代,应首选多排螺旋CT胰腺灌注.对于多发性胰岛素瘤的患者,术中超声在定位诊断中具有重要价值.     

胰岛素瘤35例诊断和治疗分析

目的提高胰岛素瘤的诊断和治疗水平。方法回顾性分析收治的35例胰岛素瘤患者的临床资料。35例患者中,男10例,女25例,97.1%(34/35)有典型的Whipple三联征。术前影像学检查有超声、增强CT、胰腺3D-CT、MRI、CT胰腺灌注扫描、EUS及术中超声(IOUS),诊断阳性率分别为50.0%(15/30),77.8%(14/18),80.0%(8/10),93.8%(15/16),91.7%(11/12),100%(1/1),100%(3/3)。结果 35例均行手术治疗。术后随访3~113个月,平均50个月,2例失访,余33例未见复发。结论无创检查中,定位诊断首选胰腺CT灌注扫描。术中触诊联合超声定位,准确率接近100%。对于良性病变,胰岛素瘤摘除术是首选的治疗方式。对于恶性胰岛素瘤,可行胰腺部分切除术或胰十二指肠切除术。     

胰岛素瘤的诊断和外科治疗

目的探讨胰岛素瘤的诊断和外科治疗方法。方法回顾性分析经手术和病理确诊的55例胰岛素瘤患者的临床资料。结果 7例为无功能性,48例(87.27%)功能性胰岛素瘤均有典型的Whipple三联征表现,且血胰岛素/血糖比值(IRI/G)0.3。术前超声,CT,MRI,内镜超声(EUS),术中超声和选择性动脉造影(DSA)诊断的阳性率分别为83.64%(46/55),62.07%(18/29),40.00%(4/10),100%(8/8),90.00%(9/10)和40.00%(2/5)。胰岛素瘤剜除术48例次,胰体尾切除术5例,胰体尾联合脾切除术3例,胰腺中段切除术1例,胰十二指肠切除术1例;肿瘤直径小于或等于2 cm者占95.00%(57个)。23.33%(14个)的肿瘤位于胰头部,33.33%(20个)位于胰体部,43.33%(26个)位于胰尾部,3例(5.46%)为多发性肿瘤。病理诊断均为胰岛素瘤,无恶性者。术后无低血糖症状发作,发生胰瘘1例。结论 Whipple三联征和IRI/G0.3可作为胰岛素瘤定性诊断的依据。联合应用超声,CT,MRI和内镜超声多种方法进行术前定位。内镜超声在胰岛细胞瘤定位诊断中的阳性率最高;术中超声是有效的定位方法。肿瘤剜除术是胰岛素瘤的最佳治疗方法。     

胰岛素瘤诊治分析：附72例报告

目的:探讨胰岛素瘤的诊断和外科治疗方法。方法:回顾性分析我院31年余诊治的72例胰岛素瘤的临床资料。结果:84.72%有典型的Whipple三联征表现。80.56%血浆免疫反应性胰岛素/血糖(IRI/G)比值>0.3。术前定位诊断方法的阳性率分别为:腹部超声78.13%,CT(平扫或增强)60.97%,多排螺旋CT胰腺灌注100%,MRI 37.50%,内镜超声(EUS)72.73%,选择性动脉造影(DSA)28.57%。术中超声联合扪诊诊断阳性率92.31%。肿瘤最大直径≤2 cm者占88.75%。37.5%的肿瘤位于胰头颈部,27.50%位于胰体部,35.0%位于胰尾部。81.58%的病例可行胰岛素瘤局部剜除术。病理诊断均为胰岛素瘤,65例(90.28%)为功能性胰岛素瘤,7例(9.72%))为无功能性胰岛素瘤;4例(5.56%)为多发性肿瘤,2例(2.78%)恶性倾向,1例(1.39%)合并多发性内分泌肿瘤1型(MEN-1)。结论:Whipple三联征和IRI/G>0.3可作为胰岛素瘤定性诊断的主要依据。应联合应用超声,CT,多排螺旋CT胰腺灌注,MRI,内镜超声和DSA多种方法进行术前定位。术中超声联合扪诊是简单有效的定位诊断方法。肿瘤的局部剜除术是多数胰岛素瘤的最佳手术治疗方式。     

