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Stricture Management: Interventional Options

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The SAGES Manual Operating Through the Endoscope

Abstract

Anastomotic stricturing is a reported complication post-gastrointestinal surgery and is associated with significant patient morbidity depending on the location of the lesion.

Anastomotic diseases can be classified based on location. Esophageal anastomotic strictures, usually after an esophagectomy, are common with an incidence between 5 and 48%. These strictures are best treated with mechanical esophageal dilation with either rigid or balloon dilators. The main rigid dilators consist of the Maloney (Medovations, USA), Hurst (Medovations, USA), and the Savary-Gilliard (Wilson-Cook, USA) variety. The other primary option, based mostly on preference, is the balloon dilator. Endolumenal stents, both self-expanding metal and plastic, are becoming more common and are being trialed as primary therapy for benign disease, rather than just palliative intervention for malignancy. Other treatment modalities, mainly applied as adjunctive procedures, include triamcinolone acetonide injections to decrease the inflammatory response and electrosurgical needle-knife division of tissue. Gastric anastomotic strictures usually occur after bariatric surgery at the site of the gastrojejunostomy, with an incidence of 0.6–27%. Balloon dilation is the most common treatment modality with efficacy rates reaching 100%, depending on time to intervention and anatomic configuration. Endolumenal stents and Savary-Gilliard dilators have also been used for gastric strictures. Colorectal anastomotic strictures are associated with low anterior resection and sigmoidectomy, with an incidence between 3 and 30%. The mainstay of therapy remains endoscopic balloon dilation. Through-the-scope balloon dilation has medium-term success rates of upwards of 86% for obstruction resolution, but is associated with high recurrence rates. For colorectal strictures, it appears that the size of the dilator is the most important factor for recurrence, and therefore larger diameters are favored. Small case series have described a double balloon approach, as well as adjuncts including argon plasma coagulation. For failures of balloon dilation, endoscopic transanal resection, endoscopic stricturoplasty with needle knife and stenting have been reported.

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Authors and Affiliations

  1. Division of General Surgery, University of Alberta Hospital, Edmonton, AB, Canada

    Jerry Dang

  2. Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA

    Noah Jacob Switzer & Shahzeer Karmali

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  1. Jerry Dang
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  2. Noah Jacob Switzer
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  3. Shahzeer Karmali
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Correspondence to Jerry Dang .

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Editors and Affiliations

  1. Digestive Disease Inst, A100, Cleveland Clinic, Cleveland, OH, USA

    Matthew Kroh

  2. Department of Surgery, University of South Florida, Tampa, FL, USA

    Salvatore Docimo Jr.

  3. BariJuve Surgical, Hoffman Estates, IL, USA

    Sofiane El Djouzi

  4. Department of Surgery, University of Wisconsin Health, Madison, WI, USA

    Amber Shada

  5. Center for Advanced Surgery, The Oregon Clinic, Portland, OR, USA

    Kevin M. Reavis

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Dang, J., Switzer, N.J., Karmali, S. (2023). Stricture Management: Interventional Options. In: Kroh, M., Docimo Jr., S., El Djouzi, S., Shada, A., Reavis, K.M. (eds) The SAGES Manual Operating Through the Endoscope. Springer, Cham. https://doi.org/10.1007/978-3-031-21044-0_8

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