OBJECTIVE To review the surgical management of pancreatic islet-cell tumors, with attention to preoperative localization, surgical therapy, and postoperative survival. METHODS Consecutive case series of patients treated surgically for pancreatic islet-cell tumor. METHODS The Johns Hopkins Hospital, a large teaching hospital in Baltimore, Md, serving both as a primary and tertiary care center. METHODS Thirty-seven patients with pancreatic islet-cell tumors treated surgically between 1979 and 1990. METHODS Success of preoperative localization studies, types of operations performed, and postoperative survival. RESULTS Preoperative computed tomography correctly localized the tumor in 20 of 34 patients (59%); angiography in 21 of 28 patients (75%), and the combination of computed tomography and angiography in 23 of 28 patients (82%). Benign islet-cell tumors were found in 19 patients, and malignant tumors in 18 patients. Twenty-four patients (65%) had functional tumors. The proportion of patients with nonfunctioning tumors increased from 0% before 1984, to 43% from 1985 to 1990. Surgical therapy was curative in 27 patients and palliative in 10. The most commonly performed operative procedures were tumor enucleation (11 patients [30%]), distal pancreatectomy (10 patients [27%]). There was no operative mortality. The actuarial survival at 40 months was 100% in patients with benign tumors and significantly lower (66%) in patients with malignant tumors. CONCLUSIONS This experience from a single institution underscores the role of preoperative localization studies and appropriate surgical management of these rare tumors.