The value of arteriography in the diagnosis and treatment of insulinomas.

Six arteriograms were performed in five patients with insulinoma. The method showed with precision the size and location of the tumor in five instances, whereas in one instance the method was unsuccessful. Arteriography was performed again with more refinements in technic, but was adequate in locating only the largest tumor. Since diagnostic accuracy of arteriography depends on the size of the tumor, and nonpalpable tumors are only occasionally located, the main problems in surgical treatment of insulinomas are unresolved.

Hypoglycemia and insular hyperplasia: review of 148 cases.

On the bases of personal experience and the series of 148 cases from an international inquiry and a review of the literature, the relation between insular hyperplasia and hypoglycemia was examined. The fundamental points in this investigation included: age, diagnostic investigations, histological findings and postoperative results. The data on the patients with insular hyperplasia indicates that 83% were of adult age. Insular hyperplasia was the only abnormal factor determined to be present. Through treatment a high percentage of cases (71%) was cured. From a practical surgical point of view, differentiation between occult insulomas and insular hyperplasia is not critical. Consequently, good results can be achieved in botlh diseases by practicing a progressive blind resection guided by examination of the operated specimen and by intra-operative blood sugar levels.

Roux-en-Y hepaticojejunostomy: a reappraisal of its indications and results.

A critical evaluation is made of 131 patients submitted to choledocho or hepaticojejunostomy. The main indications for hepaticojejunostomy were iatrogenic strictures of CBD (60 patients), and choledocholithiasis with markedly dilated duct (41 patients). The overall mortality rate was 4% representing principally renal hepatic failure, bile peritonitis and bleeding. The complications following hepaticojejunostomy included only in one case biliary fistula which required reoperation. The long-term results of 80 patients available for a followup study were as follows: 63 patients (78.7%) were symptom-free at 2-13 years followup; 8 patients had brief episodes of cholangitis which responded to antibiotic and corticosteroid treatment; 9 patients required reoperation for stricture of anastomosis. These overall results are a strong argument for hepaticojejunostomy which, compared with choledochoduodenostomy, avoids the hazards of the so-called sump syndrome and of the reflux of enteric contents in the CBD. An increased incidence of peptic ulcer disease in the patients submitted to hepaticojejunostomy was not observed. In very high strictures and in reinterventions anastomosis between left hepatic duct and Roux-en-Y jejunal limb was carried out. The results achieved with this technique, which was performed in 26 patients, were about the same following hepaticojejunostomy.

Spontaneous internal biliary fistulas.

Etiology, diagnostic investigations and surgical procedures on 58 patients with spontaneous internal biliary fistulas are reported. Cholelithiasis and peptic ulcer were found to be the presumptive cause of fistula respectively in 53 and five patients. Preoperative diagnosis was established on 31 patients while in the remaining 27 fistula was found incidentally at surgery. Surgical treatment included a wide variety of operations which were performed on the basis of the pathologic features of fistula. Over all mortality rate was 5 percent and morbidity 13 percent. The unsatisfactory results of the surgical treatment of internal biliary fistulas are another strong argument for performing early cholecystectomy in all the patients with cholelithiasis.