Post written by Daryl Ramai, MD, MPH, MSc, from the Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA.

A 94-year-old woman presented with melena and a significant drop in hemoglobin. Imaging with computed tomography revealed an intramural gastric antral mass extending into the proximal duodenum, and endoscopy demonstrated a large, bleeding pedunculated tumor in the duodenum. Initial attempts to control the bleeding with epinephrine injection, hemostatic powder, and EMR were unsuccessful because of the lesion’s size and location.

Given the persistent bleeding and recurrent transfusion requirements, the decision was made to perform endoscopic submucosal dissection (ESD). The procedure involved submucosal injection with hydroxyethyl starch, mucosal incision using a needle-type ESD knife, and the water-pressure method to safely lift the mucosa. Pre-emptive hemostasis was achieved by cauterizing a feeding artery with hemostatic forceps, and a hook-shaped knife was used to carefully dissect the stalk while minimizing injury to the duodenal wall. The lesion was segmented to facilitate safe retrieval, and the mucosal defect was closed with hemostatic clips.

Pathologic examination confirmed a hamartoma with no dysplasia or deep invasion. The patient had complete resolution of bleeding without adverse events. This case highlights that ESD can be an effective and safe therapeutic option for large pedunculated duodenal hamartomas when traditional endoscopic techniques are infeasible. Techniques such as specimen segmentation, water pressure—assisted dissection, and pre-emptive hemostasis help minimize trauma and bleeding, but such procedures should be performed only by experienced endoscopists because of the high risk of perforation in the duodenum.

This video was important to showcase because it features a rare but clinically significant scenario: a large, bleeding duodenal hamartoma in an elderly patient that could not be managed with standard techniques such as EMR or hemostatic injections.

The video shares several key points valuable for education and clinical practice:

• Hamartomas, although benign, can cause severe bleeding, necessitating advanced endoscopic interventions.
• Technical innovation and safety – This case shows advanced endoscopic techniques such as the water-pressure method, hook-shaped knife dissection, and specimen segmentation, which are critical for safely removing challenging lesions while minimizing risk of perforation.
• Management of high-risk cases – Duodenal ESD is high risk because of the thin duodenal wall and bleeding potential. This video provides a step-by-step visual guide for managing such cases, including pre-emptive hemostasis and safe specimen retrieval.
• Educational value for experts – Although duodenal hamartomas are rare, understanding their management is important for advanced endoscopists. The video serves as a practical demonstration of how to handle technically difficult, high-stakes procedures.
• Clinical relevance – This article underscores that ESD can be an effective alternative when EMR is infeasible, emphasizing the importance of careful planning.

Large lesion with stigmata of recent bleeding in the duodenal bulb.

Read the full article online.

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