Pedrazzoli S, Pasquali C, Alfano D'Andrea A
Università degli Studi di Padova, Istituto di Semeiotica Chirurgica, Italy.
Br J Surg. 1994 May;81(5):672-6. doi: 10.1002/bjs.1800810513.
The role of preoperative and intraoperative procedures for the localization of insulinoma has been extensively debated. Transhepatic portal vein sampling before surgery has been recommended when other tests fail to localize the tumour. To determine the role of different investigations, 53 patients with insulinoma, four with hyperplasia or nesidioblastosis and one with insulin autoimmune syndrome were studied. Patients were operated on in three consecutive periods during each of which a different localization procedure was considered to represent the 'gold standard'. During the first period, of 16 patients (including one with hyperplasia) investigated by arteriography, 13 underwent successful resection. Tumours in the other three patients with insulinoma were resected at a second operation, one during the first period and one each during the second and third periods. During the second period, 28 patients underwent exploration after transhepatic portal sampling: the tumour was found in all 26 patients with insulinoma operated on in this hospital, one patient with hyperplasia is receiving medical treatment and one patient had unsuccessful surgical exploration elsewhere despite positive findings on arteriography and transhepatic portal sampling performed in this department. During the third period 13 procedures were performed. All were successful using intraoperative ultrasonography without transhepatic portal sampling. In three further patients intraoperative localization failed because of non-adenomatous beta cell disease. Left-sided resection successfully cured symptoms in two patients with hyperplasia and prompted the diagnosis of insulin autoimmune syndrome. High success rates for surgical treatment of insulinoma can be achieved with transhepatic portal vein sampling or intraoperative ultrasonography. Transhepatic portal sampling is therefore unnecessary before a first operation on the pancreas for insulinoma. In the rare failures of intraoperative localization of an insulinoma, a small left pancreatic resection can help to distinguish insulinoma from hyperplasia without precluding further segmental resection.
胰岛素瘤定位的术前和术中操作的作用一直存在广泛争议。当其他检查无法定位肿瘤时，建议术前进行经肝门静脉采血。为了确定不同检查方法的作用，我们研究了53例胰岛素瘤患者、4例胰岛细胞增生症或成胰岛细胞瘤患者以及1例胰岛素自身免疫综合征患者。患者分三个连续阶段接受手术，每个阶段采用不同的定位方法作为“金标准”。在第一阶段，16例接受动脉造影检查的患者（包括1例胰岛细胞增生症患者）中，13例成功切除肿瘤。另外3例胰岛素瘤患者的肿瘤在第二次手术时切除，其中1例在第一阶段，1例在第二阶段，1例在第三阶段。在第二阶段，28例患者在经肝门静脉采血后进行探查：在本院接受手术的所有26例胰岛素瘤患者中均发现了肿瘤，1例胰岛细胞增生症患者正在接受药物治疗，1例患者尽管在本院进行的动脉造影和经肝门静脉采血检查结果呈阳性，但在其他地方的手术探查仍未成功。在第三阶段，进行了13例手术。所有手术均通过术中超声检查成功完成，未进行经肝门静脉采血。另有3例患者因非腺瘤性β细胞疾病导致术中定位失败。左侧切除术成功治愈了2例胰岛细胞增生症患者的症状，并促使诊断出胰岛素自身免疫综合征。经肝门静脉采血或术中超声检查可使胰岛素瘤手术治疗获得较高成功率。因此，在首次对胰腺进行胰岛素瘤手术前，无需进行经肝门静脉采血。在胰岛素瘤术中定位罕见的失败病例中，小范围的胰腺左侧切除术有助于区分胰岛素瘤与胰岛细胞增生症，同时不排除进一步的节段性切除。
