adenomatous polyps are the most common duodenal polyps , the other types being inflammatory , adenoma , leiomyoma , lipoma , adenocarcinoma , carcinoid , lymphoma , leiomyosarcoma , and rarely hamartomas . the spigelman system , which describes 5 ( 0 to iv ) stages , is used for rating the severity of duodenal polyposis . some form of excision , either endoscopic or surgical , for these conditions is mandatory . many procedures have been described , such as local excision , duodenectomy , pancreatoduodenectomy , and a combination of endoscopy with laparoscopic polyp excision . we present a patient with a preoperative histology proved diagnosis of isolated duodenal tubulovillous adenomatous polyp with high - grade dysplasia for whom we performed laparoscopic antrectomy . to our knowledge , laparoscopic antrectomy for a hamartomatous duodenal polyp has not been reported yet . the patient was a 56-year - old male presenting with symptoms of vague upper abdominal pain . endoscopy revealed a sessile polypoidal mass in the posterior aspect of the first part of the duodenum ( figure 1 ) , 4 cm proximal to the ampulla , from which a biopsy was taken . a ct scan showed a broad - based 3-cm x 3-cm mass limited to the duodenal mucosa with no evidence of luminal obstruction , serosal infiltration , or lymph node involvement ( figure 2 ) . based on the above findings , surgical intervention was planned . while under general anesthesia , the patient was placed in the modified lithotomy position with legs apart , skin sterilized and draped . the chief surgeon stood between the legs , the camera surgeon stood on the right , and the assistant surgeon and scrub nurse stood on the left side of the patient . the following port postions were used : 
 10-mm trocar , 3 cm above the umbilicus to the right of the midline ( telescope).12-mm disposable trocar in the left anterior axillary line at the left lumbar region ( right working hand).5-mm trocar below the subcostal margin along the right midclavicular line ( left working hand).5-mm trocar was placed in the epigastrium ( retraction of the liver).5-mm trocar in the left iliac fossa ( caudal retraction of the transverse colon ) . 10-mm trocar , 3 cm above the umbilicus to the right of the midline ( telescope ) . 12-mm disposable trocar in the left anterior axillary line at the left lumbar region ( right working hand ) . 5-mm trocar below the subcostal margin along the right midclavicular line ( left working hand ) . 5-mm trocar in the left iliac fossa ( caudal retraction of the transverse colon ) . endoscopic appearance of the polypoidal mass ( ar - rows ) in the first part of the duodenum . , the serosa of the duodenum was found to be normal , as was its mobility . the duodenum was completely kocherized , and the right gastroepiploic vessels were divided with ultrasonic shears . the stomach and the partially mobilized duodenum were lifted up , and the right gastric artery divided between clips with ultrasonic shears . the duodenum was separated from the head of the pancreas by meticulously dividing the vascular tissue between them . at this point , an endoscope was introduced and a distal 2-cm margin was found to be achievable after occluding the lumen of the duodenum beyond the lesion with an endostapler and visualizing via the endoscope . a 45-mm ( blue color ) endo - gia stapler was applied on the duodenum and fired 2 cm to 3 cm distal to the margin of the tumor , guided by the endoscope ( figure 3 ) . after thus dividing the duodenum , the stomach was divided with a 60-mm ( blue color ) endo - gia stapler , achieving an adequate proximal margin . reconstruction was achieved by a conventional rouxen - y gastrojejunostomy with 60-mm blue endo - gia stapler ( figure 4 ) . the resected specimen was placed in an endobag and delivered through the 12-mm port after enlarging it . stapler applied to distal margin : ( a ) antrum ; ( b ) second part of duodenum ; ( c ) head of pancreas ; arrow points to tip of the endoscope . gastrojejunostomy with endostapler : ( a ) divided end of antrum ; ( b ) jejunum . the patient was allowed liquids orally from the third postoperative day ( pod ) onward , followed by a soft diet thereafter . the resected specimen was cut open , and the macroscopic tumor - free margins were confirmed ( figure 5 ) . after 14-month follow - up , endoscopy showed no evidence of recurrence . histologically , the presence of mature but disorganized tissue composed mainly of lobules of brunner glands lined by cylindrical clear mucous cells were seen . the overlying mucosa , which was pushed up by the submucosal lesion , was normal . the proximal , distal , and radial margins of the resected specimen were negative for tumor , with no evidence of malignancy . villous and tubulovillous polyps of the duodenum behave in a manner similar to those occurring in the colon and rectum , having both a high rate of recurrence after endoscopic excision and a high incidence of malignancy . these types of duodenal polyps are being reported more often now , probably because of the increasing use of upper gastrointestinal endoscopy for evaluation of patients with gastrointestinal complaints and for screening examinations of patients with polyposis syndromes . biopsies correlated with the final pathology in 70% of patients in one study . in our patient , the preoperative endoscopic diagnosis was tubulovillous polyp with high - grade dysplasia ( figure 6b ) , whereas the postoperative diagnosis was hamartoma ( figure 6a ) . the probable reason for the preoperative diagnosis was this : the presence of regenerative changes due to underlying submucosal inflammation in a setting of normal villous projections of the duodenum . also , the tissue for biopsy was taken endoscopically , which would have included only mucosa . postoperatively , we knew that the hamartoma was arising from the submucosa and that the mucosa was normal . ( a ) histology showing the presence of mature but disorganized tissue composed of brunner glands , lined by