Randomized Trial of Near-infrared Incisionless Fluorescent Cholangiography.

BACKGROUND: Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies. METHODS: We conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates. RESULTS: Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury. CONCLUSIONS: In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy. REGISTRATION NUMBER: NCT02702843.

Elegir a la cirugía como especialidad: Opiniones de los estudiantes de la Universidad de Buenos Aires sobre la cirugía y los cirujanos / Choosing surgery as a specialty: Opinions of medical students about surgery and surgeons

INTRODUCCIÓN: Dado que el número de aspirantes a las residencias en cirugía en Argentina parece estar disminuyendo, se realizó este trabajo con el objetivo de estudiar cuáles eran los factores que los estudiantes consideraban indeseables a la hora de elegir la cirugía como especialidad. MATERIAL Y MÉTODOS: Entre marzo y abril de 2012 se encuestó a 100 alumnos de la materia cirugía mediante un diseño observacional de caso-control. La encuesta contenía 26 afirmaciones referidas a algunas características de la cirugía como especialidad, o a la personalidad y estilo de vida de los cirujanos, según podían ser percibidas por los estudiantes. La misma encuesta se aplicó a 20 cirujanos que estaban en contacto con los alumnos y que podían representar un modelo para ellos durante su rotación en la materia. Resultados Al comparar alumnos y cirujanos no hubo diferencias en la mayoría de las respuestas, excepto en «la cirugía no está bien pagada» (OR: 8,9; p = 0,0001), «no tiene mucha demanda laboral» (OR: 8,1; p = 0,015), «limita el crecimiento intelectual» (OR: 17,5; p = 0,014), «los cirujanos tienen muchas actividades no programadas» (OR: 9,36; p = 0,024), «tienen una relación médico-paciente limitada» (OR: 3,61; p = 0,009), «tienen poco tiempo para la familia» (OR: 4,27; p = 0,036) y «tienen riesgo alto de exposición a infecciones» (OR: 5,90; p = 0,007). CONCLUSIONES: Las mujeres estarían tan interesadas como los varones en ejercer la cirugía; hecho destacable si se considera que las especialidades quirúrgicas han sido predominantemente masculinas. El hecho de que los cirujanos coincidieran mayormente con las opiniones de los estudiantes exigiría la revisión del rol de aquellos como modelos para promover las vocaciones

INTRODUCTION: Since the number of applicants to residencies in general surgery in Argentina seems to be decreasing, we designed this work with the objective of studying the factors considered undesirable by students when choosing surgery as a specialty. Material and methods Between March and April 2012, one-hundred students were surveyed with a structured questionnaire with true/false binary answers in an observational case-control design. The survey contained 26 statements that made reference to characteristics of surgery as a specialty, or about the personality and lifestyle of surgeons, as they could be perceived by students. As a control group the same survey was applied to 20 surgeons who were in contact with the students and that could represent a role model for them during their rotation in surgery. RESULTS: Comparison between students and surgeons showed no difference in most answers, except in «surgery has poor reimbursement» (OR: 8,9; P=.0001), «there is not enough job demand» (OR: 8,1; P=.015), «surgery restrains intellectual development» (OR: 17,5; P=.014), «surgeons have too many non-scheduled activities» (OR: 9,36; P=.024), «they have a limited patient-physician relationship» (OR: 3,61; P=.009), «they have little time for family» (OR: 4,27; P=.036) and «they are exposed to infectious diseases» (OR: 5,90; P=.007). CONCLUSIONS: Women would be as interested as men in working as surgeons; a remarkable fact when considering that the surgical specialties have been predominantly filled by men. The fact that surgeons mostly coincide with the views of students means that role models should be reviewed to promote vocations

Novel technique for identification of ureters using sodium fluorescein.

