Management of Esophagogastrointestinal Anastomosis Complications

Anastomotic Stricture Management

The European Society of Gastrointestinal Endoscopy recommends using steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) to reduce the frequency of repeat dilatations in anastomotic strictures refractory to initial dilatation approaches 1
Consider needle knife incision for anastomotic strictures as an alternative to dilatation, as recommended by the European Society of Gastrointestinal Endoscopy 1
Inform patients that chest pain after dilatation is common, according to the European Society of Gastrointestinal Endoscopy 1
Repeat dilatation if needed, as symptom response after dilatation usually lasts up to 1 year, as stated by the European Society of Gastrointestinal Endoscopy 1

Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory, as recommended by the European Society of Gastrointestinal Endoscopy 1
Consider treatment of concurrent delayed gastric emptying to reduce the need for redilatations, according to the European Society of Gastrointestinal Endoscopy 1

For completely obstructed esophagus, consider a combined anterograde and retrograde dilatation (CARD) or rendezvous approach under general anesthetic as an alternative to surgery, as recommended by the European Society of Gastrointestinal Endoscopy 1
Use fluoroscopic guidance to assist with rendezvous procedures, according to the European Society of Gastrointestinal Endoscopy 1
For refractory strictures, consider discussion with and/or referral to centers with expertise in treatment and follow-up, as stated by the European Society of Gastrointestinal Endoscopy 1

Consider the use of special techniques such as EndoFLIP and Balloon pull-through to judge the optimal caliber and position of dilatation, as recommended by the European Society of Gastrointestinal Endoscopy 1
After gaining luminal patency using the CARD procedure, perform subsequent dilatation using either balloon or bougie, according to the European Society of Gastrointestinal Endoscopy 1
For anastomotic strictures refractory to initial dilatation, administer steroid injections using a 4mm-long, 23-gauge needle immediately before bougie dilatation while leaving the needle in for at least 1 min to minimize leakage, as stated by the European Society of Gastrointestinal Endoscopy 1
Use fluoroscopic guidance during dilatation of refractory esophageal strictures, as recommended by the European Society of Gastrointestinal Endoscopy 1

Consider alternative neuromuscular causes in patients with ongoing dysphagia despite a seemingly adequate esophageal diameter, according to the European Society of Gastrointestinal Endoscopy 1
Perform upper GI endoscopy, manometry, pH studies, and barium swallow in patients with post-fundoplication dysphagia to understand the mechanism before dilatation or repeat surgery, as recommended by the European Society of Gastrointestinal Endoscopy 1