Anastomotic Stricture

Anastomotic stricture is narrowing of the lumen at a surgical anastomosis in the gastrointestinal tract, which causes obstructive symptoms. It occurs weeks to months after surgery, and most commonly after esophageal, gastric, colorectal and bariatric operations.

Incidence by site

• Esophagogastric or esophagojejunal: 10 to 40%
• Colorectal: 3 to 10% (higher after low rectal anastomosis and radiotherapy)
• Gastrojejunal (after Roux-en-Y bypass): 3 to 20%
• Ileoanal pouch: 5 to 10%

Risk factors: anastomotic leak (strongest), ischemia, tension, small stapler size, radiotherapy, local sepsis, smoking, diabetes, malnutrition, gastroesophageal reflux (for the esophagus) and recurrence of the original disease (Crohn disease, cancer). The pathological process is exuberant scar formation (fibrosis) with chronic inflammation. A tumor recurrence must always be excluded. Complications: obstruction, aspiration, malnutrition, dehydration, perforation during dilatation (1 to 2%) and recurrence after treatment (about 30 to 50%).

• Esophageal: progressive dysphagia (first solids then liquids), regurgitation, weight loss and aspiration
• Gastrojejunal: nausea, vomiting after meals and intolerance of solids
• Colorectal: constipation, narrow-caliber stool, tenesmus, abdominal distension and bleeding
• A time course of weeks to 6 months after surgery
• Red flags: complete obstruction, vomiting with dehydration, weight loss, bleeding and symptoms that suggest recurrence of cancer

1. Endoscopy is first-line: a narrowed anastomosis (for example under 10 mm for esophageal, under 15 mm for colorectal), with biopsy to exclude recurrent tumor or Crohn disease.
2. Water-soluble contrast study: a fixed narrowing with proximal dilatation, and a measure of its length and tortuosity. Barium may be used when there is no leak risk.
3. CT of the chest or abdomen with contrast: wall thickening, extraluminal collections and tumor recurrence.
4. Laboratory tests: full blood count, electrolytes, albumin and iron studies.

Differentials: recurrent cancer, adhesive obstruction, motility disorder, anastomotic leak with abscess, ulcer, Crohn disease recurrence.

1. Nutritional and acid control: omeprazole 40 mg orally once to twice daily for esophageal and gastrojejunal strictures (for 8 weeks and continued if reflux), and a soft diet with small frequent meals.
2. Endoscopic balloon dilatation (first-line):
   • Through-the-scope balloon dilatation, with sequential increase in diameter by 1 to 2 mm per session to a target of 15 to 18 mm (esophageal and colorectal) and 15 mm (gastrojejunal).
   • Repeat at 2 to 4 week intervals for up to 3 to 5 sessions, and stop when the patient is symptom free for 3 months.
   • Bougie dilatation is an alternative for esophageal strictures.
   • Perforation risk is about 1 to 2%, and recognized perforation is managed with clips, a stent or surgery.
3. Intralesional steroid: triamcinolone acetonide 40 mg/mL injected into 4 quadrants (10 mg per quadrant) before dilatation, repeated at each session, for refractory strictures.
4. Incisional therapy: electrocautery radial incisions for short, fibrotic strictures.
5. Self-expanding stent (fully covered metal or biodegradable) for refractory strictures, left in place for 4 to 8 weeks. Migration is common.
6. Surgery for refractory, long or complete strictures, or failed endoscopic treatment: revision of the anastomosis with resection of the stenotic segment and a new anastomosis, with a well-vascularized, tension-free technique. Cefazolin 2 g IV with metronidazole 500 mg IV as single doses before incision, and enoxaparin 40 mg SC once daily for 7 days.
7. Complications of treatment: perforation, bleeding, stent migration and recurrence.

Follow-up at 4 weeks, 3 months and 12 months. Counsel on dietary modification, smoking cessation and early return for dysphagia or vomiting.