选择性动脉钙刺激后肝静脉血清胰岛素测定用于胰岛素瘤定位的研究

目的 探讨选择性动脉钙刺激后肝静脉血清胰岛素测定(ASVS)术前定位胰岛素瘤的临床应用价值.方法 对2000年5月至2010年6月收治的28例术前行ASVS检查的胰岛素瘤患者的病史资料进行回顾性分析.结果 28例患者中男12例,女16例,均有Whipple三联征表现.手术切除瘤体32枚,78.1%瘤体直径＜20 mm;术后病理均证实为胰岛素瘤,其中26例单发,2例多发.ASVS检查6例肠系膜上动脉出现最高峰值比,9例胃十二指肠动脉出现最高峰值比,6例脾动脉近段出现最高峰值比,6例脾动脉远段出现最高峰值比,1例检查结果阴性.ASVS最高峰比值数值的中位数、平均数分别为8.8倍、14.8倍.ASVS正确定位25例,错误定位2例,1例检查结果阴性,ASVS准确率为89.3%(25/28),高于同组CT、MRI(CT、MRI定位准确率分别为56.5%,60.0%);ASVS敏感度为96.2%,高于同组CT、MRI(CT、MRI敏感度分别为69.6%,75.0%).结论 ASVS术前定位胰岛素瘤较CT、MRI有优势,但ASVS创伤大,应作为CT、MRI等常规影像学检查阴性时定位胰岛素瘤的补充定位手段.

Abstract：

Objective To evaluate the clinical value of selective intra-arterial calcium stimulated venous sampling ( ASVS) for the localization of pancreatic insulinoma preoperatively.Methods The clinical data of 28 insulinoma patients admitted from May 2000 to June 2010 in Ruijin Hospital undergoing selective intra-arterial calcium stimulated venous sampling with diagnosis of insulinomas before surgery were analyzed retrospectively.Results There were 12 males and 16 females.All the patients had Whipple's triad, and with proved insulinomas by postoperative pathology.There were 26 cases of single insulinoma and 2 cases of multiple insulinomas with altogether 32 insulinomas resected.78.1% of insulinomas were less than 20 mm.All patient were examined by selective intra-arterial calcium stimulated venous sampling.The peak ratio of insulin to the baseline after calcium stimulation appeared at the superior mensenteric artery (SMA) in 6 cases, and the peak ratio of insulin to the baseline after calcium stimulation appeared at gastroduodenal artery(GDA), proximal splenic artery (SAP) and distal splenic artery (SAD) in 9 cases, 6 cases and 6 cases respectively; Selective intra-arterial calcium stimulated venous sampling accurately located 25 cases, and selective intra-arterial calcium stimulated venous sampling located 2 cases wrongly.In one patient, the selective intra-arterial calcium stimulated venous sampling was falsely negative.The mean and median peak ratio of insulin to the baseline after calcium stimulation were 8.8 folds and 14.8 folds respectively.Accurate rate of selective intra-arterial calcium stimulated venous sampling was 89.3% (25/28) and it was higher than that of computed tomography (CT) (56.5% ) , magnetic resonance imaging (MRI) (60.0%).Sensitivity of selective intra-arterial calcium stimulated venous sampling was 96.2%, which was higher than that of computed tomography ( 69.6% ) , magnetic resonance imaging (75.0% ).Conclusion Selective intra-arterial calcium stimulated venous sampling is superior to computed tomography, or magnetic resonance imaging as a preoperative localizing tool for insulinomas, since this procedure is invasive it should be used when other preoperative morphologic studies (computed tomography or magnetic resonance imaging) failed.     