BACKGROUND: The unique property of sodium fluorescein has made it ideal for use in medical applications such as diagnostic ophthalmology and intravenous angiography. It is mainly excreted via the renal system and although extensively used in these diagnostic applications, it has not been widely used to aid in the visualization of the ureters. It is possible to visualize the urinary tract by shining a source of light and studying the fluorescence using a special filter. The goal of our study was to assess the real-time visualization of ureters using intravenous sodium fluorescein under the stimulus of a 530 nm wavelength light. MATERIALS AND METHODS: Nine 250 gm Wister rats were given an intravenous dose of 0.01 ml of sodium fluorescein. A laparotomy was immediately performed following the administration of dye. Anesthesia was performed with an intraperitoneal dose of ketamine-xylazine. The retroperitoneum was exposed and observed under an alternating white xenon and a 530 nm excitation light with an objective to visualize the organs captured within the fluorescence of the compound (sodium fluorescein). RESULTS: Under xenon light, the location of the kidneys and urinary bladder were visualized, but not the ureters. The light was then changed to a 530 nm wavelength mode when the location and orientation of the ureters was visualized along with the peristaltic movements. Fluorescence visualization of the ureters was noted 5-10 min following kidney visualization. In addition, the vascular structures in close proximity to the ureters were also visualized. None of the rats underwent any retroperitoneal dissection, and in one case, partial mobilization of a kidney was undertaken. All rats were euthanized at the completion of the procedure. CONCLUSION: Intravenous administration of sodium fluorescein enables fluorescence visualization of the ureters in a rat model, after activation with a 530 nm light transmitter.

Choosing surgery as a specialty: opinions of medical students about surgery and surgeons.

INTRODUCTION: Since the number of applicants to residencies in general surgery in Argentina seems to be decreasing, we designed this work with the objective of studying the factors considered undesirable by students when choosing surgery as a specialty. MATERIAL AND METHODS: Between March and April 2012, one-hundred students were surveyed with a structured questionnaire with true/false binary answers in an observational case-control design. The survey contained 26 statements that made reference to characteristics of surgery as a specialty, or about the personality and lifestyle of surgeons, as they could be perceived by students. As a control group the same survey was applied to 20 surgeons who were in contact with the students and that could represent a role model for them during their rotation in surgery. RESULTS: Comparison between students and surgeons showed no difference in most answers, except in «surgery has poor reimbursement¼ (OR: 8,9; P=.0001), «there is not enough job demand¼ (OR: 8,1; P=.015), «surgery restrains intellectual development¼ (OR: 17,5; P=.014), «surgeons have too many non-scheduled activities¼ (OR: 9,36; P=.024), «they have a limited patient-physician relationship¼ (OR: 3,61; P=.009), «they have little time for family¼ (OR: 4,27; P=.036) and «they are exposed to infectious diseases¼ (OR: 5,90; P=.007). CONCLUSIONS: Women would be as interested as men in working as surgeons; a remarkable fact when considering that the surgical specialties have been predominantly filled by men. The fact that surgeons mostly coincide with the views of students means that role models should be reviewed to promote vocations.

Preferencias de los estudiantes de medicina de la Universidad de Buenos Aires en la elección de la especialidad / Medical students' preferences on specialty selection in Buenos Aires University

Introducción. Los factores que influyen en la elección de una especialidad son la demanda laboral, la remuneración, el prestigio, el tiempo de formación y la posibilidad de tener un estilo de vida 'controlable'. Sin embargo, la influencia de la cultura podría modificar el peso de estas variables a la hora de elegir una especialidad. Objetivo. Analizar los factores que influían sobre la elección de la especialidad médica por parte de los estudiantes. Sujetos y métodos. Entre marzo y mayo de 2010 se encuestaron 125 estudiantes que cursaban quinto año o el internado. Por medio de una encuesta anónima se recogió información sobre los factores que podrían influir en la elección futura de la especialidad. Resultados. La pediatría fue la especialidad más elegida, pero se la consideró entre las menos lucrativas, con más tiempo de formación y prestigio moderado, aunque con una adecuada demanda laboral. La cirugía fue la segunda más elegida y considerada como la de mayor prestigio y mejor remunerada. La clínica médica requeriría más tiempo de formación, con más oportunidades laborales, pero peor remuneradas. Tanto la clínica médica como la cirugía se eligieron como las de estilo de vida menos 'controlable', hallándose en tercer lugar la pediatría. Conclusión. Las características de remuneración, prestigio, estilo de vida, tiempo de formación y demanda laboral, en general, parecen no haber influido significativamente en la elección de la especialidad (AU)

