In this video, we describe a case of endoscopic submucosal dissection for definitive management of a large, bleeding duodenal angiolipoma. A 77-year-old female with multiple medical comorbidities presented with a several-month history of persistent melanoma. After a negative initial upper endoscopy and colonoscopy, she underwent a capsule endoscopy, which showed a bleeding lesion in the distal duodenum. A repeat upper endoscopy was performed, which showed a large, pedunculated polyp in the fourth portion of the duodenum, which was biopsied and tattooed. Biopsies showed peptic duodenitis. Given persistent melanoma and a concern for neoplasia within the polyp, she was referred for endoscopic resection. Upper endoscopy was performed, which showed a large, nearly obstructive polyp in the fourth portion of the duodenum at the ligament of trites. The top of the polyp was noted to be ulcerated with stigmata of recent hemorrhage. The stalk itself was approximately two centimeters in thickness and was located at a very endoscopically unstable position in the distal duodenum, requiring endoscopic resection to be carefully planned to minimize the risk of uncontrollable bleeding. First, the vascular supply to the polyp was reduced by placing four standard clips at the base of the stalk. Next, preparations were made for endoscopic submucosal dissection. An ESD technique was specifically chosen so that blood vessels can be selectively and preemptively cauterized during the resection to minimize blood loss during the procedure. A scissor-type knife was chosen for the endoscopic resection. This knife is fully rotatable with an insulated outer surface, such that only the surfaces between the jaws have cutting and coagulation effects and can be used for incision, dissection, and vessel sealing. The stalk was injected with a head of starch solution mixed with indigocarmine and epinephrine. Here, the initial mucosal incision was made using the scissors-type knife. We then carefully dissected through the thick stalk using the knife. A transparent distal attachment cap was essential for maintaining stability of the endoscope in this difficult location in the distal duodenum. Large visible vessels within the stock were sealed and subsequently ligated by applying a soft coagulation current. After the large central vessels were ligated, the distal side of the lesion was ultimately reached. The lesion was therefore able to be completely resected in an en bloc fashion and retrieved using a Roth net. The resection defect was then carefully examined with no evidence of muscle injury or perforation. Remaining visible vessels within the resection bed were cauterized with coagulation forceps. The final specimen measured 6 centimeters by 3 centimeters by 2 centimeters. Histoglithology was consistent with submucosal angiolipoma. The patient was discharged home following the procedure. Her diet was slowly advanced, and she was closely followed up over the next several weeks. Her melanoc entirely resolved. Duodenal angiolipomas are exceedingly rare but benign submucosal tumors consisting of mature adipose tissue and a prominent vascular component. Endoscopic resection offers a minimally invasive alternative to surgical resection of large or bleeding polyps in the duodenum. However, endoscopic resection in the duodenum is inherently challenging due to an unstable endoscope position. Furthermore, resection of thick pedunculated lesions is challenging due to the risk for major bleeding. We demonstrated in this case that ESD with precoagulation of large vessels allows for large pedunculated lesions to be resected in a safe and controlled fashion. When managing a thick pedunculated lesion, consider preemptively placing clips along the base of the stock to reduce the vascular supply. Utilize a scissors-type ESD knife to preemptively seal and ligate large vessels within the stock. Resection defects in the duodenum should be closed to avoid delayed adverse events, such as bleeding and perforation.

endoscopic submucosal dissection

duodenal angiolipoma

bleeding

ESD

challenging duodenal polyps