功能性胰岛素瘤的外科诊治分析

功能性胰岛素瘤是最常见的胰腺内分泌肿瘤，其临床表现各异，多被误诊或漏诊。本文将我科收治的32例功能性胰岛素瘤患者的临床资料作一回顾性分析，报道如下。     

动脉留置针采血对血气分析检测结果的影响

目的 探讨经动脉留置针采血对血气分析检测结果的影响。方法 采用自身对照法。对12例需多次采集动脉血作血气分析的重度呼吸衰竭患者分别同时在左、右桡动脉用常规动脉穿刺采血法和动脉留置针采血作血气分析检测。结果 两种动脉采血法血气分析检测结果比较，差异无显著性意义（均P〉0．05）。结论 动脉留置针采血作血气分析检测可用于在短期内需多次采集动脉血作血气分析检测的危重症患者，以减少动脉穿刺次数，减轻患者的痛苦。     

使用不同移植物行选择性冠状静脉动脉化的中远期疗效观察

目的比较使用乳内动脉和大隐静脉作为桥血管行选择性冠状静脉动脉化搭桥治疗弥漫性右冠状动脉狭窄病变的中远期疗效。方法回顾性分析2003年1月至2012年12月在北京安贞医院行选择性冠状静脉动脉化搭桥75例患者的临床资料,其中术中使用大隐静脉作为桥血管进行心中静脉动脉化搭桥患者54例(大隐静脉桥组);使用乳内动脉作为桥血管进行心中静脉动脉化搭桥的患者21例(乳内动脉桥组)。于2013年11月随访患者的生存情况、近期心绞痛复发率、近期复查超声心动图和冠状动脉血管成像(CTA)等。结果乳内动脉桥组患者总生存率稍高于大隐静脉桥组(100.0%vs.83.3%),但生存曲线分析结果显示两组生存率差异无统计学意义(P=0.055)。部分患者复查CTA结果显示大隐静脉桥组患者(n=39)的桥血管和心中静脉均发生明显栓塞,而乳内动脉桥患者(n=18)的桥血管和心中静脉均有明显显影,保持通畅(P0.001)。两组患者心功能指标如左心室射血分数(LVEF)值均较术前明显增加,但两组差异无统计学意义。结论选择性冠状静脉动脉化搭桥术过程中,与大隐静脉桥相比,使用乳内动脉桥可以明显提高中远期桥血管和心中静脉的通畅率,是治疗弥漫性右冠状动脉狭窄病变的有效手段。     

真空静脉采血失败的补救

一次性自动定量静脉采血管是利用负压原理而达到定量采血的目的。其特点是使用方便、防止感染。但在临床使用中偶有采血管因负压不足而致采血失败的现象发生。笔者总结出一种补救方法，介绍如下。     

动脉内钙刺激试验中静脉血样定位胰腺胰岛素瘤的价值

术中有经验的双手扪摸和术中 B超扫描几乎可定位绝大部分的胰岛素瘤病例。在术前的定位检查中 ,动脉内钙注射和肝静脉血采样是一个较好的方法(ASVS)。作者复习 1991～ 2 0 0 0年 2 0例该检查的结果 ,2例拒绝手术 ,余 18例均经手术证实为胰岛素瘤。11例在ASVS前均未作出定位诊断。术前其他检查有 CT(2 0例 )、B超 (9例 )、磁共振成像 (8例 )、选择性动脉造影 (6例 )和内镜超声扫描 (8例 )。ASVS操作步骤按 Doppman所述 (Radiology1991;178:2 37)。经股动脉置管分别至胃十二指肠、肠系膜上、脾和肝动脉。取葡萄糖酸钙 (10 %溶液 ) 0 .…     

前臂动脉化静脉皮瓣的临床应用

我院应用４例前臂动脉化静脉皮瓣及离体标本的灌注，探讨了此皮瓣的血循环机理。动脉血经静脉支部分直接回流，部分进入微静脉经毛细血管达真毛细管网。另部分动脉血入微静脉经动静脉吻合支返回微动脉入后微动脉再入真毛细血管网。因静脉瓣的阻碍，使引流侧皮瓣远端灌流困难，易造成缺血坏死而灌流侧易成瘀血性坏死。因此理想血供应是动脉化干及引流干均应顺静脉血流方向缝接，减少静脉瓣阻力。动脉化静脉皮瓣易发生肿胀、充血、瘀血     

