Surgical Management of Sporadic Pancreatic Insulinomas in a Resource-Limited Setting: A Report of Two Cases

Insulinoma is the most common functional pancreatic neuroendocrine tumor, typically benign, solitary, and sporadic, with an estimated incidence of 1-4 cases per million per year worldwide. It causes recurrent hypoglycemia through inappropriate insulin secretion, classically presenting as Whipple's triad and confirmed by a prolonged supervised fasting test. Surgical enucleation remains the preferred treatment for small, well-localized benign insulinomas, allowing maximal preservation of pancreatic parenchyma. We report two cases of sporadic pancreatic insulinoma managed by open enucleation at a tertiary referral center in Senegal, West Africa, where advanced diagnostic modalities such as endoscopic ultrasound (EUS), somatostatin receptor scintigraphy, and selective arterial secretagogue injection (SASI) testing were unavailable. The first case was a 30-year-old woman presenting with a severe hypoglycemic coma complicated by status epilepticus on postpartum day 10. Abdominal CT scan identified a pancreatic head lesion. Biochemical workup confirmed insulinoma with a fasting blood glucose of 0.30 g/L (30 mg/dL; 1.7 mmol/L), elevated fasting insulin at 32.7 µU/mL, and C-peptide at 2.92 ng/mL. Open enucleation was performed; the postoperative course was complicated by a transient infectious syndrome managed with broad-spectrum antibiotics. Histopathology confirmed a well-differentiated Grade 1 neuroendocrine tumor. Complete resolution of hypoglycemic episodes was achieved with no recurrence at 1 year. The second case involved a 55-year-old man with a 12-year history of recurrent neuroglycopenic episodes. CT scan revealed an isthmic pancreatic lesion. Enucleation was performed; the postoperative course was complicated by a high-output pancreatic fistula (Grade B, ISGPS 2016 classification), managed conservatively with fasting, parenteral nutrition, and close radiological monitoring, without surgical reintervention. Histopathology confirmed a low-grade neuroendocrine tumor. No recurrence of hypoglycemia was observed at 5 months. These cases demonstrate that open enucleation is a feasible, effective, and parenchyma-sparing option for benign sporadic insulinomas, even in resource-limited settings where advanced localization and intraoperative techniques remain unavailable.