On the bases of personal experience and the series of 148 cases from an international inquiry and a review of the literature, the relation between insular hyperplasia and hypoglycemia was examined. The fundamental points in this investigation included: age, diagnostic investigations, histological findings and postoperative results. The data on the patients with insular hyperplasia indicates that 83% were of adult age. Insular hyperplasia was the only abnormal factor determined to be present. Through treatment a high percentage of cases (71%) was cured. From a practical surgical point of view, differentiation between occult insulomas and insular hyperplasia is not critical. Consequently, good results can be achieved in botlh diseases by practicing a progressive blind resection guided by examination of the operated specimen and by intra-operative blood sugar levels.
A critical evaluation is made of 131 patients submitted to choledocho or hepaticojejunostomy. The main indications for hepaticojejunostomy were iatrogenic strictures of CBD (60 patients), and choledocholithiasis with markedly dilated duct (41 patients). The overall mortality rate was 4% representing principally renal hepatic failure, bile peritonitis and bleeding. The complications following hepaticojejunostomy included only in one case biliary fistula which required reoperation. The long-term results of 80 patients available for a followup study were as follows: 63 patients (78.7%) were symptom-free at 2-13 years followup; 8 patients had brief episodes of cholangitis which responded to antibiotic and corticosteroid treatment; 9 patients required reoperation for stricture of anastomosis. These overall results are a strong argument for hepaticojejunostomy which, compared with choledochoduodenostomy, avoids the hazards of the so-called sump syndrome and of the reflux of enteric contents in the CBD. An increased incidence of peptic ulcer disease in the patients submitted to hepaticojejunostomy was not observed. In very high strictures and in reinterventions anastomosis between left hepatic duct and Roux-en-Y jejunal limb was carried out. The results achieved with this technique, which was performed in 26 patients, were about the same following hepaticojejunostomy.
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