Intraoperative Duodenal Wall Thickening: “A Decision-Guiding Intraoperative Marker” in Clinically Benign Gastric Outlet Obstruction?

Background Distinguishing benign from malignant gastric outlet obstruction (GOO) remains a major clinical challenge. Despite comprehensive preoperative evaluation, occult malignancy and advanced fibrosis may be overlooked, complicating treatment selection, particularly in the era of minimally invasive and endoscopic bypass techniques. This study aimed to evaluate the clinical and pathological characteristics of clinically benign GOO, focusing on the prognostic significance of intraoperative duodenal wall thickening. Methods This observational study included adult patients who underwent surgical treatment for clinically benign GOO between September 2023 and December 2025, identified from a prospective institutional gastrectomy database. Preoperative assessment included endoscopy with biopsy, contrast-enhanced computed tomography, tumor markers, and nutritional evaluation. All patients underwent distal subtotal gastrectomy with Roux-en-Y reconstruction using a laparoscopic-first approach. Intraoperative duodenal wall thickening was prospectively recorded, and its association with postoperative outcomes was analyzed. Results Twenty-two patients were included (median age 58.5 years; 59.1% male). All demonstrated gastric dilatation and normal tumor markers. Helicobacter pylori infection was present in 95.5%, and 54.5% had prior balloon dilatation. Conversion occurred in 27.3%, stump leakage in 13.6%, and 30-day mortality in 9.1%. Occult carcinoma was identified in 4.5%. Duodenal wall thickening was significantly associated with conversion ( P < 0.001), major complications ( P = 0.002), and stump leakage ( P = 0.036). All survivors had durable symptom resolution. Conclusion In clinically benign GOO, intraoperative duodenal wall thickening is a clinically actionable marker associated with increased surgical complexity, morbidity, and possible occult malignancy, supporting its role in guiding intraoperative decision-making, including conversion, operative caution, and selection between resection and non-resectional strategies.