Laparoscopic enucleation and spleen saving distal pancreatectomy for synchronous insulinoma and nesidioblastosis in an adult patient

Abstract

Introduction: Insulinoma is the most common functional neoplasm of the endocrine pancreas. Patients typically present with features known as Whipple triad. 90% of insulinomas are found to be benign solitary adenomas amenable to surgical resection. Method: We present a case of a lady who had endogenous hyperinsulinism with two DOTATATE avid nodules in the pancreatic body and tail who subsequently underwent laparoscopic enucleation and spleen saving distal pancreatectomy. Results: The patient presented initially with features suggestive of Whipple triad. Further workup by the endocrinologist showed results consistent with endogenous hyperinsulinism. Computed Tomography (CT) scan and DOTATATE scan showed that she had one intensely DOTATE-avid exophytic nodule arising from the pancreatic body that is suspicious for a neuroendocrine tumour while the second DOTATATE-avid nodule is close to the pancreatic tail. There is no suspicious nodal or distant DOTATATE-avid metastasis detected. Her case was discussed in the multidisciplinary meeting and the decision was to proceed with laparoscopic enucleation of both lesions. She subsequently underwent laparoscopic enucleation of pancreatic body lesion with spleen saving distal pancreatectomy. She was discharged well on post operative day 3 and remained symptom free during subsequent follow-ups. Final histology came back as grade 1, well differentiated insulinoma of the pancreatic body and incidental pancreatic nesidioblastosis in the pancreatic tail. Conclusion: Laparoscopic enucleation of pancreatic neuroendocrine tumour is feasible and safe method to resect pancreatic neuroendocrine tumour with less morbidity.