Introduction. Factors associated with medical students' specialty choice are work market opportunities, expected income, prestige, length of training and controllable life style possibility. However, cultural influence may modify the weight of these variables at time of choosing a specialty. Aim. To analyze the factors influencing on medical students' specialty preferences. Subjects and methods. From March to May of 2010, 125 medical students' from 5th and 6th year were surveyed. Information was collected by an anonymous questionnaire about factors influencing on a future specialty choice. Results. Opinions about which specialties were regarded as better remunerate, has most prestige, a controllable life style, need more length of training and/or has a good job market were obtained. Pediatrics was the most selected but it was considered one with the worst payment, with less length of training, moderate prestige, although an adequate job market. Surgery was the second choice and was regarded as the one with most prestige and best remuneration. On the other hand, internal medicine was considered to need more length of training, with better work opportunities, but worse remuneration. Internal medicine as well as surgery, is regarded as having the less controllable life style, being pediatrics on third place. Conclusion. The characteristics of income, prestige, life style, length of training and job market opportunities, in general seem to not significantly relate on specialty selection (AU)

Implementacion del listado de verificacion de cirugia segura / Implementation checklist for safe surgery

Antecedentes: El listado de verificación de los procedimientos es una herramienta útil dentro de las estrategias para seguridad de las intervenciones quirúrgicas. Objetivo: Utilidad de la lista de verificación para detección de fallas humanas o técnico-mecánicas. Lugar: División Quirófanos de Hospital Universitario Estatal. Diseño: Observacional exploratorio prospectivo con análisis retrospectivo. Población: Operaciones programadas consecutivas realizadas durante 12 meses. Método: Indicación a viva voz en distintos momentos operatorios de un listado de control de normas a cumplir por el cirujano responsable, el anestesiólogo y la enfermera (o instrumentadora)circulante. Resultados: Hubo 3680 operaciones programadas con implementación del listado de verificación en el 100%de los casos. Hubo 2116 fallas (57,5%): de ellas, atribuibles al factor humano el 98,12% y técnico mecánicas sólo el 0,18%. En el preoperatorio, la falla más frecuente fue la falta de consentimiento informado; en el intraoperatorio, la falta de previsión de eventos críticos y en el período postoperatorio inmediato, falta de protocolos operatorios y discrepancia en el recuento de gasas. Conclusión: La incidencia del error en cirugía necesita reducirse mediante un sistema normaltizado de conductas facilitado por el listado de verificación, procedimiento rápido y sencillo que exige el compromiso del equipo quirúrgico actuante.

Implementación del listado de verificación de cirugía segura

Antecedentes: El listado de verificación de los procedimientos es una herramienta útil dentro de las estrategias para seguridad de las intervenciones quirúrgicas. Objetivo: Utilidad de la lista de verificación para detección de fallas humanas o técnico-mecánicas. Lugar: División Quirófanos de Hospital Universitario Estatal. Diseño: Observacional exploratorio prospectivo con análisis retrospectivo. Población: Operaciones programadas consecutivas realizadas durante 12 meses. Método: Indicación a viva voz en distintos momentos operatorios de un listado de control de normas a cumplir por el cirujano responsable, el anestesiólogo y la enfermera (o instrumentadora) circulante. Resultados: Hubo 3680 operaciones programadas con implementación del listado de verificación en el 100% de los casos. Hubo 2116 fallas (57,5%): de ellas, atribuibles al factor humano el 98,12% y técnico-mecánicas sólo el 0,18%. En el preoperatorio, la falla más frecuente fue la falta de consentimiento informado; en el intraoperatorio, la falta de previsión de eventos críticos y en el período postoperatorio inmediato, falta de protocolos operatorios y discrepancia en el recuento de gasas. . Conclusión: La incidencia del error en cirugía necesita reducirse mediante un sistema normaltizado de conductas facilitado por el listado de verificación, procedimiento rápido y sencillo que exige el compromiso del equipo quirúrgico actuante.(AU)

