摘要
目的:探讨经动脉钙剂刺激肝静脉采血(ASVS)检查术前定位胰岛素瘤的临床价值。方法:对8例临床定性诊断为胰岛素瘤的患者术前行ASVS检查,选择性插管至肝固有动脉(PHA)、胃十二指肠动脉(GDA)、肠系膜上动脉(SMA)、脾动脉近段(SAP)和脾动脉远段(SAD),分别快速注入10%的葡萄糖酸钙进行激发,于激发前和激发后30、60、90、120和180s经肝静脉采血2ml测血胰岛素值,不同动脉激发试验的间隔时间至少为15分钟。计算不同动脉激发值与基础值之比值,若胰岛素峰值达到或超过基础值的4倍以上,即提示该动脉为肿瘤的供血动脉,肿瘤即被定位于相应的胰腺区域。若两支以上动脉内激发的胰岛素峰值大于等于4倍基础胰岛素水平,将比值最高者的动脉所供应的胰腺区域认定为肿瘤所在区域。结果:8例患者在行ASVS操作过程中无明显的不良反应,检查后无并发症产生。其中在本院行手术治疗并经病理证实为胰岛素瘤的有6例,2例失访,6例手术患者术后证实均为孤立性胰岛素瘤,病灶大小为0.7~1.6cm,6例中有5例ASVS结果与最终诊断完全一致,ASVS定位准确性为83.3%,优于经腹超声(16.7%)、CT(33.3%)、MRI(50%)。结论: ASVS在胰岛素瘤术前定位中准确性高而且安全,尤其适合于其他影像学检查阴性或不同检查方法诊断有出入的隐匿型胰岛素瘤。
Objective : To evaluate the clinical value of intra-arterial calcium stimulation and venous sampling (ASVS) for localization of insulinoma preoperatively. Methods: Eight patients with clinically proved insulinoma underwent ASVS test ,proper hepatic artery(PHA)、gastroduodenal artery(GDA)、superior mensenteric artery(SMA)、proximal and distal splenic arteries(SAP and SAD) were selectively catheterized for stimulation by rapid injection of calcium gluconate. Blood was sampled through hepatic vein before and 30, 60, 90, 120, 180 s after stimulation for gauging the insulin levels.A gap of 15 minutes between every two stimulations was preserved.The tumor would be regionalized in the corresponding area if the peak value of insulin after stimulations in certain artery reached or higher than 4 times of the baseline level.If two or above arteries reached or higher than 4 times of the baseline level, The tumor site was considered to be at the corresponding area supplied with certain artery stimulated showing the peak ratio of insulin to the baseline. Results: Eight patients didn’t have adverse reactions during ASVS and applications after ASVS.Six solitary insulinomas with the size as 0.7-1.6cm were diagnosed after surgery,two patients were lost.The results of ASVS were identical to the final diagnosis in 5 cases,the accuracy of ASVS was 83.3%, demonstrating the superiority over BUS( 33.3%) , CT( 75%) , MRI( 80%) .Conclusion: ASVS is an accurate and safe technique to localize insulinomas preoperatively, especially for occult insulinomas with negative or discrepancy findings in imaging studies.
引文
[1]徐少明,龚渭华,田华等.胰岛细胞瘤35例诊治分析[J].中国实用外科杂志, 2006, 26 (3) : 197 -199.
[2]张婷婷,母义明,王先令等.胰岛素瘤术前影像学定位诊断价值的探讨[J].中国实用内科杂志,2009,29(3):243-245.
[3]曾缨,王凌云,郑民缨等. 55例胰岛素瘤所致神经精神症状的临床研究[J].中国神经精神疾病杂志, 2006, 32(2) : 176-178.
[4]茅江泳,林擎天.胰岛素瘤的诊断和治疗[J].肝胆胰外科杂志,2006,18(3):170-171.
[5]杨华,巴建明,陆菊明等.31例胰岛素瘤临床及定位诊断分析[J].临床内科杂志,2006,23(11):747-749.
[6]马钢,郭克建,田雨霖等.胰岛素瘤的诊断和治疗:附137例报告[J].中国普通外科杂志,2007 ,16 (10) :943-944。
[7] Chung J C , Choi S H , Jo S H , et al. Localization and surgical treatment of the pancreatic insulinomas [J] .ANZ J Surg, 2006,76(12) : 1051-1055.
[8] Fidler JL,Fletcher JG, Reading CC, et al. Preoperative detection of pancreatic insulinomas on multiphasic helical CT [J].AJR, 2003, 181: 775-780.
[9]薛华丹,刘炜,孙昊等.多层螺旋CT与内镜超声对胰岛素瘤术前定位诊断的比较研究[J].中国医学影像学杂志,2009,17(4):269-272.
