Extensive hyperplastic recurrence after complete R0 resection by endoscopic submucosal dissection of a gastric hyperplastic polyp with dysplasia.

Endoscopic submucosal dissection (ESD) is an effective, safe technique for treating gastric lesions [1]. Hyperplastic polyps have an underestimated risk formalignancy, which has been reported to be 3.7% in 809 lesionsmeasuringmore than 1cm [2]. Thus, complete en bloc resectionwith ESD is an option to avoid local recurrence [3], particularly when hyperplasia is associatedwith dysplasia. We report the case of a 68-year-old man who underwent a complete R0 resection by ESD of a 2-cm hyperplastic polyp with low grade dysplasia that was located on the posterior wall of the antrum (●" Fig.1). The specimen was 6cm in size, with large safety margins (●" Fig.2). Follow-up endoscopy 3 months later revealed good scarring without any local recurrence histologically. Biopsy revealed antral atrophic gastritis and intestinal metaplasia. At 1-year follow-up, extensive recurrence had appeared on the whole posterior wall of the antrum that measured more than 8 cm and crossed the pylorus (●" Fig.3, ●" Fig.4). We attempted a new ESD procedure, but severe fibrosis prevented submucosal access. To differentiate recurrence from a profuse scarring process, we performed a snare resection of a 25-mm fragment, which confirmed hyperplasia without dysplasia, in addition to granulation scarring tissue. Such recurrence has previously been described after surgery, but never after endoscopic resection [4]. Because of the significant size of the lesion, the fibrosis, and the potential for malignancy, surgery was scheduled. Various risk factors for hyperplastic gastric polyps have been proposed, such as chronic active gastritis and concomitant Helicobacter pylori infection [5]. In our patient, earlier biopsies never revealed such an infection, but he had a long history of proton pump inhibitor use. To summarize, we report a profuse recurrence of hyperplasia after curative en bloc ESD of a hyperplastic polyp with low grade dysplasia. This uncommon evolution might be linked to the large area of resection by ESD, which led to a significant scarring process. Long-term followup appears to be justified in patients who undergo resections of this type.