胰岛素瘤的诊断和治疗：附137例报告

目的总结胰岛素瘤的诊断方法和外科治疗效果。方法回顾性分析近26年来收治的胰岛素瘤137例患者的临床资料。结果男77例,女60例。137例均具有典型的Whipple三联症。B超,CT,MRI检查的阳性率分别为35.1%,67.9%,58.1%。126例手术治疗患者中,102例(80.9%)行胰岛素瘤摘除术,4例(3.2%)行胰十二指肠切除术,16例(12.7%)行胰体尾切除术,另外4例(3.2%)行开腹探查术。切除的122例肿瘤中,良性占96.7%,恶性3.3%;单发肿瘤98.4%,多发1.6%。86.9%肿瘤直径≤2.0cm。13.1%肿瘤位于胰头;位于胰体和胰尾者分别为46.7%和40.2%。结论Whipple三联症,结合IRI,IGR,C-肽,以及胰岛素原的检测水平,可作为胰岛素瘤的定性诊断依据。胰岛素瘤的定位诊断仍很困难,联合应用多种影像学检查方法有助于提高检出率。治疗首选肿瘤摘除术,如果术中探查未能找到肿瘤,不宜盲目行胰体尾切除术,应排除其他原因所致低血糖症,同时进一步完善影像学检查方法,明确定位后,再考虑二次手术治疗。     

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目的 总结胰岛素瘤的诊断和治疗经验.方法 回顾性分析北京协和医院1953-2007年诊治404例胰岛素瘤的临床资料.结果 肿瘤直径＜2cm者占79.6%.36.2%的肿瘤位于胰头部,28.2%位于胰体部.35.6%位于胰尾部.18例(4.5%)为恶性胰岛素瘤,34例(9.0%)为多发性肿瘤.96.0%有典型的Whipple三联征.89.6%血胰岛素/血糖比值＞0.3.术前定位检查发现胰岛素瘤敏感性经腹超声检查36.8%,普通平扫CT24.7%,增强CT66.7%,多排螺旋CT胰腺灌注92.7%,MRI 31.6%,生长抑素受体显像33.3%,超声内镜(EUS)79.1%,选择性动脉造影(SAG)84.6%,经皮经肝门静脉置管取血(眦)测定胰岛素88.1%,动脉刺激静脉取血(ASVS)测定胰岛素87.0%.术中定位诊断方法的敏感性细针穿刺活检89.2%,术中超声(包括腹腔镜超声)检查90.0%.73.1%的病例可行肿瘤的局部摘除术.结论 多排螺旋CT胰腺灌注是目前胰岛素瘤术前定位诊断的首选方法.随着微创外科技术在胰腺外科中的应用,对部分条件适宜的病例可选用腹腔镜手术,但对多发胰岛素瘤仍应仔细开腹探查,避免遗漏病灶.     

胰岛素瘤的诊断与治疗

目的 探讨胰岛素瘤的诊断治疗经验.方法 对本院2008年3月至2012年12月收治的10例胰岛素瘤资料进行回顾性研究.其中男2例,女8例;年龄11 ～ 52岁,平均（32±15）岁.通过对患者进行定性、定位检查确诊,并进行手术干预和随访观察.结果 7例为单纯性胰岛素瘤,3例为多发性内分泌肿瘤-1型（MEN-1）相关的胰岛素瘤;9例为良性肿瘤,1例为交界性肿瘤.10例均有典型的Whipp1e三联征.肿瘤直径＜2 cm者占79.5％.手术切除肿瘤16个,其中12.5％位于胰头部,6.25％位于胰颈部,25％位于胰体部,56.25％位于胰尾部.术前定位检查发现的胰岛素瘤敏感性：经腹超声检查30.5％,多排螺旋增强CT 68.9％,薄层CT灌注扫描79.5％.术中定位诊断方法的敏感性：术中多普勒超声检查100％.81.25％的病例可行肿瘤的局部摘除术.随访6个月～5年,10例病情稳定,血糖均在正常范围之内.结论 手术切除是胰岛素瘤的最佳治疗方式.薄层CT多期动态增强扫描是目前胰岛素瘤术前定位诊断的首选方法,术中多普勒超声显著提高手术切除率.加强对胰岛素瘤的认识,早期诊断并合理积极的手术治疗,能够改善患者生活质量.     

