Urgent endoscopic submucosal dissection of an obstructing, bleeding giant duodenal "Brunneroma"

Endoscopic submucosal dissection (ESD) is an advanced technique for the en bloc resection of complex GI lesions, although its use as an urgent alternative to surgery has rarely been reported. This video demonstrates the urgent application of ESD using the Saline-Immersion/irrigation TEchnique (SITE) to treat a giant, bleeding, and obstructing Brunner's gland hamartoma.

A 36-year-old man presented with melena, syncopal episodes, and severe anemia. A 2-month history of postprandial discomfort and recent black stools was reported. Upon presentation, the patient was hypotensive and tachycardic. CT imaging showed a large duodenal filling defect, and the urgent gastroscopy revealed a giant pedunculated lesion at the first part of the duodenum with an ulcerated stalk and visible vessels. Initial hemostasis was achieved, but recurrent bleeding prompted urgent SITE-ESD.

The lesion was successfully resected en bloc in under 40 minutes. Because of the lesion's size, retrieval through the pylorus required snare cutting into smaller pieces, facilitated by SITE. The patient recovered without adverse events and was discharged on day 4. Histopathology confirmed a Brunner's gland hamartoma without dysplasia.

This case demonstrates that ESD can serve as an urgent, organ-preserving definitive option in specific cases. SITE enhances lesion handling and safe retrieval, especially when size limits conventional removal.