Background: The checklist procedure is a useful tool within the strategies for safety of surgical interventions. Objective: Utility of the checklist for detection of technical or human failures. Place: Operating rooms Division of State University Hospital. Design: Observational prospective exploratory with retrospective analysis. Population: Consecutive scheduled operations during 12 months. Method: Indication loudly in different operative moments of a standards checklist for the responsible surgeon, the anesthesiologist and nurse circulating. Results: There were 3680 operations programmed with implementation of the checklist in 100 %. There were 2116 failures (57.5%): of them attributable to the human factor 98,12% and technicals only 0.18%. In the preoperative, the most common failure was the lack of informed consent; in the intraoperative, lack of foresight critical events and in the immediate postoperative period, lack of operative protocols and discrepancy in the counting of gauze. . Conclusion: The incidence of error in surgery needs to be reduced by a guidelines provided by the checklist, rapid and simple procedure which requires the commitment of the surgical team acting.(AU)

Short esophagus: selection of patients for surgery and long-term results.

BACKGROUND: After improvements in antireflux surgery (ARS), a percentage of reherniations still has cause of failure attributed to a reopening of the hiatal closure or to an untreated short esophagus. However, the existence of short esophagus and its treatment results still are matters of debate. METHODS: The consecutive medical records containing prospective collective data for patients with gastroesophageal reflux disease (GERD) during the period 2001-2009 were analyzed retrospectively. Every patient considered to be a candidate for ARS was studied with a dynamic contrast radiologic study (DCRxS) in which the esophageal length was evaluated. The choice of surgical technique takes into account the motility status of the esophagus and its estimated length. In the postoperative period, every patient had a DCRxS and an endoscopy 1 year after surgery and then after 3 years. Satisfaction with the procedure was surveyed. RESULTS: The consecutive medical records of 437 GERD patients showed that 171 underwent ARS. During the preoperative DCRxS, a short esophagus was suspected in 26 patients. A short esophagus was confirmed for 11 patients (6.4% of the surgically treated patients), and a Collis procedure plus a funduplication was performed. At the preoperative endoscopy, two patients had a normal mucosa, four patients had esophagitis, and five patients had Barrett's esophagus (BE). In the postoperative period, seven patients presented with a healthy mucosa, one BE had disappeared, and the remaining four BEs remained unchanged. During an average follow-up period of 43 months, no reherniations occurred. The 11 patients achieved good symptoms control and would choose surgery again. CONCLUSIONS: Short esophagus can be suspected during preoperative studies, and in this series, it was confirmed in 6.4% of the patients who had surgery. A Collis fundoplication procedure seems to be an adequate operation to control reflux symptoms and to avoid reherniation over the long-term follow-up period.

Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy.

INTRODUCTION: There have been attempts to minimize the invasiveness of laparoscopic cholecystectomy by reducing the size and/or the number of the operating ports and instruments. These attempts create technical challenges related principally to retraction and triangulation necessary to expose the surgical field for a safe surgery. A new technique based on retraction and triangulation with magnetic instruments for single port laparoscopic surgery is presented. METHODS: Between March 2007 and December 2008, 40 laparoscopic cholecystectomies were performed with single-port laparoscopic surgery with the assistance of magnetic forceps (IMANLAP project). The surgical technique is described, and the intraoperative and postoperative course of the patients is assessed. RESULTS: There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. Depending on the patient's anatomy, a 1-mm needle was added in some cases. There were no interactions observed between the magnetic devices and the anesthetic monitoring and the rest of the devices of the operation room. CONCLUSIONS: This new procedure is feasible and safe. The main goal is control of the magnetic field, allowing enough controlled strength for retraction and sufficient triangulation for adequate exposure of the surgical field. This allows for the use of a single port through which an optic device with a working channel can perform the operation with safety. Finally, the procedure can be performed in a manner similar to the traditional laparoscopic cholecystectomy, and it also appears to be simple to learn.

