Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

Abstract

IntroductionBrunner's gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunner's glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion.Case presentationA 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunner's glands correspondent to a Brunner's gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure.ConclusionBGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

A Rare Cause of Upper Gastrointestinal Bleeding: Brunner’s Gland Hamartoma

“…Diagnosis of Brunner's gland hamartoma may be challenging. It may not be diagnostic most of the time even in cases where a biopsy is conducted due to observation of a submucosal lesion in upper GIS endoscopy (8). Endoscopic appearance may be mistaken with a pressing pancreatic mass or primary duodenal carcinomas, as it was in our patient.…”

“…Definite pathogenesis remains unknown, however, there are publications suggesting that it may be associated with hyperacidity, inflammation and pancreatitis (3,7,8). Generally, those with small dimensions progress asymptomatically and cause no symptoms (7,8).…”

“…Generally, those with small dimensions progress asymptomatically and cause no symptoms (7,8). They may be confronted incidentally in upper GIS endoscopy performed because of other reasons.…”

“…Endoscopic appearance may be mistaken with a pressing pancreatic mass or primary duodenal carcinomas, as it was in our patient. There are cases which could not be diagnosed preoperatively despite imaging methods, including endoscopy, barium tests and CT, and were diagnosed with laparotomy (8). In centers having the opportunity, endoscopic ultrasonography may be a favorable diagnostic tool and may exclude other benign and malignant causes (9).…”

“…The best approach for symptomatic masses is surgical or endoscopic removal of the mass (10). Although endoscopy is a favorable option especially for pedunculated masses as it is non-invasive, it may be impossible to remove large masses by this method even for experienced endoscopists (8). For large masses, excision of the mass through duodenotomy, as it was performed for the patient represented in the article, seems as the best option.…”