胃肠道间质瘤23例诊治体会

胃肠道间质瘤(gastrointestinal tumors,GIST)是消化道最常见的间叶源性肿瘤.我院2005年1月至2011年1月共诊治23例GIST患者,现报告如下. 临床资料 1.一般资料:23例均经病理确诊为GIST的患者,男12例,女11例,发病年龄34～76岁,中位年龄55岁.肿瘤的发生部位:胃15例,小肠6例,结直肠2例.首发症状:消化道出血13例(62%),腹部包块4例(17%),腹痛、腹胀3例(13%),另有3例(13%)是在体检或是在行其他手术中发现.辅助检查:23例均行CT检查,均能发现病灶,内镜检查确诊2例.术后病理检查肿瘤直径3～15cm,,均为梭形细胞.23例经免疫组织化学检查:CD117阳性率为87%(20/23),CD34阳性率70%(16/23),两者均阳性率43%(10/23).清扫31枚淋巴结均未发现淋巴结转移.     

胰腺内分泌肿瘤的诊断与外科治疗

目的提高胰腺内分泌肿瘤的诊断和治疗水平。方法回顾性分析1978年1月至2004年12月经手术治疗、病理证实的38例胰腺内分泌肿瘤病人的临床资料。结果胰腺内分泌肿瘤以胰岛素瘤和无功能性胰岛细胞瘤最常见,分别占57．9%和36.8%,恶性胰岛素瘤和多发性胰岛素瘤各占胰岛素瘤的13．6%,无功能性胰岛细胞瘤中恶性占64．3%;21例(95%)胰岛素瘤成功术前定位和手术切除,1例多发性胰岛素瘤摘除术后 4年后复发,再次手术治愈;86％无功能性胰岛细胞瘤患者以无痛性肿块入院,肿瘤平均大小为8．5cm,6例行胰体尾部切除,4例行胰十二指肠切除,2例行肿瘤摘除,1例行囊肿内引流术,1例行活检术;全组术后并发胰瘘7例(18%)。结论 B超、CT是胰腺内分泌肿瘤有效的诊断方法,肿瘤局部剜出与规范切除是治疗胰腺内分泌肿瘤的有效方法,其预后较好。     

Prognosis after surgery for multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors: Functionality matters

BackgroundMetastasized pancreatic neuroendocrine tumors are the leading cause of death in patients with multiple endocrine neoplasia type 1. Aside from tumor size, prognostic factors of pancreatic neuroendocrine tumors are largely unknown. The present study aimed to assess whether the prognosis of patients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors differs from those with resected multiple endocrine neoplasia type 1-related insulinomas and assessed factors associated with prognosis.MethodsPatients who underwent resection of a multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors between 1990 and 2016 were identified in 2 databases: the DutchMEN Study Group and the International MEN1 Insulinoma Study Group databases. Cox regression was performed to compare liver metastases-free survival of patients with a nonfunctioning pancreatic neuroendocrine tumors versus those with an insulinoma and to identify factors associated with liver metastases-free survival.ResultsOut of 153 patients with multiple endocrine neoplasia type 1, 61 underwent resection for a nonfunctioning pancreatic neuroendocrine tumor and 92 for an insulinoma. Of the patients with resected lymph nodes, 56% (18/32) of nonfunctioning pancreatic neuroendocrine tumors had lymph node metastases compared to 10% (4/41) of insulinomas (P = .001). Estimated 10-year liver metastases-free survival was 63% (95% confidence interval 42%–76%) for nonfunctioning pancreatic neuroendocrine tumors and 87% (72%–91%) for insulinomas. After adjustment for size, World Health Organization tumor grade, and age, nonfunctioning pancreatic neuroendocrine tumors had an increased risk for liver metastases or death (hazard ratio 3.04 [1.47–6.30]). In pancreatic neuroendocrine tumors ≥2 cm, nonfunctioning pancreatic neuroendocrine tumors (2.99 [1.22–7.33]) and World Health Organization grade 2 (2.95 [1.02–8.50]) were associated with liver metastases-free survival.ConclusionPatients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors had a significantly lower liver metastases-free survival than patients with insulinomas. Postoperative counseling and follow-up regimens should be tumor type specific and at least consider size and World Health Organization grade.     