[10] Doppman JL, Miller DL, Chang R, et al. Insulinoma: localization with selective intraarterial injection of calcium [J].Radiology, 1991, 178: 237-241.
[11] Leow MK,Loh KC,Kon WYC,et al.Clinical Utility of Selective Intra-arterial Calcium-stimulatedHepaticVenous Sampling in Regionalization of Insulinoma s:The Singapore Experience[J].Ann Acad Med Singapore,2003,32(1):86-91.
[12] Tseng L M , Chen J Y,Won J G,et al. The role of intra-arterial calcium stimulation test with hepatic venous samp ling(IACS) in the management of occult insulino mas [J].AnnSurg Oncol , 2007,14(7) : 2121-2127.
[13] MansourJC,Chen H.Pancreatic Endocrine tumor[J].Surg Res,2004,120(1):139- 161.
[14]金征宇,赵平,李晓光等.经动脉钙刺激试验术前定位诊断胰岛素瘤的价值[J].中华放射学杂志, 2002, 36: 44 - 47.
[15]冯留顺,李旭辉,李捷等.胰岛素瘤的诊断和治疗[J].中国普通外科杂志,2007,16(5):480-482.
[16]赵玉沛,从林,张太平等.胰岛素瘤404例诊治分析[J].中国实用外科杂志,2008, 28 (5) : 357.
[17] Ravi K, Britton B J. Surgical app roach to insulinomas: are preoperative localisa tion tests necessary ? [J] . Ann R CollSurg Engl , 2007 , 89(3) :212-217.
[18] Gourgiotis S, Moustafellos P , Zavos A , et al. Localisation and surgical treatment of insulinomas [J] .Int J Clin Pract ,2007,61 (4):558-561.
[19] Thoeni RF,Blankenberg F. Pancreatic imaging:computed tomography and magnetic resonance imaging[J].Radiol Clin North Am,1993,31:1085-1113.
[20] D ' Onofrio M,Mansueto G,Vasori S,et al.Contrast-enhanced ultrasonogarphic detection of small pancreatic insulinom[J].JUltrasoud,Med,2003,22(4):413-417.
[21] Mclean AM,Fairclough PD.Endoscopic ultrasound in the localization 0f pancreatic islet cell tumours[J].Best Pract Res clin Endocrinol Metab,2005,19(2):177-193.
[22] Sweet M P,Izumisato Y,Way L W,et al. Laparoscopic enucleation of insulinomas [J].Arch Surg, 2007, 142(12) : 1202 -1205.
[23] Comi RJ , Garden P , Doppman JL. Insulinoma. In : Vay Liang W,ed.The pancrease : biology pathobiology and disease[J].2 nd ed. New York :Raven Press Ltd , 1993. 979-996.
[24] Fendrich V,Bartsch DK,Langer P,et a1.Diagnosis and surgical treatment of insulinoma—experiences in 40 cases[J].Dtsch Med Wochenschr,2004,129 94l-946.
[25]翁光明,雷桂兰.胰岛β细胞瘤的诊治进展[J].现代中西医结合杂志,2008,17(26):4204-4205.
[26] Pitre J,Soubrane O,Dousset B,et al. Pancreatic echo-endoscopy and preoperative loalization of insulinomas[J].Ann Chir,1998,52:369-373.
[27] King CM,Reznek RH,Dacie JE,et al. Imaging islet cell tumors[J].Clin Radio,1994,49:295-303.
[28] Vinik AI, Delbridge L , Moattari R , et al . Transhepatic portal vein catheterization for localization of insulinomas : a ten year experienc[J].Surgery ,1991 , 109 :1211.
[29] Sung YM,Do YS,Shin SW,et al.Selective Intra-arterial Calcium stimulation with Hepatic Venous Sampling for preoperative loalization of Insulinoma[J].Korean J,Radiol,2003,4(2):101-108.
[30]吴达明,张华,汪登斌等.动脉内钙剂刺激试验在功能性胰岛素瘤术前定位中的应用[J].放射学实践,2006,21(1):44-47.
[31]宋琦,吴达明,张华等.动脉钙刺激静脉采血检查术前定位胰岛素瘤的临床价值[J].介入放射学杂志,2006,15:588-591.
[32] Doppman JL , Chang R , Fraker DL , et al . Localization of insulinomas to regions of the pancreas by intra2arterial stimulation with calcium[J].Ann Intern Med , 1995 ,123 :269-273.
[33] Thompson JC, Townsend CM.Endocrine pancreas in Townsend CM:Textbook of Surgery(16th edition)[M].Philadelphia PA :WB Saunders Company, 2000:646-661.
[34] Bottger TC , Junginger T. Is preoperative radiographic localization of islet cell tumors in patients with insulinoma necessary ? [J].World J Surg , 1993 ,17 : 427-432.
[35]公伟,梁飞等.胰岛素瘤的定位诊断方法[J].山东医药,2007,47(24):54-55.
