- Email: [email protected]
Endoscopic removal of a huge duodenal Brunner’s gland adenoma: a new technique
Endoscopic removal of a huge duodenal Brunner’s gland adenoma: a new technique Chi-Hung Huang, MD, Chin-Lin Perng, MD, Yi-Hwan Yang, MD, Yi-Ming Shyr, MD, Hwai-Jeng Lin, MD, FACG, GuanYing Tseng, MD, I-Ting Yu, MD, Full-Young Chang, MD, Shou-Dong Lee, MD, FACG
Endoscopic polypectomy is widely applied for the removal of GI polyps. The electrosurgical snare technique is the most commonly used method. This technique guarantees that blood vessels in the stalk are coagulated before cutting. If the head of the polyp is too large to be snared within a small lumen (e.g., bulb or second portion of duodenum), it poses a technical challenge to the endoscopist. Herein we report a case of a huge duodenal Brunner’s gland adenoma that was easily and safely removed by a new technique of endoscopic polypectomy.
Figure 1. Endoscopic view of the stalk of the Brunner’s gland adenoma with several small ulcers arising on the anterior wall of bulb.
CASE REPORT A 22-year-old man presented with melena and hematochezia following a period of flatulence and decreased appetite. Physical examination was unremarkable except for pale conjunctiva and skin pallor. Hemoglobin was 10.5 gm/dL (normal value 14 to 18 gm/dL). Gastroduodenoscopy showed a huge pedunculated polyp extending from the anterior wall of the duodenal bulb to the second portion of the duodenum; several small ulcers with oozing of blood were seen near the base of the stalk (Fig. 1). The polyp was so large that it almost obstructed the lumen. Electrosurgical snare polypectomy was attempted with end-viewing and side-viewing endoscopes, but this was unsuccessful. In addition, the polyp could not be pulled back into the stomach due to its large diameter. Endoscopic polypectomy was therefore performed as follows in the operating room. (1) An end-viewing endoscope was used (GIF-2T20; Olympus Optical Co. Ltd., Tokyo, Japan). (2) Epinephrine (1:10,000), 10 mL, was injected into the oozing site and the base of the stalk to stop the bleeding and coapt the blood vessel present in the stalk. (3) The snare (SD-9L-1; Olympus Optical Co. Ltd.) was kept in a semiopened position and used as a “knife” to cut the stalk with blended current (30 watt, UES-10; Olympus Optical Co. Ltd.) (Fig. 2). (4) Finally, the polyp was excised (Fig. 3) and a heat probe (CD20-Z, HPU; Olympus Optical Co. Ltd.) was applied to the remnant of stalk to coagulate any remaining blood vessels. The resected specimen was 5.5 × 3 × 3 cm in size (Fig. 4). At microscopy, the polyp consisted of normal Brunner’s glands without evidence of From the Division of Gastroenterology, Department of Medicine, Department of Surgery, and Department of Pathology, Veterans General Hospital-Taipei, and School of Medicine, National YangMing University, Taipei, Taiwan. Reprint requests: Chin-Lin Perng, MD, Division of Gastroenterology, Department of Medicine, Veterans General Hospital-Taipei, 201 Shih-Pai Road, Sec. 2, Taipei, Taiwan 11217. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/99253 868
GASTROINTESTINAL ENDOSCOPY
Figure 2. Polypectomy being performed using semiopened snare. malignancy. There were no complications and the patient was discharged 3 days later on treatment with an H 2 antagonist. A follow-up endoscopy 6 weeks later showed a healed ulcer on the anterior wall of the bulb.
DISCUSSION Benign duodenal tumors account for only 0.008% of postmortem tumors. Brunner’s gland adenomas are extremely rare and represent 10.6% of benign duodenal tumors.1 Feyrter2 described three patterns of abnormal growth of Brunner’s glands: (1) diffuse nodular hyperplasia, (2) circumscribed nodular hyperplasia, and (3) Brunner’s gland adenoma. Only the third type is a true polypoid tumor that may be large and even pedunculated. They are rarely malignant. Endoscopic electrosurgical snare resection is widely used for removal of pedunculated polyps. The ease of polypectomy depends on the size, shape and location of the polyp. In our case, the tip of the polyp was VOLUME 50, NO. 6, 1999
Brief Reports
Figure 3. Endoscopic view of the remnant of the stalk immediately after polypectomy.
