We describe six patients (five women and one man; median age, 47 years; range, 39 to 54) with postprandial symptoms of neuroglycopenia owing to endogenous hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass surgery. Except for equivocal evidence in one patient, there was no radiologic evidence of insulinoma. Selective arterial calcium-stimulation tests, positive in each patient, were used to guide partial pancreatectomy. Nesidioblastosis was identified in resected specimens from each patient, and multiple insulinomas were identified in one. Hypoglycemic symptoms diminished postoperatively. We speculate that hyperfunction of pancreatic islets did not lead to obesity but that beta-cell trophic factors may have increased as a result of gastric bypass.

Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

The term ''ectopic varices'' is sometimes reserved for abnormally dilated veins associated with gastrointestinal mucosa and, therefore, with the potential for gastrointestinal hemorrhage. However, the term has also been used loosely to describe portosystemic collateral veins in the abdominal wall and retroperitoneum. The distinction between ''ectopic varices'' and collaterals that are commonly found on the abdominal wall and retroperitoneum of patients with portal hypertension is one of semantics. Thus, ectopic varices may be best defined as large portosystemic venous collaterals occurring anywhere in the abdomen except in the cardioesophageal region.Ectopic varices are an unusual cause of gastrointestinal hemorrhage, but account for up to 5% of all variceal bleeding. 1 The clinician caring for patients with gastrointestinal bleeding must be aware of this entity, because diagnosis and management of ectopic varices differ from that of esophagogastric varices. Furthermore, the prognosis from bleeding ectopic varices may be poor, with one study quoting 40% mortality at initial bleed from duodenal varices. 2 The literature on this subject consists mainly of small series and case reports with no randomized trials of therapeutic modalities. However, a review of the literature does provide sufficient information from which rational management decisions can be made. PREVALENCEEctopic varices account for between 1% and 5% of all variceal bleeding. 1,3 Ectopic varices are a relatively common finding at endoscopy in patients with portal hypertension. The prevalence seems to be related to the cause of the portal hypertension and the technique used to show the varices. In patients with intrahepatic portal hypertension, duodenal varices are seen in 40% of patients undergoing angiography, 3 whereas anorectal varices have been reported in between 10% and 40% of cirrhotic patients undergoing colonoscopy. 4,5 It is important to differentiate anal varices from hemorrhoids: Anal varices collapse with digital pressure, whereas hemorrhoids do not. 4 In patients with portal hypertension caused by obstruction of the portal or splenic veins, duodenal varices are more prevalent than in patients with intrahepatic portal hypertension. The prevalence is higher if angiography is used to show varices. In fact, most patients with portal or splenic vein thrombosis are likely to have duodenal varices shown on angiography. 6,7 The majority of patients with duodenal varices visualized on endoscopy have extrahepatic portal hypertension. In contrast to duodenal varices, it appears that most cases of varices in other portions of the small intestine and colonic varices are seen in patients with intrahepatic portal hypertension who have previously undergone abdominal surgery. 6 In the west, because the prevalence of extrahepatic portal hypertension is low, most bleeding from ectopic varices is usually associated with intrahepatic portal hypertension. 6,8 Stomal varices are a particularly common cause of ectopic varices and occur in patients with intrah...

Although fasting hypoglycemia is characteristic of patients with insulinoma, postprandial symptoms have been reported with increasing, albeit low, frequency. Trends in the evaluation and preoperative management include a shift to outpatient diagnostic testing, an emphasis on successful preoperative localization to avoid blind pancreatic exploration, and a validation of the diagnostic criteria for hyperinsulinemic hypoglycemia.

Large juvenile nasopharyngeal angiofibromas are a therapeutic challenge because of their relation to major vasculature and cranial nerves at the base of the skull, and their propensity for recurrence. A classification scheme based on the growth pattern of this tumor is proposed to help the surgeon choose a procedure to access this lesion. This report describes the results obtained with the surgical removal of large (class III and IV) nasopharyngeal angiofibromas through the infratemporal fossa approach. Fourteen patients were cured and one individual developed a recurrence which was totally removed at a second procedure. Surgical morbidity was minimal and there was no mortality. Radiation therapy was necessary in only one patient who had tumor infiltration of the cavernous sinus.