Although fundamental advances have been achieved in the last 20 years, the treatment for CHI remains extremely difficult and a tremendous challenge. Many children with CHI remain dependent on medication for years with severe side effects, or they can discontinue hyperglycemic medication after near-complete pancreatectomy, which comes at the price of an equally bad disease, diabetes.

Medical therapy has dramatically reduced the number of extensive surgical procedures necessary and appears to help preventing severe hypoglycemia and brain damage after a limited (50%-75%) resection of the pancreas. Despite the advances made in the last 20 years, therapy of CHI remains far from optimal. “We continue to search for evidence-based markers in diffuse disease to select the cases who benefit from surgery and those who do not. What is the optimal dimension of resection in diffuse disease which should result in euglycemia, but not in diabetes, in every individual case: is it 50%, 95%, or 98%? Research to develop new drugs to treat hypoglycemia that have with fewer side effects is also a high priority.” (Barthlen & de Lonlay, Sem Pediatr Surg 2011, 20: 1-2).
 In case of nesidoblastosis in adults, the therapeutic challenges are comparable to CHI.

Curative resection of insulinomas using endoscopic minimally invasive surgery is an attractive approach to further reduce morbidity. Endoscopic resection of insulinomas is currently performed in selected patients but the localization of the lesion needs to be determined with highest accuracy prior to endoscopic operation in order to avoid morbidity and the necessity to change to open laparotomy. Currently used intraoperative examinations for localization of lesions (palpation, ultrasound) would require complementation by other techniques that are optimally suited for laparoscopic use. In open as well as laparoscopic surgical procedures, less partial pancreatectomies and lower morbidity could be achieved if the resection margins could be determined with higher accuracy. In case of malignant insulinoma, optimized surgical resection and highly specific systemic therapies in order to improve the prognosis are warranted.

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