located just at the superior duodenal angle where manipulation is usually difficult because of the narrow operating field. In addition, the diameter of this polyp was so large that it almost obstructed the lumen. Conventional electrosurgical snare technique was tried by an experienced endoscopist but was unsuccessful. We therefore used the semiopened snare as a knife to cut the stalk. Thus, this new technique can be considered as an alternative method if the conventional electrosurgical snare technique fails. In English language reports, 11 patients (including the present patient) with Brunner’s gland adenoma have been successfully treated by endoscopic polypectomy without complication.3-10 All of these polyps were resected using the standard electrosurgical snare polypectomy technique. Only one patient presented with active bleeding requiring endoscopic homeostasis.9 The polyp described here is the second in which endoscopic control of bleeding was required.
VOLUME 50, NO. 6, 1999
REFERENCES 1. Raiford TS. Tumors of the small intestine. Arch Surg 1932;25:122-77. ¨ 2. Feyrter F. Uber Wucherungen der Brunnerschen Drusen. Virch Arch Path Anat 1934;293:509-26. 3. Appel MF, Bentlif PS. Endoscopic removal of bleeding Brunner gland adenoma. Arch Surg 1976;111:301. 4. Shirazi SS, Deckinga BG. Brunner gland adenoma of the duodenum. Arch Surg 1977;112:306-7. 5. Kehl O, Buhler H, Stamm B, Amman RW. Endoscopic removal of a large, obstructing and bleeding duodenal Brunner’s gland adenoma. Endoscopy 1985;17:231-2. 6. Khawaja HT, Deakin M, Colin-Jones DG. Endoscopic removal of a large ulcerated Brunner’s gland adenoma. Endoscopy 1986;18:199-201. 7. Matsmoto T, Iida M, Matsui T, Yao T, Fujishima M. A large Brunner’s gland adenoma removed by endoscopic polypectomy. Endoscopy 1990;22:192-3. 8. Wang HP, Lin JT, Wong JM, Wang TH, Wang TH. A large Brunner’s gland adenoma of duodenum removed by endoscopic polypectomy: report of a case. Chin J Gastroenterol 1994;11:201-5. 9. Walden DT, Marcon NE. Endoscopic injection and polypectomy for bleeding Brunner’s gland hamartoma: case report and expanded literature review. Gastrointest Endosc 1998;47:403-7. 10. Singh K, Singh LM, Nagi B, Malik AK. Endoscopic removal of duodenal Brunneroma. Trop Gastroenterol 1991;12:40-2.
GASTROINTESTINAL ENDOSCOPY
869
Endoscopic polypectomy is widely applied for the removal of GI polyps. The electrosurgical snare technique is the most commonly used method. This technique guarantees that blood vessels in the stalk are coagulated before cutting. If the head of the polyp is too large to be snared within a small lumen (e.g., bulb or second portion of duodenum), it poses a technical challenge to the endoscopist. Herein we report a case of a huge duodenal Brunner’s gland adenoma that was easily and safely removed by a new technique of endoscopic polypectomy.
Figure 1. Endoscopic view of the stalk of the Brunner’s gland adenoma with several small ulcers arising on the anterior wall of bulb.
CASE REPORT A 22-year-old man presented with melena and hematochezia following a period of flatulence and decreased appetite. Physical examination was unremarkable except for pale conjunctiva and skin pallor. Hemoglobin was 10.5 gm/dL (normal value 14 to 18 gm/dL). Gastroduodenoscopy showed a huge pedunculated polyp extending from the anterior wall of the duodenal bulb to the second portion of the duodenum; several small ulcers with oozing of blood were seen near the base of the stalk (Fig. 1). The polyp was so large that it almost obstructed the lumen. Electrosurgical snare polypectomy was attempted with end-viewing and side-viewing endoscopes, but this was unsuccessful. In addition, the polyp could not be pulled back into the stomach due to its large diameter. Endoscopic polypectomy was therefore performed as follows in the operating room. (1) An end-viewing endoscope was used (GIF-2T20; Olympus Optical Co. Ltd., Tokyo, Japan). (2) Epinephrine (1:10,000), 10 mL, was injected into the oozing site and the base of the stalk to stop the bleeding and coapt the blood vessel present in the stalk. (3) The snare (SD-9L-1; Olympus Optical Co. Ltd.) was kept in a semiopened position and used as a “knife” to cut the stalk with blended current (30 watt, UES-10; Olympus Optical Co. Ltd.) (Fig. 2). (4) Finally, the polyp was excised (Fig. 3) and a heat probe (CD20-Z, HPU; Olympus Optical Co. Ltd.) was applied to the remnant of stalk to coagulate any remaining blood vessels. The resected specimen was 5.5 × 3 × 3 cm in size (Fig. 4). At microscopy, the polyp consisted of normal Brunner’s glands without evidence of From the Division of Gastroenterology, Department of Medicine, Department of Surgery, and Department of Pathology, Veterans General Hospital-Taipei, and School of Medicine, National YangMing University, Taipei, Taiwan. Reprint requests: Chin-Lin Perng, MD, Division of Gastroenterology, Department of Medicine, Veterans General Hospital-Taipei, 201 Shih-Pai Road, Sec. 2, Taipei, Taiwan 11217. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/99253 868
GASTROINTESTINAL ENDOSCOPY
Figure 2. Polypectomy being performed using semiopened snare. malignancy. There were no complications and the patient was discharged 3 days later on treatment with an H 2 antagonist. A follow-up endoscopy 6 weeks later showed a healed ulcer on the anterior wall of the bulb.
