Endoscopic Submucosal Dissection (ESD) of a Large Bleeding Brunner’s Gland Hamartoma in an 85-year-old Patient

Large duodenal polyps, while uncommon, may cause bleeding and intestinal obstruction that necessitate treatment. Surgery confers significant morbidity and mortality [1]. Endoscopic treatment, while preferred, is challenging because of the thin duodenal wall, the limited operating space and the rich vascularity. Endoscopic mucosal resection (EMR) is associated with incomplete resection while ESD achieves higher en bloc rate at the expense of a higher perforation rate [2]. We present a frail 85 year-old female with symptomatic iron deficiency anaemia (Haemoglobin 4.9 g/dL) and bloating from a large lumen-occluding duodenal polyp, which was resected by ESD. Upper endoscopy revealed a prolapsing duodenal bulb polyp, that could not be visualised in its entirety to facilitate the deployment of a snare. ESD was performed under general anaesthesia. The base was clipped after adrenaline injection (1:100 000). The polyp was resected above the clips, with a scissors-type ESD knife, carefully ensuring that the duodenal walls were not touched. The base was closed for good measure with additional clips. The polyp was retrieved with a snare to navigate the upper oesophageal sphincter. The specimen size was 5 x 4.5 cm. The histology was Brunner gland hamartoma. The patient made an uneventful recovery. Her symptoms resolved (haemoglobin 12.6 g/dL). This case illustrates the significant morbidity posed by an otherwise benign duodenal polyp. It also demonstrates that duodenal ESD of a lumen-occluding polyp may be safely and successfully performed with a scissors-type ESD knife, that allows for controlled resection in a limited working space.

Publication History

Article published online:
27 March 2025

• References

• 1 Pérez-Cuadrado-Robles E, Quénéhervé L, Margos W, Moreels TG, Yeung R, Piessevaux H, Coron E, Jouret-Mourin A, Deprez PH. ESD versus EMR in non-ampullary superficial duodenal tumors: A systematic review and meta-analysis [Internet] U.S. National Library of Medicine. 2018; [cited 2024 Nov 6]. Available from. https://pubmed.ncbi.nlm.nih.gov/30083591/
• 2 Zhu M, Li H, Wu Y, An Y, Wang Y, Ye C, Zhang D, Ma R, Wang X, Shao X, Guo X, Qi X. Brunner’s gland hamartoma of the duodenum: A literature review [Internet] U.S. National Library of Medicine. 2021; [cited 2024 Nov 6]. Available from. https://pubmed.ncbi.nlm.nih.gov/33914269/