术前超选择性动脉栓塞对直肠癌根治术后血运转移影响的临床研究

目的:探讨腹腔镜直肠癌根治术前行超选择动脉栓塞对直肠癌血运转移的影响。方法:将60例直肠癌患者随机分为4组,A组行常规开腹手术,B组于开腹手术前行超选择直肠上动脉栓塞,C组行常规腹腔镜手术,D组于腹腔镜手术前行超选择直肠上动脉栓塞。4组患者分别于术前1 d、术后1年内每3个月应用逆转录聚合酶链式反应技术检测患者外周血癌胚抗原(carcinoembryonic antigen,CEA)mRNA含量。结果:A、B两组患者术后CEA mRNA差异有统计学意义(P<0.05);C、D两组患者间差异亦有统计学意义(P<0.05);A、C两组及B、D两组患者之间差异亦有统计学意义(P<0.05)。结论:腹腔镜直肠癌根治术前行超选择直肠上动脉栓塞治疗可明显降低直肠癌转移率,提高直肠癌根治效果,可望延长患者的生存时间、减轻痛苦、提高生存质量。     

胃癌病人术前选择性动脉栓塞化疗对肿瘤血管的影响

目的　探讨胃癌术前选择性动脉栓塞化疗对肿瘤血管的影响。方法　 40例胃癌患者分为灌注化疗组 (GAI)和栓塞化疗组 (GAE )。两组于介入治疗前、治疗后 1,3d测定周围静脉及术中胃静脉血肿瘤坏死因子 α(TNF α)和血栓调节蛋白 (TM )浓度。治疗后 7～ 10d行胃癌根治术。观察胃组织病理学改变。结果　与GAI组比较 ,GAE组各时点周围静脉和胃静脉血TNF浓度明显增高 (P <0 .0 5 ) ,胃静脉血TM浓度明显降低 (P <0 .0 5 ) ,并与胃静脉血TNF水平呈负相关关系 (r =-0 .77,P <0 .0 5 )。组织学检查发现GAE组胃癌细胞及胃脂肪淋巴组织中癌细胞变性坏死明显 ,肿瘤血管炎症、内膜增厚、毛细血管血栓形成。结论　胃癌术前选择性动脉栓塞化疗 ,可能是通过TNF介导的肿瘤血管内皮损伤及血管内凝血 ,导致肿瘤坏死     

Value of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas

BACKGROUND: Intra-arterial calcium stimulation with hepatic venous sampling (ASVS) for insulin gradients has been reported to be the most sensitive preoperative localizing technique for insulinomas. We reviewed our experience with ASVS to localize and guide the treatment of insulinomas over the past decade. METHODS: Eighteen patients who underwent ASVS before surgical exploration for insulinoma were studied. The accuracy of ASVS was compared with intraoperative findings and other localizing studies. RESULTS: There were no complications arising from the procedures. A more than 2-fold step-up in insulin level 30 to 60 seconds after injection to at least 1 feeding artery was observed in 16 patients. Fourteen of the 16 solitary tumors (87.5%) were correctly located; 100% (6/6 tumors) at the head and 80% (8/10 tumors) at the body/tail. The overall accuracy of this test was 89%, compared with 11%, 33%, 38%, and 63% of ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, respectively. Six enucleations and 10 distal resections were performed, which included 2 laparoscopic procedures. The combination of intraoperative ultrasonography with preoperative ASVS identified all tumors. CONCLUSIONS: ASVS is the most accurate preoperative localization tool for the localization of insulinomas and, in combination with intraoperative ultrasonography, can enhance surgical success.     