DISCUSSION Benign duodenal tumors account for only 0.008% of postmortem tumors. Brunner’s gland adenomas are extremely rare and represent 10.6% of benign duodenal tumors.1 Feyrter2 described three patterns of abnormal growth of Brunner’s glands: (1) diffuse nodular hyperplasia, (2) circumscribed nodular hyperplasia, and (3) Brunner’s gland adenoma. Only the third type is a true polypoid tumor that may be large and even pedunculated. They are rarely malignant. Endoscopic electrosurgical snare resection is widely used for removal of pedunculated polyps. The ease of polypectomy depends on the size, shape and location of the polyp. In our case, the tip of the polyp was VOLUME 50, NO. 6, 1999
Brief Reports
Figure 3. Endoscopic view of the remnant of the stalk immediately after polypectomy.
located just at the superior duodenal angle where manipulation is usually difficult because of the narrow operating field. In addition, the diameter of this polyp was so large that it almost obstructed the lumen. Conventional electrosurgical snare technique was tried by an experienced endoscopist but was unsuccessful. We therefore used the semiopened snare as a knife to cut the stalk. Thus, this new technique can be considered as an alternative method if the conventional electrosurgical snare technique fails. In English language reports, 11 patients (including the present patient) with Brunner’s gland adenoma have been successfully treated by endoscopic polypectomy without complication.3-10 All of these polyps were resected using the standard electrosurgical snare polypectomy technique. Only one patient presented with active bleeding requiring endoscopic homeostasis.9 The polyp described here is the second in which endoscopic control of bleeding was required.
VOLUME 50, NO. 6, 1999
REFERENCES 1. Raiford TS. Tumors of the small intestine. Arch Surg 1932;25:122-77. ¨ 2. Feyrter F. Uber Wucherungen der Brunnerschen Drusen. Virch Arch Path Anat 1934;293:509-26. 3. Appel MF, Bentlif PS. Endoscopic removal of bleeding Brunner gland adenoma. Arch Surg 1976;111:301. 4. Shirazi SS, Deckinga BG. Brunner gland adenoma of the duodenum. Arch Surg 1977;112:306-7. 5. Kehl O, Buhler H, Stamm B, Amman RW. Endoscopic removal of a large, obstructing and bleeding duodenal Brunner’s gland adenoma. Endoscopy 1985;17:231-2. 6. Khawaja HT, Deakin M, Colin-Jones DG. Endoscopic removal of a large ulcerated Brunner’s gland adenoma. Endoscopy 1986;18:199-201. 7. Matsmoto T, Iida M, Matsui T, Yao T, Fujishima M. A large Brunner’s gland adenoma removed by endoscopic polypectomy. Endoscopy 1990;22:192-3. 8. Wang HP, Lin JT, Wong JM, Wang TH, Wang TH. A large Brunner’s gland adenoma of duodenum removed by endoscopic polypectomy: report of a case. Chin J Gastroenterol 1994;11:201-5. 9. Walden DT, Marcon NE. Endoscopic injection and polypectomy for bleeding Brunner’s gland hamartoma: case report and expanded literature review. Gastrointest Endosc 1998;47:403-7. 10. Singh K, Singh LM, Nagi B, Malik AK. Endoscopic removal of duodenal Brunneroma. Trop Gastroenterol 1991;12:40-2.
GASTROINTESTINAL ENDOSCOPY
869