What is the role of gastrectomy in treating gastric hyperplasia with gastric outlet obstruction?

Role of Gastrectomy in Gastric Hyperplasia with Gastric Outlet Obstruction

Gastrectomy is NOT the primary treatment for gastric hyperplasia causing gastric outlet obstruction—endoscopic mucosal resection should be attempted first, with gastrectomy reserved only for cases where endoscopic management fails or when malignancy cannot be excluded. 1, 2

Initial Diagnostic Approach

The workup must differentiate benign hyperplastic polyps from malignancy, as management differs fundamentally:

• Perform upper endoscopy immediately to visualize the obstruction, obtain multiple biopsies for histologic diagnosis, and assess feasibility of endoscopic intervention 3, 4
• Obtain CT scan with oral and IV contrast to determine the extent of obstruction, assess for metastatic disease if malignancy is suspected, and evaluate resectability 4, 5
• Complete blood count to assess for anemia from chronic bleeding 4, 5
• Comprehensive metabolic panel to evaluate electrolyte abnormalities and renal function from vomiting 4, 5

Treatment Algorithm for Gastric Hyperplasia

First-Line: Endoscopic Management

Endoscopic mucosal resection is the treatment of choice for symptomatic gastric hyperplastic polyps causing obstruction, as it provides both tissue diagnosis and symptomatic relief 1, 2:

• Polyps >5mm should be removed due to potential malignant transformation risk 2
• Use submucosal lifting agents (such as hydroxypropylmethylcellulose) to create a cushion under the polyp for safe resection 1
• For polyps prolapsing through the pylorus, retrieve the polyp back into the gastric lumen with a tripod before performing snare polypectomy 1, 2
• This approach resolves symptoms while providing definitive histopathologic diagnosis 1

When Gastrectomy May Be Indicated

Gastrectomy should only be considered in the following specific scenarios:

• Failed endoscopic resection due to polyp size, location, or technical factors 1, 2
• Histology reveals malignant transformation on biopsy, requiring oncologic resection 3
• Recurrent obstruction after multiple endoscopic attempts 2
• Inability to exclude malignancy despite adequate tissue sampling 1, 2

Critical Distinction: Malignant vs. Benign Obstruction

This distinction is crucial because treatment pathways diverge completely:

If Malignancy is Confirmed

• For resectable gastric cancer with obstruction: Surgical resection (distal or total gastrectomy with D2 lymphadenectomy) is the primary treatment 3
• For unresectable/metastatic disease with life expectancy >2 months: Surgical gastrojejunostomy is preferred over gastrectomy 3, 4, 5
• For unresectable disease with life expectancy <2 months: Endoscopic self-expanding metal stent placement, not gastrectomy 3, 4, 5

If Hyperplasia is Confirmed

• Endoscopic resection is definitive treatment, not gastrectomy 1, 2
• Gastrectomy would be overtreatment for benign disease unless endoscopic management is impossible 1, 2

Palliative Gastrectomy Considerations

Palliative gastrectomy may be considered for malignant obstruction in highly selected patients with good performance status, absence of distant metastases, and life expectancy >6 months 3, 6:

• Palliative resection provides longest median symptom-free and overall survival compared to stenting or gastrojejunostomy in gastric cancer patients 6
• However, this applies to malignant disease, not benign hyperplasia 6
• Independent prognostic factors favoring palliative resection include younger age, higher BMI, better pre-procedure gastric outlet obstruction scoring system (GOOSS), and ability to receive chemotherapy 6

Common Pitfalls to Avoid

• Do not perform gastrectomy without tissue diagnosis—hyperplastic polyps appear grossly similar to polyps with neoplastic transformation 1
• Do not assume all antral masses causing obstruction are malignant—hyperplastic polyps are a rare but treatable benign cause 1, 2
• Do not bypass endoscopic options—even large polyps (up to 25mm) causing complete obstruction can be successfully managed endoscopically 1, 2
• Ensure adequate biopsy sampling—multiple biopsies are essential as there are no gross appearance differences between benign and malignant-transforming polyps 1

Supportive Care During Workup

While establishing diagnosis and planning definitive treatment:

• Nasogastric tube placement for gastric decompression and prevention of aspiration 4
• Intravenous fluid resuscitation with isotonic crystalloids to correct dehydration and electrolyte abnormalities 4
• Anti-emetics for symptom control 4
• Bowel rest until obstruction is relieved 4