Natural orifice surgery: initial clinical experience.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience. METHODS: Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance. RESULTS: Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred. CONCLUSION: The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.

Insulinoma associated with pregnancy.

OBJECTIVE: To report three cases of insulinoma associated with pregnancy. DESIGN: Case report. SETTING: Divisions of Endocrinology and Gastroenterologic Surgery, Hospital de Clínicas, University of Buenos Aires, Argentina. PATIENT(S): Three patients with hypoglycemic signs due to insulinoma appearing during pregnancy or shortly after delivery. INTERVENTION(S): Laparoscopic excision of insulinoma in two and laparotomy in one of the patients were performed after the end of their pregnancies. MAIN OUTCOME MEASURE(S): Disappearance of hypoglycemic crises and histologic proof of insulinomas. RESULT(S): In two of the three patients, hypoglycemia occurred within 2-12 weeks after delivery, suggesting that signs could have been masked because of metabolic changes during gestation; in the third patient, hypoglycemia appeared in the first trimester but was misinterpreted. CONCLUSION(S): Insulinoma is often not suspected during the first trimester of pregnancy because signs resemble episodes of hypotension or emesis. Later, with the increase in insulin resistance, symptoms subside.

Colecistectomía laparoscópica ambulatoria: experiencia sobre mil casos / Outpatient laparoscopic cholecystectomy: our experience

Antecedentes: La colecistectomía laparoscópica (CL) es considerada el tratamiento de elección de la litiasis vesicular sintomática. Diferentes series quirúrgicas han demostrado la seguridad y factibilidad de la colecistectomía laparoscópica ambulatoria (CLA) en pacientes seleccionados. Objetivo: Evaluar la factibilidad, seguridad y beneficios de la CLA. Lugar de aplicación: Centro Autónomo de cirugía ambulatoria y de corta estadía. Diseño: Estudio retrospectivo. Población: Pacientes seleccionados entre noviembre de 1998 y mayo de 2004. Método: Registro consecutivo de casos seleccionados. Resultados: Fueron seleccionados 1000 pacientes (de un total de 1130) para CLA con una edad promedio de 48,5 años, 78 por ciento eran ASA I, 22 por ciento ASA II, 6,1 por ciento diabéticos y 13 por ciento presentaban antecedentes de cirugía abdominal previa. La CLA fue exitosa en 956 pacientes con un tiempo operatorio promedio de 58´. Se realizó CIO en el 89,5 por ciento y se dejó drenaje en 19 pacientes. En 44 pacientes no fue posible la modalidad ambulatoria: 8 por litiasis coledociana asintomática, 11 conversiones, 9 por vómitos, 11 casos por dolor, 4 por preferencia del paciente y uno por hemoperitoneo. La tasa de complicaciones fue del 7,6 por ciento. Conclusiones: La CLA es factible y segura en pacientes seleccionados, en manos de un equipo quirúrgico entrenado y bajo un estricto control del dolor y emesis en el postoperatorio

Colecistectomía laparoscópica ambulatoria: experiencia sobre mil casos / Outpatient laparoscopic cholecystectomy: our experience