Role of intraoperative ultrasonography in the surgical management of insulinomas

The findings in 35 surgically treated patients with insulinoma and 43 tumors of these patients were analyzed to confirm the efficacy of diagnostic modalities and surgical interventions. The rate of accurate preoperative tumor localization was 72% by angiography, 53% by computed tomographic scan, 55% by ultrasonography, and 83% by percutaneous transhepatic portal vein sampling. Extensive operative exposure and palpation detected 81% of the tumors and intraoperative ultrasonography demonstrated 96% of the tumors. Intraoperative ultrasonography was significantly better than any other diagnostic procedure and was able to demonstrate the anatomical relationship of the insulinoma to the essential structures of the pancreas. Intraoperative ultrasonography also helped determine the safest route for enucleating the insulinomas. Five patients (14%) in our series had metastatic diseases; 2 of these patients with metastases beyond the lymph nodes died due to the growth of tumors. The other 33 patients were free of insulinoma syndrome after the removal of the insulinomas. Streptozotocin was used in 1 patient with recurrent malignant insulinoma, with encouraging results.     

Preoperative localization of insulinomas is not necessary.

BACKGROUND: Insulinomas are infrequent but are important to recognize and surgically remove. Several diagnostic tests have been used to increase the chances of operative success. The value of preoperative testing for insulinomas is the subject of this review. STUDY DESIGN: All patients treated at the Cleveland Clinic for insulinoma between 1985 and 1995 were retrospectively reviewed. All patients had biochemical evidence of primary hyperinsulinemia. RESULTS: There were 21 patients, 10 men and 11 women, with a median age of 58 years. Eighteen patients (85%) had a single insulinoma, two patients (10%) had multiple insulinomas, and one patient (5%) had nesidioblastosis. In addition, two patients (10%) had malignant insulinoma. A total of 13 patients (62%) had successful preoperative localization of their tumors, and all of these were found during exploration either by the surgeon (12 patients) or by intraoperative ultrasonography (1 patient). The remaining eight patients (38%) did not have their lesion localized by preoperative tests. In seven patients these tumors were found at operation, three by the surgeon and four by intraoperative ultrasonography. One patient failed preoperative and intraoperative localization and was later diagnosed with nesidioblastosis. Enucleation was performed in 13 patients and distal pancreatectomy in 7; the patient with nesidioblastosis had a negative laparotomy and a subsequent distal pancreatectomy. The mortality and morbidity rates were 0% and 14%, respectively. Only two patients, including the patient with nesidioblastosis, remained symptomatic after operation. CONCLUSIONS: The diagnosis of an insulinoma does not require extensive localization studies before operation. The combination of surgical exploration and intraoperative ultrasonography identified more than 90% of insulinomas. When technically feasible, enudeation is curative and can be accomplished with low morbidity.     

Exérèse vidéolaparoscopique des insulinomes. Étude de cinq observations *

Study aimEvaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases.Patients and methodFrom 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head (n = 1), body (n = 3) or tail (n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used.ResultsFour resections were exclusively performed with videolaparoscopy: three enuclations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up.ConclusionSelected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.     

