Grasping forceps assisted endoloop/snare polypectomy of a giant duodenal hamartoma.

Abstract

A 42-year-old man underwent esophagogastroduodenoscopy (EGD) at our institute for melena with severe anemization. A giant polypoid lesion with some superficial erosions was found at the proximal descending part of duodenum, next to the upper angle. The lesion had a maximum transverse diameter of 4 cm, with an overall length of 7 cm (Figure 1(a)). Histology revealed Brunner’s gland hyperplasia. Figure 1. Endoscopic images before endoscopic removal (a), during forceps-assisted endoloop placement (b), and during (c) and following polypectomy (d). Due to the lesion size and location, endoscopic resection was performed under general anesthesia with a double-channel endoscope (Olympus Medical, Center Valley, PA, USA) in order to use more accessories simultaneously. The lesion was held with grasping forceps inserted through a detachable snare loop (Endoloop; Olympus America, Center Valley, PA, USA), which was then advanced, tightened and detached at the base of the lesion to prevent bleeding (Figure 1(b)). With the grasping forceps inserted through a polypectomy snare (AcuSnare, Wilson-Cook Medical, Inc., Winston-Salem, NC, USA), the lesion was finally ensnared, and resection was performed under direct vision between the grasping forceps and the endoloop (Figure 1(c) and (d)). No adverse events occurred and the patient was discharged the next day. Histology showed a Brunner’s gland hamartoma (Figure 2). No more episodes of bleeding were observed, with no lesion recurrence at 6 month endoscopy follow up (Figure 3). Figure 2. Histological images at 0.039× magnification of the Brunner’s gland hamartoma, stained with hematoxylin-eosin (a), Alcian-PAS (b) and SMA (c), highlighting the glandular PAS positive component (white*), the muscular (red*) and the vascular ... Figure 3. Narrow band imaging (NBI) endoscopic view at 6 month follow up. Brunner’s gland hamartoma is a rare tumor-like lesion, with an average size of 2 cm, rarely larger than 5 cm, that locates in the first portion of duodenum; its pathogenesis is unknown and malignant change is rarely observed [Levine et al. 1995; Kim et al. 2013]. Clinical presentation of Brunner’s gland hamartoma is variable. Obstruction and gastrointestinal bleeding are the most common clinical manifestations [Chen et al. 2005]. If local surgical resection of this lesion via duodenotomy is described for those large lesions (up to 6 cm in diameter) [Levine et al. 1995], endoscopic polypectomy has also been reported as a safe and less invasive treatment for smaller pedunculated hamartomas [Walden and Marcon, 1998; Chen et al. 2005]. Endoscopic removal of large pedunculated polyps is technically demanding because a large polyp on a long and thick stalk may move relatively freely within the lumen, making the ensnaring of the polyp very difficult. Furthermore the unique anatomical features of the duodenum, such as the relatively small size of the lumen, make it even much more challenging. The grasping forceps assisted technique appeared as a very helpful endoscopic approach for resection of this polyp, avoiding any surgical intervention for removal of such a benign lesion. The grasping forceps assisted technique was first reported by Akahoshi and colleagues for removal of colonic and gastric pedunculated polyps with an average diameter of 19 mm (range from 11 to 30 mm) [Akahoshi et al. 1999]. To the best of our knowledge, this is the first application of this technique in the duodenum. This new alternative approach for removal of large benign peduncolated lesions such as duodenal hamartomas seems to be useful and safe, avoiding surgery with its associated costs, postoperative length of stay and complications.