LAUSR

A duodenal Brunner’s gland hamartoma is an extremely rare benign tumor of the duodenum, representing less than 1% of primary tumors of the small intestine [1]. Most patients are asymptomatic, but sometimes the condition can cause symptoms such as obstruction or gastrointestinal hemorrhage [2]. In symptomatic patients, endoscopic or surgical treatment is required. When possible, endoscopic management is the first-line treatment, especially for pedunculated lesions [3]. We present here the case of a 43-yearold man referred for endoscopic treatment of a giant pedunculated polyp in the anterior wall of the duodenal bulb (▶Video 1) that was discovered during an anemia check-up. A computed tomography scan revealed an intramucosal pedunculated polyp of 8–10 cm in size, without any sign of malignancy. Endoscopic treatment was indicated to avoid surgery. Initially, a standard polypectomy was considered, but the mass was too large to fit into a snare (▶Fig. 1). We therefore decided to remove the lesion by endoscopic submucosal dissection (ESD), which was achieved with an en bloc resection specimen of 10×5×4.5 cm in size (▶Fig. 2). To reduce the risk of delayed bleeding, prophylactic clip closure was performed. Pathological examination revealed a Brunner's gland hamartoma, with an absence of dysplasia. The patient was discharged 48 hours after the intervention, having had no adverse events. Surgical treatment is usually reserved for lesions that are impossible to remove endoscopically, such as in the case of giant tumors or when snaring has failed [4]; however, ESD was feasible for this giant lesion. A hybrid-ESD technique for a duodenal hamartoma was previously described 15 years ago by Ohba et al. [5]. In expert centers, ESDmay be an alternative treatment approach for complex lesions, thereby avoiding surgery and allowing for a precise pathology examination.