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??Analysis of diagnosis and treatment of insulinomas in multiple endocrine neoplasia Type 1(MEN-1) patients ZHANG Tai-ping, ZHAN Han-xiang, ZHAO Yu-pei, et al. Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
Corresponding author: ZHAO Yu-pei, E-mail: zhao8028@263. net
Abstract Objectives To investigate the strategy for diagnosis and surgical procedure of insulinoma in multiple endocrine neoplasia Type 1(MEN-1) patients based on a retrospective study; Methods Medical records of patients diagnosed as MEN-1 related insulinoma from 1995 to 2010 in Peking Union Medical College Hospital were reviewed retrospectively. Clinical data was collected and statistically analyzed; Results A total of 21 patients were diagnosed as MEN-1 related insulinomas, which including 6 males and 15 females, 6 of them had family history of pancreatic endocrine tumor or MEN-1. Multiple tumors were found in 9 cases; 2 cases were malignant insulinomas. Parathyroid was the most common affected gland in these patients, followed by pituitary and adrenal gland.19 patients underwent operations, the lesions were resected in one-stage or subsequent stage based on the severity of high hormone levels harmfulness. Tumor enucleation was the most common operative procedure. In total, 58 lesions were resected, of which 65.5% are < 1 cm in size. Pancreatic fistula (Grade B) occurred in 5 patients, all these patients recovered by conservative treatment; Conclusions MEN-1 related insulinomas have special clinical characteristics, much more attentions should be paid to the high risk populations. Comprehensive exploratory surgery, intraoperative ultrasonography and blood glucose testing can help to remove all lesions. Other involvement glands can be treated in one or the following stage treatment, Surgeons should collaborate with relevant departments and some difficult cases can transferred to the big-volume centers.     

选择性动脉钙刺激后肝静脉血清胰岛素测定用于胰岛素瘤定位的研究

目的 探讨选择性动脉钙刺激后肝静脉血清胰岛素测定(ASVS)术前定位胰岛素瘤的临床应用价值.方法 对2000年5月至2010年6月收治的28例术前行ASVS检查的胰岛素瘤患者的病史资料进行回顾性分析.结果 28例患者中男12例,女16例,均有Whipple三联征表现.手术切除瘤体32枚,78.1%瘤体直径＜20 mm;术后病理均证实为胰岛素瘤,其中26例单发,2例多发.ASVS检查6例肠系膜上动脉出现最高峰值比,9例胃十二指肠动脉出现最高峰值比,6例脾动脉近段出现最高峰值比,6例脾动脉远段出现最高峰值比,1例检查结果阴性.ASVS最高峰比值数值的中位数、平均数分别为8.8倍、14.8倍.ASVS正确定位25例,错误定位2例,1例检查结果阴性,ASVS准确率为89.3%(25/28),高于同组CT、MRI(CT、MRI定位准确率分别为56.5%,60.0%);ASVS敏感度为96.2%,高于同组CT、MRI(CT、MRI敏感度分别为69.6%,75.0%).结论 ASVS术前定位胰岛素瘤较CT、MRI有优势,但ASVS创伤大,应作为CT、MRI等常规影像学检查阴性时定位胰岛素瘤的补充定位手段.

