胰岛素瘤64例的诊断与外科治疗

Diagnosis and surgical treatment of insulinoma in 64 Patients

目的总结胰岛素瘤的诊断与外科治疗方法。方法回顾性分析64例胰岛素瘤的临床资料。结果64例均表现Whipple三联征。术前BUS、CT及强化CT、MRI、DSA诊断阳性率分别为46．9％（30／64），58．2％（23／39），66．7％（18／27），91．7％（11／12）。IOUS诊断阳性率为92％（23／25）。单个肿瘤58例，多发肿瘤6例。单发者位于胰头19例，其中直径4cm1例，胰体17例，胰尾22例；多发者6例均为2枚肿瘤，4例位于胰体，2例分别位于胰体和胰尾各1枚。治疗行肿瘤局部切除39例，胰体尾切除13例加作脾切除6例，胰尾切除8例加作脾切除4例，胰体表面肿瘤直径2cm行腹腔镜下单纯肿瘤摘除1例，自左向右分段切除（盲切法）2例，行胰头十二指肠切除1例。良性肿瘤62例，恶性2例。术后胰瘘3例、急性胰腺炎4例均经非手术治愈。64例术后低血糖症状消失。62例良性胰岛素瘤术后随诊1～5年血糖正常，其中2例分别于术后4年和5年复发，再次手术发现胰尾近脾门处分别有直径1cm和1．5cm肿瘤，经胰尾切除后治愈。45例随访8年血糖正常，17例失访。2例恶性胰岛素瘤分别于术后3年和4年复发，因肝转移死亡。结论Whipple三联征和测定IRI／G〉0．3是定性诊断的依据。术中触诊联合IOUS是最有效的肿瘤定位诊断方法。胰岛素瘤切除术是最佳的治疗方法。

Objective To summarize diagnosis and surgical treatment of insulinoma. Methods Clinical data of 64 patients with insulinoma from 1980 to 2006 were analyzed retrospectively. Results All patients had Whipple＇s triad. Accurate preoperative localization rate of B ultrasonography, CT and enhanced CT, MRI, DSA was 46.9% （30/64）, 58.2 % （23/39） and 91.7% （ 11/12）, respectively. Localization rate of intraoperative ultrasonography （IOUS） was 92% （23/25）. The tumors were single in 58 cases, and multiple in 6 cases. In the location of single tumor, 19 of them were in the head, 17 in the body, and 22 in the tail; while for multiple tumors, 2 tumors were both located in the body in 4 patient, and 2 tumors were separately located in the body and tail respectively in 2 patients. Treatment Local enucleation was performed in 39 cases, resection of pancreatic body and tail in 13 cases, resection of pancreatic body and tail plus splenectomy in 6 cases, resection of pancreatic tail in 8 cases, resection of pancreatic tail plus splenectomy in 4 cases, laparoscopic resection of insulinoma in 1 case, piecewise resection of pancreas from left to right （blind resection） in 2 cases, pancreaticoduodenectomy in 1 case. The tumor was benign in 62 cases, and malignant in 2 cases. Pancreatic fistula developed after operation in 3 cases, acute pancreatitis in 4 cases, and in these cases, they healed after non-operative treatment. All patients had no symptoms of hypoglycemia after operation. At follow-up visit in 62 cases, 2 case of benign tumor recurred 4 years after operation, and was cured by resection of the pancreas body with tumor, 2 malignant tumors cases, recurred and died of hepatic metastasis in 3 years and 4 years after operation. Conclusions Whipple＇s triad and IRI/G 〉 0.3 are the bases for qualitative diagnosis of insulinoma. Meticulously palpating the gland combined with IOUS during operation is the most effective method for accurate tumor localization. Resection of insulinoma is the best mode of surgical treatment of insulinoma.