[Diagnostics and treatment of organic hyperinsulinism--experience in 105 cases]. / Diagnostika a lécba organického hyperinzulinismu--zkusenosti u 105 pacientu.

BACKGROUND: Organic hyperinsulinism causes hypoglycaemia manifesting mainly in the fasting state. We summarize our experience with diagnosis and treatment of 105 patients with organic hyperinsulinism. METHODS AND RESULTS: The diagnosis was confirmed in all patients by spontaneous hypoglycemia and neuroglycopenic symptoms, both developed during fasting test. Endoscopic ultrasonography was the most reliable method for the insulinoma localization (77% of insulinomas confirmed by surgery in the same location within the pancreas), less positive results were obtained by digital subtraction angiography (29%) and still less was found by computed tomography (18%). The localization remains unclear in about 20-25% of insulinomas despite of combined different exploring techniques. Surgical removal of insulinoma by enucleation is the best way of treatment, in some cases laparoscopic removal is a method of choice. From total number of 95 surgically treated patients the successful removal of insulinoma was performed in 84 patients (88%) and another 3 had histopathology diagnosis of micronodular polyadenomatosis. CONCLUSIONS: Insulinoma was not found during surgery and subsequent thorough histopathology investigation of the whole resecate in 8 patients which have to be treated like other non-surgically treated patients by diazoxide together with diabetic diet.

[Personal experience with the treatment of organic hyperinsulinism]. / Nase zkusenosti s lécbou organického hyperinzulinismu.

In 1981-1997 at the Third Medical Clinic 52 patients with confirmed organic hyperinsulinism were treated. Forty-three were operated and the remaining nine were treated conservatively. An insulinoma was removed surgically in 35 patients, in one female microadenomatosis was detected. The operation was successful in 84%, while topographic preoperative examination aroused suspicion of a focus (i.e. insulinoma) only in 49% of the operated patients. A total of 11 patients (four after surgery and seven not operated) were treated successfully with diazoxide, in nine patients this treatment is still administered. According to the response to diazoxide it is possible to differentiate "responsive" and "non-responsive" insulinomas. Pharmacological treatment is thus justified only in the first group of patients. Surgically and pharmacologically treated patients have no signs of hyperinsulinism. The authors experience suggests that surgical treatment is indicated when the diagnosis is unequivocal even when the topographic finding of imaging methods is negative, as in 35% of operated patients the insulinoma was found only on operation.

[Indications for peroperative cholangiography in cholecystectomy]. / Indikace k peroperacní cholangiografii pri cholecystektomii.

In a group of 466 cholecystectomies with peroperative cholangiography the authors revealed sensitivity of the examination for cholangiolithiasis (255 before operation) in 95.3%, for diagnosis of all benign diseases of the bile ducts (288 operations) in 95.8%. They established six indication criterias for peroperative cholangiography during cholecystectomy: 1. jaundice or elevated serum bilirubin before operation, 2. pancreatitis or elevated amylase values in blood or urine before operation, 3. elevated alkaline phosphatase (ALP) or gamma-glutamyl transpeptidase (GMT) serum values before operation, 4. small (under 3 mm) or multiple (more than 10) gallstones, 5. a choledochus wider than 10 mm, 6 a cystic duct wider than 3 mm. As indication suffices positivity of one of the criteria. By introducing these indications it was possible to reduce peroperative cholangiography during cholecystectomies by cca 40% with a 0.1% risk of diagnostic errors in the diagnosis of benign diseases of the bile ducts.

[The surgery patient with gastroduodenal ulcers]. / Chirurgický pacient s vredovou chorobou gastroduodena.

The authors evaluate the contemporary change of indications for surgery of gastroduodenal ulceration. From a group of 670 patients operated in the course of three years at the Second Surgical Clinica of the General Faculty Hospital in Prague 46 patients were subjected to acute surgery. Among these operations surgery on account of perforating pyloric ulcers (34%) predominated followed by bleeding duodenal ulcers (23%). In the remaining patients with a prolonged history of conservative treatment the authors observed a more complicated local situation (infiltrate, penetration) which influenced not only the surgical operation but also the pretentiousness of postoperative care, but unfortunately also a higher lethality rate-18.3%. In the conclusion the authors reflect on the possibility of earlier indication of surgery in particular in ulcers poorly controlled by conservative treatment or those after haemorrhage treated successfully by conservative treatment.

[Personal experience with surgical treatment of insulinoma]. / Nase zkusenosti s chirurgickou lécbou inzulinomu.

In 1981-2000 at the IIIrd Medical Clinic 60 patients were treated with confirmed organic hyperinsulinism. A surgical operation was indicated in 51 patients. In 42 a localized tumour was removed, in one diffuse adenomatosis was involved. In three of the operated patients a malignant, enddocrinologically active insulinoma was confirmed. Two patients were re-operated on account of a relapse. The remaining 9 patients were treated conservatively from the onset. For localization of the tumour before operation US, CT and angiographic examinations were used. US and angiography were an asset in 25 patients (49%). In some instances we encountered however on angiography falsely positive findings. US was positive before surgery in 12 patients (23%), angiography in 21 (41%) and CT only in 2 (4%). The insulinoma was detected only on surgery in 14 patients (33%) of the operated insulinomas. The tumour was found in the head of the pancreas in 13 patients (31%), in the body of the pancreas in 14 (33%) and in the tail of the pancreas in 15 (36%). Surgery was successful in 82%, while the topographic preoperative examination aroused suspicion of a focus (i.e. insulinoma) only in 49% of the operated patients. A total of 17 patients (8 after surgery and 9 without surgery) were successfully treated with diazoxide, in 9 patients this treatment is still administered. According to the response to diazoxide insulinomas can be divided into "responsive" and "non-responsive" ones. Pharmacological treatment is therefore justified only in the first group of patients. Operated and pharmacologically treated patients have no signs of hyperinsulinism. Our experience indicates that a surgical approach is suitable when the diagnosis is unequivocal, even when there is a negative topographic finding of imaging methods as in 33% of the operated patients the insulinoma was detected only on operation.