无创性检查在胰岛素瘤定位诊断中的价值

目的 探讨无创性检查方法在胰岛素瘤定位诊断中的价值.方法 回顾性分析北京协和医院2005年1月至2008年11月手术治疗的88例胰岛索瘤患者的临床资料.其中男性40例,女性48例;年龄15～74岁,平均46.5岁.结果 B超、增强CT、多排螺旋CT胰腺灌注、磁共振成像、奥曲肽显像、超声内镜、腹腔镜超声和术中超声的诊断阳性率分别为19.3%(17/88)、52.4%(11/21)、95.5%(64/67)、1/6、30.0%(6/20)、83.9%(26/31)、8/8和5/5.其中8例多发胰岛素瘤患者共切除肿瘤31个,多排螺旋CT胰腺灌注、术中超声的定位诊断准确率分别为48.4%(15/31)和100%(14/14).结论 目前胰岛素瘤的术前定位诊断已进入无创检查时代,应首选多排螺旋CT胰腺灌注.对于多发性胰岛素瘤的患者,术中超声在定位诊断中具有重要价值.     

131例胰岛素瘤的诊断和治疗

目的 总结胰岛素瘤的诊断和治疗经验.方法 回顾性分析1966年1月-2007年12月收治的131例胰岛素瘤患者的临床资料. 结果全组病例均有Whipple三联征表现;64例有不同的精神症状表现.空腹或发作时血糖均<2.8 mmol/L;胰岛素释放指数检测88例,均>0.3;术前B超75例,检出肿瘤8例;腹部CT68例,检出17例;腹部MRI 10例,检出5例;术中B超44例,明确肿瘤定位43例.手术方式:肿瘤摘除术88例,胰体尾切除40例,胰十二指肠切除2例,活检1例.130例术后血糖渐恢复正常,术后胰瘘20例,急性胰腺炎32例;常规应用术中B超后无胰瘘和胰腺炎发生.结论 根据Whipple三联征、胰岛素释放指数等明确胰岛素瘤定性诊断不难;手术探查联合术中B超是有效的定位诊断方法.     

Selective venous sampling for localization of hyperfunctioning parathyroid glands

Selective venous sampling with parathyroid hormone assay was used in 46 patients with primary hyperparathyroidism. All patients had previously been operated on in the neck region. In 80 per cent of the patients the method correctly located the position of the hyperfunctioning gland(s). No complications were observed. The method was found to be of great value when evaluating patients with persistent or recurrent hyperparathyroidism.     

胰腺钩突部功能性胰岛素瘤的定位诊断和治疗

Functional insulinoma accounts for 85% of insulinoma, and it is evenly distributed in the head, body and tail of the pancreas. The main clinical manifestation of patients with functional insulinoma is endocrine disorder, and 92% of them presented with neurological symptoms. Preoperative localization of functional insulinoma is difficult because of the small size of the tumor. A 31-year-old male patient with the chief complaint of paroxysmal dizziness and confusion was admitted to the First Affiliated Hospital of Kunming Medical College on May 3,2010. The patient was preliminarily diagnosed with functional insulinoma by detecting the levels of fasting blood glucose,serum insulin and fasting serum C-peptide, as well as the presence of Whipple's triad. Ultrasonography and enhanced computed tomography demonstrated that a well-defined tumor of 13.0 mm ×13.0 mm in size was located in the pancreatic uncinate process.On May 27, 2010, the patient received surgical resection of the tumor, and histological examination of the resected specimen confirmed insulinoma.     

Intra-operative quick insulin assay to confirm complete resection of insulinomas guided by selective arterial calcium injection (SACI)

