JOP. J Pancreas (Online) 2009 Mar 9; 10(2):196-199. JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577] 196 CASE REPORT Pancreas Sparing Resection for Giant Hamartoma of Brunner’s Glands Vikas Gupta 1 , Virendra Singh 2 , Naveen Kalra 3 , Kim Vaiphei 4 Departments of 1 General Surgery, 2 Hepatology, 3 Radiodiagnosis, 4 Histopathology, Postgraduate Institute of Medical Education and Research. Chandigarh, India ABSTRACT Context Benign proliferative changes of the Brunner's glands account for about 10% of neoplasias of the duodenal bulb. Case report The authors present a case of giant hamartoma of Brunner’s glands. The patient presented clinically with vague epigastric discomfort. A pancreas-sparing duodenal resection was performed. The patient made an uneventful recovery and is well at a one year follow-up. The diagnosis was established on histopathology. Conclusion Duodenal hamartomas are rare and may become very large, mandating surgical removal. A pancreas-sparing duodenal resection is one of the modalities of treating such lesions. INTRODUCTION Brunner’s glands are mucus secreting acinar glands situated in the deep mucosa and submucosa of the duodenum which empty into the crypts of Lieberkühn [1]. Brunner’s gland hyperplasia in the duodenum is a rare, benign, hamartomatous, proliferative disorder of the duodenum and accounts for about 10% of neoplasias of the duodenal bulb [1, 2]. It is characterized by the proliferation of the acinar glands [1, 2, 3]. Owing to its rarity, these lesions can be mistaken for malignancy on radiological and endoscopic examination s [2, 4, 5, 6]. Small masses can present with bleeding, intussusceptions and are rarely asymptomatic [2, 7, 8]. Large masses may cause obstructive and compressive symptoms which may depend upon the location of the tumour [4, 5, 9]. These lesions sometimes become enormous and are called giant brunneromas [4, 5, 9]. A variety of endoscopic and surgical approaches have been described to tackle these lesions based on their size and location [4, 5, 8, 9]. The present report describes successful surgical management of a large lesion by an organ-sparing procedure. CASE REPORT Clinical Presentation A 28-year-old woman presented with pain in the upper abdomen and occasional vomiting of 3 months duration. General physical, systemic and abdominal examinations were normal. Her biochemical, hematological and coagulation parameters were normal. She underwent an esophagogastroduodeno- scopy, which revealed an extramucosal mass lesion in the gastric antrum, and the first and second parts of the duodenum, displacing the lumen eccentrically. Duodenal biopsy showed non specific inflammation. Imaging A contrast-enhanced computerized tomogram of the abdomen revealed an exophytic mass arising from the medial wall of the first and second parts of the duodenum displacing the pancreas medially. However, the fat plane between the mass and the pancreas was preserved (Figure 1). Operative Findings and Technique Initial exploration was performed by a bilateral subcostal incision. A generous Kocher’s maneuver was performed to facilitate the examination. There was a 8x10 cm exophytic mass arising from the antrum of the stomach and medial wall of the duodenum (1 st and 2 nd parts) extending beyond the papilla (Figure 2). The tumour could easily be separated from the pancreas. Therefore, the decision to perform a pancreas-sparing resection was taken. The gastric antrum was divided as is done in a classical pancreaticoduodenectomy. The proximal jejunum was transected about 15 cm distal to the ligament of Treitz. The jejunum and the duodenum Received January 4 th , 2009 - Accepted January 12 th , 2009 Key words Brunner Glands; Duodenal Neoplasms; Hamartoma; Hyperplasia; Pancreas; Polyps Correspondence Vikas Gupta Department of General Surgery, Gastrointestinal Surgery Unit, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Phone: +91-172.275.6645; Fax: 91-172-274.4401; Mobile: +91-987.204.1120; +91-991.420.9645 E-mail: vikaspgi@gmail.com Document URL http://www.joplink.net/prev/200903/12.html