Antecedentes: La colecistectomía laparoscópica (CL) es considerada el tratamiento de elección de la litiasis vesicular sintomática. Diferentes series quirúrgicas han demostrado la seguridad y factibilidad de la colecistectomía laparoscópica ambulatoria (CLA) en pacientes seleccionados. Objetivo: Evaluar la factibilidad, seguridad y beneficios de la CLA. Lugar de aplicación: Centro Autónomo de cirugía ambulatoria y de corta estadía. Diseño: Estudio retrospectivo. Población: Pacientes seleccionados entre noviembre de 1998 y mayo de 2004. Método: Registro consecutivo de casos seleccionados. Resultados: Fueron seleccionados 1000 pacientes (de un total de 1130) para CLA con una edad promedio de 48,5 años, 78 por ciento eran ASA I, 22 por ciento ASA II, 6,1 por ciento diabéticos y 13 por ciento presentaban antecedentes de cirugía abdominal previa. La CLA fue exitosa en 956 pacientes con un tiempo operatorio promedio de 58´. Se realizó CIO en el 89,5 por ciento y se dejó drenaje en 19 pacientes. En 44 pacientes no fue posible la modalidad ambulatoria: 8 por litiasis coledociana asintomática, 11 conversiones, 9 por vómitos, 11 casos por dolor, 4 por preferencia del paciente y uno por hemoperitoneo. La tasa de complicaciones fue del 7,6 por ciento. Conclusiones: La CLA es factible y segura en pacientes seleccionados, en manos de un equipo quirúrgico entrenado y bajo un estricto control del dolor y emesis en el postoperatorio (AU)

Colecistectomía laparoscópica ambulatoria: experiencia sobre mil casos / Outpatient laparoscopic cholecystectomy: our experience

Antecedentes: La colecistectomía laparoscópica (CL) es considerada el tratamiento de elección de la litiasis vesicular sintomática. Diferentes series quirúrgicas han demostrado la seguridad y factibilidad de la colecistectomía laparoscópica ambulatoria (CLA) en pacientes seleccionados. Objetivo: Evaluar la factibilidad, seguridad y beneficios de la CLA. Lugar de aplicación: Centro Autónomo de cirugía ambulatoria y de corta estadía. Diseño: Estudio retrospectivo. Población: Pacientes seleccionados entre noviembre de 1998 y mayo de 2004. Método: Registro consecutivo de casos seleccionados. Resultados: Fueron seleccionados 1000 pacientes (de un total de 1130) para CLA con una edad promedio de 48,5 años, 78 por ciento eran ASA I, 22 por ciento ASA II, 6,1 por ciento diabéticos y 13 por ciento presentaban antecedentes de cirugía abdominal previa. La CLA fue exitosa en 956 pacientes con un tiempo operatorio promedio de 58´. Se realizó CIO en el 89,5 por ciento y se dejó drenaje en 19 pacientes. En 44 pacientes no fue posible la modalidad ambulatoria: 8 por litiasis coledociana asintomática, 11 conversiones, 9 por vómitos, 11 casos por dolor, 4 por preferencia del paciente y uno por hemoperitoneo. La tasa de complicaciones fue del 7,6 por ciento. Conclusiones: La CLA es factible y segura en pacientes seleccionados, en manos de un equipo quirúrgico entrenado y bajo un estricto control del dolor y emesis en el postoperatorio (AU)

[Clinical experience in 37 cases of insulinoma]. / Experiencia clinica sobre 37 casos de insulinoma.

Insulinoma is the most frequent pancreatic islet cell tumor. Clinical manifestations include adrenergic and neuroglycopenic symptoms. Diagnosis is established through demonstration of inappropriately elevated insulin serum concentrations in the presence of hypoglycemia. The aim of this study is to show our experience in the management of insulinoma. Since 1988, 23 women (48 +/- 18 years) and 14 men (45 +/- 19 years) were studied. Seventy three percent of them suffered mainly from neuroglucopenic symptoms while 27% referred adrenergic signs. Mean duration of symptoms before diagnosis was 2.7 +/- 2 years. Mean fasting serum glucose was 32.4 +/- 8.7 mg/dl, insulin 38.2 +/- 39.7 microU/ml (RIA, n=11) or 23.8 +/- 18.1 microU/ml (chemoluminescence, n=26) and C-peptide 1.15 +/- 1.60 nmol/l (n=14). Twenty one patients developed clinical and/or biochemical hypoglycaemia within 9.0 +/- 5.2 hours of supervised fast. Preoperative localization was performed in 73% by imaging techniques, arterial calcium stimulation and/or intraoperative ultrasonography and palpation by the surgeon. Thirty six patients were operated on by conventional surgery in 25, or laparoscopic approach in 11 cases. In 22 patients, a solitary tumor was excised (61.1%). Six cases presented multiple insulinomas. Five patients had malignant insulinomas. In one case, a pattern of nesidioblastosis was found and 2 patients presented unspecific findings. In 3 patients another tumour (glucagonoma) was found (1 of them with MEN 1). One patient was treated with verapamil with good clinical response. Mean postoperative follow up was 60.4 +/- 59.9 months.

