Abstract

Insulinomas are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism.We reported two cases with pancreatic insulinoma. The first one in a 47 years old male with a 21×20 mm insulinoma localized between body and tail of the pancreas; the second one in a 30 years old female with a 7 mm insulinoma localized at the middle of pancreatic body. In both cases, the tumor was removed by laparoscopic enucleation in August 2017 in Al-Najaf city, Iraq. In the postoperative period of both cases, the blood glucose level and insulin level returned to normal.

Introduction

Insulinoma are the most common functional pancreatic endocrine neoplasm, and present with typical clinical syndrome known as Whipple’s triad. Patient can be presented with profound syncopal attack or less severe symptoms that are averted by frequent eating.
Common symptoms include palpitation, trembling, diaphoresis, confusion, and seizure. The family may report that the patient has undergone personal changes.
Diagnosis is by signs and symptoms, close monitoring of the patient in the ward for 72 hours, and checking fasting blood sugar every 4-6 hours, and when the patient becomes symptomatic, we check insulin level and c-peptide to rule out exogenous insulin and other hypoglycemic agents.
After clinching the diagnosis, we should localize the mass, which is best done by CT scan and EUS. Visceral angiography with venous sampling is rarely used to accurately localize the tumor.
The majority of insulinoma are benign and solitary (>90%). Only 10% are malignant. The tumor is eitherapproached by open resection or laparoscopic simple enucleation. Tumors located close the pancreatic duct that are >2 cm in size may require distal pancreatectomy or Whipple’s procedure. Intraoperative ultrasound is used to determine the tumor relation to the main pancreatic duct, and is used as a guide for intraoperative decision making.
Approximately 90% of insulinoma are sporadic and 10% associated with MEN I syndrome. Those associated with MENI syndrome are usually multifocal with high rate of recurrence.

Case presentation

We report two cases of insulinoma enucleation done by laparoscopic surgery (minimally invasive technique)

Case 1:

47 years old male presented with recurrent syncopal attacks, palpitations, diaphoresis, with recurrent fall of blood glucose level below 50 mg/dl. Physical examination was unremarkable.
Investigations showed randum blood sugar below 50 mg/dl, insulin level 98.2 u/L, c-peptide 6.9 u/L, and the patient was diagnosed with insulinoma.
Localization of the mass was done by CT scan with IV contrast, which revealed well avid enhancing mass measuring 21×20 mm between body and tail of the pancreas.