[36] Zeiger MA, Shawker TH, Norton JA. Use of intraoperative ultrasonography to localize islet cell tumor[J].World J Surg, 1993,17( 4) :448- 454.
[37]杨志英,刘展,赵平等.国内近20年胰岛素瘤的回顾分析[J].中华医学杂志,2001,81(12):757-758.
[1] Minn AH,Kayton M,Lorang D,et al.Insulinomas and expression of an insulin splice variant[J].Lancet,2004,363(9406):363-367.
[2]刘敏,母义明,潘长玉,等.胰岛B细胞瘤的诊疗进展[J].中国实用内科杂志,2006,26(22):1767-1769.
[3]朱预.中国胰腺内分泌外科50年胰岛细胞肿瘤的50年[J].中华肝胆外科杂志,2006,12(7):133-135.
[4] McAuley G,Delaney H,Colville J,et al.Multimodality preoperative imaging of pancreatic insulinomas[J].Clin Rdiol,2005,60(10):1039-1050.
[5] Vick C,Zech CJ,Hopfiner,et al.Imaging of neuroendocrine tumours of the pancreas[J].Radiologe,2003,43(4):293-300.
[6] Pereira PL,Wisikrchen J.Morphological and functiongal investigationgs of neuroendocrine tumours of the pancreas[J].Eur Radiol,2003,13(9):2133-2146.
[7]魏伟,汤恢焕,霍胜军等.胰岛素瘤误诊9例分析[J].中国误诊学杂志,2008,8(4):875-876.
[8] De Herder WW .Insulinoma[ J ].Neuroendocrinology,2004,80(Suppl1):20-22.
[9]张俊清,郭晓蕙.胰岛素瘤10例临床特点分析[J].中国实用内科杂志,2006,26 (22): 1805-1807.
[10]侯俊珍,张金苹.胰岛素瘤病例分析[J].中国临床医生, 2009,37(1):71-73.
[11]岳欣,顾锋,夏维波等.胰岛素瘤的术前定性及定位诊断99例分析[J].中国实用内科杂志,2006,26(22):1795-1797.
[12] Kuzin NM, EgorovAV, Kondrashin SA, et al. Preoperative and intraoperative topographic diagnosis of insulinomas[J].World J Surg , 1998, 22(6) : 593 .
[13] Ravi K, Britton BJ. Surgical app roach to insulinomas: are p reoperative localization tests necessary? [J].Ann R Coll Surg Engl , 2007, 89 (3) : 212
[14]施巍巍,张挺,沈波等.功能性胰岛素瘤21例诊治体会[J].江苏医药,2009,35(2):154-155.
[15] Chavan A,Kirchhoff TD,Brabant G,et a1.Role of the intra-arterial calcium stilnulation test in the preoperative localization of insulinomas[J].Eur Radiol,2000,10(10):1582-1586.
[16]张太平,赵玉沛,蔡力等.胰岛素瘤定位诊断方法的选择与评价[J].中华肝胆外科杂志,2005,11(12):818-820.
[17]林珊,李坤成,许卫.胰岛细胞瘤的CT和MRI表现[J].医学影像学杂志,2007,17(6):620-622.
[18] Fidler JL,Fletcher JG,Reading CC,et al.Preoperative detection of pancreatic insulinomas on multiphasichelical CT [J].AJR Am J Roentgenol,2003, 181(3):775-780.
[19] Rappeport ED, Hansen CP, Kjaer A, et al. Multidetector computed tomography and neuroendocrine pancreaticoduodenal tumors [J].Acta Radiol, 2006, 47 (3) : 248
[20]龙学颖,李宜雄,王宪伟等.胰岛素瘤术前CT定位诊断的回顾性分析[J].中南大学学报(医学版),2009,34(2):165-170.
[21] Falconi M,Molinari E,carbognin G,et a1.what preoperative assessment is necessary for insulinomas?Calculating the degree of waste:analysis of 29 cases [J].chir Ital,2002,54(5):597-604。
[22] Kaczirek K,Ba-Ssalamah A,Schima W,et a1.The importance of preoperative localization pmcedures in organic hyperinsulinism-ex-perience in 67 patients[J]. Wien Klin W0chenschr,2004,116(11-12):373-378.
[23]陈曦,吴增斌,何永刚等.选择性动脉钙刺激静脉采血检测胰岛素定位胰岛素瘤的临床研究[J].中华普通外科杂志,2003,18(5):296-298.
[24] Mirallie E,Pattou F,Malvaux P,et a1.Value 0f endoscopic ultrasonography and somatostatin receptor scintigmphy in the preopera-tive localization ofinsulinomas and gastrinomas:experience of 54 cases[J].Gastroenterol clin Biol,2002,26(4):360-366.