Experiencia clinica sobre 37 casos de insulinoma / Clinical experience in 37 cases of insulinoma

El insulinoma es el tumor neuroendocrino pancreático más frecuente. Se manifiesta por signos adrenérgicos y de neuroglucopenia. Su diagnóstico se confirma documentando la existencia de hipoglucemia junto a una inapropiada secreción de insulina. Desde 1988 fueron estudiados 23 mujeres (48 ± 18 años) y 14 varones (45 ± 19 años) con diagnóstico de insulinoma. La evolución de la enfermedad hasta el diagnósticofue de 2.8 ± 2.1 años. Veintisiete pacientes (73%) presentaron principalmente síntomas de neuroglucopenia, y el 27% refirió síntomas adrenérgicos. El laboratorio mostró glucemia en ayunas 32.4 ± 8.7 mg/dl, insulina (RIA) 38.2 ± 39.7 μU/ml (n=11), insulina (quimioluminiscencia) 23.8 ± 18.1 μU/ml (n=26), péptido C1.15 ± 1.6 nmol/l (n=14). El test de ayuno prolongado fue diagnóstico a las 9.0 ± 5.2 horas (n=21). La localizaciónpreoperatoria fue posible en el 73% por imágenes, arteriografía con estimulación de calcio y/o ecografía intraoperatoria. Once casos fueron operados por laparoscopia, y el resto por vía convencional. El diagnósticofue confirmado por histología e inmunohistoquímica. Veintidos pacientes (61.1%) presentaron insulinomas únicos(16 en cuerpo y cola, 6 en la cabeza y proceso uncinado), 6 eran portadores de insulinomas múltiples, 5 deinsulinomas malignos, 1 de nesidioblastosis del adulto y en 2 casos los hallazgos fueron incaracterísticos. En 3 pacientes se halló un glucagonoma asociado (1 de ellos con NEM1). Una paciente no fue operada recibiendotratamiento con verapamilo, con buena respuesta clínica. El seguimiento postquirúrgico fue de 60.4 ± 59.9 meses

Insulinoma is the most frequent pancreatic islet cell tumor. Clinical manifestations include adrenergic and neuroglycopenic symptoms. Diagnosis isestablished through demonstration of inappropriately elevated insulin serum concentrations in the presence ofhypoglycemia. The aim of this study is to show our experience in the management of insulinoma. Since 1988,23 women (48 ± 18 years) and 14 men (45 ± 19 years) were studied. Seventy three percent of them sufferedmainly from neuroglucopenic symptoms while 27% referred adrenergic signs. Mean duration of symptoms beforediagnosis was 2.7 ± 2 years. Mean fasting serum glucose was 32.4 ± 8.7 mg/dl, insulin 38.2 ± 39.7 μU/ml(RIA, n= 11) or 23.8 ± 18.1 μU/ml (chemoluminescence, n=26) and C-peptide 1.15 ± 1.60 nmol/l (n=14). Twenty one patients developed clinical and/or biochemical hypoglycaemia within 9.0 ± 5.2 hours of supervised fast. Preoperative localization was performed in 73% by imaging techniques, arterial calcium stimulation and/or intraoperative ultrasonography and palpation by the surgeon. Thirty six patients were operated on by conventional surgery in 25, or laparoscopic approach in 11 cases. In 22 patients, a solitary tumor was excised (61.1%). Six cases presented multiple insulinomas. Five patients had malignant insulinomas. In one case, a pattern of nesidioblastosis was found and 2 patients presented unspecific findings. In 3 patients another tumour(glucagonoma) was found (1 of them with MEN 1). One patient was treated with verapamil with good clinicalresponse. Mean postoperative follow up was 60.4 ± 59.9 months