cylindrical clear mucous cells , muscularis propria is split with proliferation in the lamina propria ; ( b ) endoscopic biopsy findings of regenerative changes due to underlying submucosal inflammation in a setting of normal villous projections suspicious of polyp with high - grade dysplasia . hamartomas are rare duodenal lesions and were first described by cruveilhier at the end of the 19th century . about 50% of patients complain of epigastric pain , gastrointestinal hemorrhage , or rarely intussusception ; in the remaining cases , hamartoma is an incidental finding . it usually presents as a pedunculated polyp located in the first part of the duodenum , measuring from 0.7 cm to 12 cm ( average 4 cm ) , similar to our patient on both counts . hamartoma is a benign lesion , and very few cases of brunner gland hamartoma have been reported in association with epithelial dysplasia , duodenal adenocarcinoma , and carcinoid tumors . prior to treatment , all patients diagnosed with duodenal polyps should undergo screening for colonic polyposis , because duodenal adenomas are common in patients with familial adenomatous polyposis ( 30% to 70% ) and vice versa . the use of endoscopic retrograde cholangiopancreatography ( ercp ) to evaluate biliary duct involvement in patients with ampullary lesions or altered liver function tests is mandatory prior to surgery . ercp was not needed in our patient , as jaundice was absent and the bile ducts were not dilated . treatment options ( flow chart ) for duodenal polyps are either endoscopic , surgical , or a combination of both . endoscopic intervention includes snare excision , thermal ablation , argon plasma coagulation ( apc ) , and photodynamic therapy ( pdt ) . most of the studies on endoscopic therapy reported on in the literature use snare excision . in addition , thermal ablation , apc , or pdt may be used with equally good outcomes . the size of the lesion in our patient was 3 cm x 3 cm , sessile with a broad base and histological evidence of high - grade dysplasia , which qualifies the lesion as spigelman stage iii . the literature reveals that endoscopic treatment is usually insufficient to guarantee a polyp - free duodenum and is fraught with complications . recurrence rates are usually low in isolated duodenal lesions like our case , though recurrence of duodenal polyps of fap patients treated endoscopically are unacceptably high ( 50% to 100% ) . surgical options used to treat duodenal polyposis include local surgical treatment ( duodenotomy with polypectomy and/or ampullectomy ) , pancreas and pylorus - sparing duodenectomy , and pancreaticoduodenectomy . no randomized studies have been reported in the literature to help guide surgical selection , though studies have shown that local excision of duodenal adenomas is associated with a high risk of local recurrence , so duodenectomy or pancreaticoduodenectomy should be considered . pancreaticoduodenectomy is the appropriate treatment for spigelman stage iv duodenal polyposis and can be considered for stage iii . surgical polypectomy alone fails to guarantee a polyp - free duodenum and also carries a risk of postoperative complications , whereas pancreatoduodenectomy eliminates the risk of duodenal cancer , though with a high morbidity rate . even though the postoperative diagnosis in our patient was benign hamartoma , polypectomy would have been impossible to achieve as the lesion had a wide base , and too much duodenal tissue would have to be removed to achieve clearance . antrectomy is ideal in cases like ours , where a solitary polyp not amenable to endoscopic excision is located proximal to the ampulla . the pylorus had to be sacrificed because the proximal margin of the tumor was only 1 cm from the sphincter , and pylorus preservation may have resulted in inadequate clearance . we prefer roux - en - y anastomosis to billroth ii , as the former is associated with a much lower risk of postgastrectomy syndrome . ( a ) shaded area showing the extent of resection and tumor margins ( arrow ) ; ( b ) completed roux - en - y anastomosis . duodenal polyps are mostly asymptomatic , and optimizing adequate treatment for these patients can be quite challenging . we believe that even though antrectomy is not a routine indication for duodenal polyps , it was the procedure of choice in our case . laparoscopic surgery is an attractive option , with all the conventional benefits of minimal access .
background : adenoma is the most common cause of duodenal polyps , while hamartomas are very rare . 
 we present a patient with a preoperative histology proved diagnosis of isolated duodenal tubulovillous adenomatous polyp with high - grade dysplasia for whom we performed laparoscopic antrectomy.case report : the patient was a 56-year - old male with vague upper abdominal pain . 
 investigations revealed a 3-cm x 3-cm mass arising from the duodenal mucosa with no evidence of extraserosal spread . 
 histopathology documented an adenomatous polyp with high - grade dysplasia , so a laparoscopic antrectomy was performed.results:the patient had an uneventful postoperative period , requiring only 2 doses of parenteral analgesics . 
 he was discharged on the seventh postoperative day . 
 the final histopathological findings were consistent with benign hamartoma . 
 no recurrence has been reported after 14 months of follow - up with endoscopy.discussion:many procedures have been described for polyps , such as endoscopic excision , duodenectomy , pancreatoduodenectomy , and laparoscopic polyp excision . in our patient , the decision to perform duodenectomy was based on the preoperative findings of a sessile tubulovillous adenomatous polyp with high - grade dysplasia . 
 histologically , the 2 entities can be identical , especially with the small tissue volume obtained from endoscopic biopsy.conclusion:given these observations , antrectomy was probably ideal , because endoscopic excision would have been inadequate and even dangerous while pancreatoduodenectomy would have been too radical .