Abstract：

Objective To evaluate the clinical value of selective intra-arterial calcium stimulated venous sampling ( ASVS) for the localization of pancreatic insulinoma preoperatively.Methods The clinical data of 28 insulinoma patients admitted from May 2000 to June 2010 in Ruijin Hospital undergoing selective intra-arterial calcium stimulated venous sampling with diagnosis of insulinomas before surgery were analyzed retrospectively.Results There were 12 males and 16 females.All the patients had Whipple's triad, and with proved insulinomas by postoperative pathology.There were 26 cases of single insulinoma and 2 cases of multiple insulinomas with altogether 32 insulinomas resected.78.1% of insulinomas were less than 20 mm.All patient were examined by selective intra-arterial calcium stimulated venous sampling.The peak ratio of insulin to the baseline after calcium stimulation appeared at the superior mensenteric artery (SMA) in 6 cases, and the peak ratio of insulin to the baseline after calcium stimulation appeared at gastroduodenal artery(GDA), proximal splenic artery (SAP) and distal splenic artery (SAD) in 9 cases, 6 cases and 6 cases respectively; Selective intra-arterial calcium stimulated venous sampling accurately located 25 cases, and selective intra-arterial calcium stimulated venous sampling located 2 cases wrongly.In one patient, the selective intra-arterial calcium stimulated venous sampling was falsely negative.The mean and median peak ratio of insulin to the baseline after calcium stimulation were 8.8 folds and 14.8 folds respectively.Accurate rate of selective intra-arterial calcium stimulated venous sampling was 89.3% (25/28) and it was higher than that of computed tomography (CT) (56.5% ) , magnetic resonance imaging (MRI) (60.0%).Sensitivity of selective intra-arterial calcium stimulated venous sampling was 96.2%, which was higher than that of computed tomography ( 69.6% ) , magnetic resonance imaging (75.0% ).Conclusion Selective intra-arterial calcium stimulated venous sampling is superior to computed tomography, or magnetic resonance imaging as a preoperative localizing tool for insulinomas, since this procedure is invasive it should be used when other preoperative morphologic studies (computed tomography or magnetic resonance imaging) failed.     

功能性胰岛β细胞瘤的外科诊治分析

目的探讨功能性胰岛β细胞瘤的诊断和治疗方法。方法收集我院1998年4月至2008年4月收治的42例功能性胰岛β细胞瘤患者的临床资料,对其临床表现、检查手段和治疗结果进行回顾性分析。结果42例患者均有Whipple三联征,IRI／G〉0．3有39例。术前行B超和CT检查,分别发现16例（38％）,32例（76％）,术前B超联合CT检查发现34例（81％）,术中B超联合扪诊发现40例（95％）。肿瘤位于胰头15例,胰体12例,胰尾15例;术后病理证实良性肿瘤40例,胰岛细胞增生1例,恶性1例。单纯肿瘤切除25例;胰体尾联合脾切除6例;单纯胰体尾切除9例,1例联合左肾切除;胰十二指肠切除2例。术后胰漏5例,4例为肿瘤摘除者,1例为胰十二指肠切除。1例术后因多器官功能衰竭死亡。结论功能性胰岛β细胞瘤定位诊断尤其重要,术中B超是发现肿瘤较好的手段。手术方式取决于肿瘤大小和位置,合理的手术方式选择能减少术后并发症的发生。     

Insulinomas associated with multiple endocrine neoplasia type I: the need for a different surgical approach.

Insulinomas are usually solitary (greater than 90%) benign pancreatic tumors readily cured by enucleation or resection. To determine whether the 4% of insulinomas associated with multiple endocrine neoplasia type 1 (MEN-I) require a different surgical approach, we analyzed our experience in seven patients with MEN-I insulinomas treated during the past 28 years at the University of California, San Francisco, and 53 patients reported in the English literature. We found: (1) MEN-I insulinomas were associated with an antecedent history of other endocrinopathy or a family history of MEN-I in six of our seven patients, allowing preoperative identification of these patients. (2) All seven of our patients had hyperparathyroidism and four had pituitary tumors. Overall 83.6% of patients had hyperparathyroidism and 45.4% had pituitary tumors. (3) In our patients, MEN-I insulinomas were usually multiple (median 3; range 1 to 14). Overall, 76.3% of patients had multiple islet cell tumors. (4) Distal subtotal pancreatectomy with enucleation of any tumors identified in the head of the gland was done in five of our patients. Four are now normoglycemic and one is diabetic. Enucleation alone failed in one patient. The seventh patient was diagnosed at autopsy. Because the diagnosis of MEN-I can generally be made, preoperative strategy can address the unique pathologic features of insulinomas associated with MEN-I. The tumors are usually multiple, so local resection will fail. We recommend subtotal pancreatectomy in addition to enucleation of tumors in the head of the pancreas.