Insulinoma of the Pancreas

Insulinoma is the most common functioning tumor of pancreas even though its prevalence is rare. The diagnosis and the treatment of insulinoma is very important because the tumor can induce critical and permanent neurologic deficit. We experienced ten patients with insulinoma and treated by surgical interventions at the Department of Surgery, Yonsei university college of medicine from 1983 to 1996. All the data were analysed retrospectively. The mean age of patient was 45 years (range: 17 to 69) and the sex ratio of male to female was 1:2.3. The most common clinical manifestation was weakness. The preoperative mean levels of fasting blood sugar, plasma insulin, C-peptide, insulin to glucose ratio were 41(mg/dl), 40.07(U/ml), 4.03(ng/ml), 1.51, respectively. The detection rates of localizing tools on our cases were showed as follows: THPVS(100% in 5 cases), EUS(67% in 3 cases), MRI(33% in 3 cases), CT scan(33% in 9 cases), angiography(33% in 6 cases) and US (20% in 10 cases). The intraoperative ultrasound(IOUS) was performed in the last three cases to try to find occult insulinoma and the relationship with main duct of pancreas in operative field. The types of surgical interventions were enucleation in 5 patients, distal pancreatectomy in 4 patients, pancreatoduodenectomy in 1 patient. The tumors were located in nearly equal frequencies over the entire pancreas: head(30%), neck & body (30%), tail(40%). All of the tumors were single and 90% of them were solid and benign. The mean diameter of the tumors was 1.5cm. Symptoms of hypoglycemia and laboratory values such as fasting blood sugar, plasma insulin, C-peptide, insulin glucose ratio were improved in all the patient after operation. We suggest that the THPVS is the most sensitive preoperative test for localizing insulinomas and recommend the IOUS as a tool for detecting occult or multiple insulinoma and identifing the relationship with main duct of pancreas in operative field.

Two Cases of the Hepatocellular Cancinoma in Pregnancy

Hepatocellular carcinoma (HCC) during pregnancy is a rare event and reports are isolated and highly scattered. HCC during pregnancy carries a poor prognosis because of difficulty in diagnosis due to the fetus. The impact of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC during pregnancy remains controversial. At present, the screening of maternal serum alpha-fetoprotein(AFP) in the second trimester of pregnancy is a standard procedure for detection of fetal malformation. An elevated maternal serum AFP level may not always be of fetal origin and some maternal diseases could present an elevated maternal serum AFP. The ultrasonography for abdomen has been accepted as a simple and safe method for this group. We have experienced two cases of HCC during pregnancy over the last 5 years. One was diagnosed with a palpble abdominal mass which was revealed to be HCC at 12 weeks of pregnancy and died 2 months after the diagnosis without treatmemt. The second was incidentally found to have abnormal serum AFP at 17 weeks of pregnancy and underwent the extended right hepatic lobectomy without complication. We suggest that careful physical examination and abdominal ultrasonography seems to be the best screening tools for early diagnosis of HCC in pregnancies with high serum AFP level.

Laparoscopic Extracorporporeal Knot Thying Using an Instrument for Knot Pushing and Tightening

Priciples of kont-tying have assumed a new and enhanced role in operative laparoscopy. The surgeon should be familiar with extracorporeal knot-tying techniques. For extracorporeal knot-tying, a knot pusher is used to properly secure the knot. But a knot pusher has some limitation for tightening of the knot. I developed an instrument which has a slit and hole.(slit for knot pushing and hole for knot tightening) for a secure knot. By using this instrument(Lee's knot presser) it is very easy and secure for knot-tying. The surgeon can confirm and control the knot tightening.