Background and aims Insulinomas are rare endocrine disorders. Pre-operatively, conventional imaging techniques often fail to localise the tumor. In addition, due to the lack of quick insulin assays, intra-operative confirmation of complete resection was impossible until recently. Materials and methods Six patients with biochemical evidence of an insulinoma underwent pre-operative localisation studies and selective arterial calcium injection (SACI). In addition, insulin was measured before surgery and every 10–15 min after resection of the tumor using a quick insulin assay. Results Pre-operative localisation studies identified the tumor correctly as follows: endosonography: three of four, magnetic resonance imaging: two of four and SACI: six of six. Tumors in the head and body were enucleated while those in the tail were resected (n = 2, each). Those three patients, in whom magnetic resonance imaging and/or endosonography could localise the tumors pre-operatively, underwent laparoscopic surgery while the remaining three patients underwent open surgery. Intra-operatively, insulin dropped to normal levels within 20 min in all cases. After a follow-up of 0.8–3 years, all patients remained biochemically cured. Conclusions Pre-operatively, SACI appears to be a very sensitive localisation technique and may be most helpful in guiding the surgeon if conventional imaging techniques fail to localise the tumor. Complete removal of an insulinoma can be reliably predicted using a quick insulin assay. This paper was presented at the 2nd Biennial Meeting of the European Society of Endocrine Surgeons (ESES), May 18–20, 2006, Krakow, Poland.     

胰岛素瘤外科诊断与治疗的变革

Insulinoma is derived from beta cells, and the yearly incidence of insulinoma is 1-4 per one million. Insulinoma patients were often misdiagnosed with epilepsy or cerebrovascular diseases because of the clinical and epidemiological features of insulinoma. The diagnosis of the insulinoma is usually made biochemically with the presence of low blood glucose ( <2.5 mmol/L), elevated insulin ( ≥6 mU/L) and C-peptide levels ( ≥ 200 pmol/L), and no sulfonylureas in the blood.Supervised 72-hour fasting test has been verified as the gold standard in establishing a biochemical diagnosis of insulinoma.Localization of insulinoma is useful for selecting surgical procedures, and the methods for localization can be divided into noninvasive (transabdominal ultrasound, computed tomography,magnetic resonance imaging and endoscopic ultrasound), invasive (angiography and arterial stimulation venous sampling) and intraoperative diagnosis. Surgical treatment is the only curative method at present, and the common approaches include enuclea tion, partial pancreatic resection, resection of the body and tail of pancreas and duodenum-preserving pancreatic head resection.Most patients with sporadic insulinoma had long-term survival after the surgery. For insulinoma patients with multiple endocrine neoplasia type 1, an aggressive surgical approach is recommended.     

Selective venous catheterization for the localization of phosphaturic mesenchymal tumors

Tumor‐induced osteomalacia (TIO) is characterized by renal phosphate wasting, hypophosphatemia, and aberrant vitamin D₃ metabolism and is caused by fibroblast growth factor 23 (FGF‐23)–producing mesenchymal tumors, which are often difficult to locate. We investigated the utility of selective venous sampling in tumor localization. The primary endpoint was identification of the FGF‐23 concentration ratio between the venous drainage of the tumor bed and the general circulation that was diagnostic of the location of an FGF‐23‐secreting tumor. Fourteen subjects underwent 15 sampling procedures after functional and anatomic imaging studies. Subjects fit into three imaging categories: no suspicious site, multiple sites, and single site (positive controls). FGF‐23 levels were measured by ELISA. Suspicious tumors were resected for diagnosis, confirmation, and cure. In subjects with a positive venous sampling study and subsequent cure, a minimum ratio of 1.6 was diagnostic. In 7 of 14 subjects there was suggestive imaging, a diagnostic ratio, and an associated TIO tumor (true positive). Four of these required complicated resection procedures. In 4 of 14 subjects with no suspicious site on imaging studies, an FGF‐23 diagnostic ratio was not detected (true negative). Biopsy or resection of a single lesion in 2 of 14 subjects with a diagnostic ratio failed to identify a TIO tumor (false positive). A diagnostic FGF‐23 ratio was absent in 1 of 14 subjects whose tumor was a single highly suspicious lesion on imaging studies (false negative). These data yield a sensitivity of 0.87 [95% confidence interval (CI) 0.47–0.99] and a specificity of 0.71 (95% CI 0.29–0.96). Selective venous sampling for FGF‐23 was particularly useful in subjects with multiple suspicious sites or an anatomically challenging planned resection but not in the absence of a suspicious lesion on imaging studies. © 2011 American Society for Bone and Mineral Research.