[25]唐世龙,覃谦,李君久等PET/CT准确定位胰岛素瘤一例[J].中华肝胆外科杂志,2007,13(11),725.
[26] MaruyamaH,MatsutaniS,SaishoH,etal.Realtime bloodpoo images of contrast enhanced ultrasound with definity in the detection of tumor nodules in the liver. [J].BrJRadiol,2005,78(930):512-518.
[27]安力春,吕发勤,李文秀等.超声造影与DSA定位诊断胰岛素瘤[J].中国医学影像技术,2009,25(4):639-641.
[28] Nesje LB ,Varhaug JE,Husebye ES,et al .Endoscopic ultrasonography for preoperative diagnosis and localization of insulinomas[J].Scand J Gastroenterol, 2002,37:732-737.
[29] VarasLorenzoMJ, Miquel Collell JM, Maluenda Colomer, et al. Preoperative detection of gastrointestinal neuroendocrine tumors using endoscopic ultrasonography[J].Rev Esp Enferm Dig, 2006, 98 (11) : 828.
[30] Fendrich V,Bartsch DK,Langer P,et a1.Diagnosis and surgical treatment ofinsulinoma-experiences in 40 cases[J].Dtsch Med wochenschr,2004,129(17):94l-946.
[31] Ardengh JC,Valiati LH,Geocze S.Identification of insulinomas by endoscoic ultrasonography[J].Rev Assoc Med Bras,2004,50(2):167-171.
[32] Mclean AM,Fairclough PD.Endoscopic ultrasound in the localization of pancreatic islet cell tumours [J].Best Pract Res Clin Endocrinol Metab,2005,19(2):177-193.
[33] Schumacher B, Frieling T, et al. Prospective study on the detection of insulinomas by endoscopic ultrasonography[J].Endoscopy,1996, 28 (3) : 273.
[34] Jaroszewski DE,Schlinkert RT,Thompson GB,et a1.Laparoscopic localization and resection of insulinomas[J].Arch surg,2004,139(3):270-274.
[35] Grover AC,Skarulis M,Alexander HR,et a1.A prospective evaluation of laparoscopic exploration with intraoperative ultrasound as a technique for localizing sporadic insulinomas[J].surgery,2005,138(6):1003-1008.
[36] Ahmad A,Michel G.Laparoscopic pancreatic surgery for islet cell tumors of the pancreas[J].WorId J Surg,2004,28:1239-1247.
[37]王国君,窦京涛,王志强等.内镜超声与选择性腹腔动脉造影用于胰岛素瘤定位诊断的比较[J].中国实用内科杂志,2006,26(22):1829-1830.
[38] Takeshit K,Kutomi K,Takada K,et al.3D pancreatic arteriography with MDCT during intraarterial infusion of contrast material in the detection and localization of insulinomas[J].AJR Am J Roentgeno,2005,184(3):852.
[39] Hiramoto JS,Feldstein VA,LaBerge JM,et a1.Intraoperative ultrasound and preoperative localization detects all occult insulinomas;discussion 10256[J].Arch surg,2001,136(9):1020-1025.
[40] Suzuki K,Takahashi S,Aiura K,et al. Evaluation of the usefulness of percutaneous transhepatic portal catheterization for preoperatively diagnosing the localization of insulinomas[J].Pancreas,2002(1),24:96-102.
[41] Doppman JL, Miller DL, Chang R, et al. Insulinoma: localization with selective intraarterial injection of calcium[J].Radiology, 1991, 178: 237 - 241.
[42] Lairmore TC,Moley JF.Endocrine pancreatic tumors[J].Scand J Surg,2004,93(4):311-315.
[43] Wiesli P,Brandle M,Schmid C,et a1.Selective arterial calcium stimulation and hepatic venous sampling in the evaluation of hyperinsulinemic hypoglycemia:potential and limitations[J].J Vasc Interv Radiol,2004,15:1251-1256.
[44]汤志刚,纪涛,邱陆军等.功能性胰岛B细胞瘤的外科诊治分析[J].临床外科杂志,2008,16(12):817-819.
[45] Chatziioannou A, KehagiasD, Mourikis D, et al. Imaging and localization of pancreatic insulinomas[J].Clin Imaging,2001, 25:275-283.
[46]李殿秋,李新颖,史纪文等.胰岛细胞瘤术中B超定位诊断分析[J].中国实验诊断学,2008,12(7):896-897。
[47]武正炎,沈美萍,刘训良等.胰岛素瘤术中血糖监测的评价[J].中华普通外科杂志,2000,15(12):712-713.
[48] Iwanaka T,M atsumo toM , Yo sh ikawa Y, et al.Accurate localization of an insulinoma by preoperative selective intra-arterial calcium injection and intraoperative glucose monitoring[J].Pediatr Surg Int, 2000, 16: 118-1201.