Therapeutic Strategies for Postoperative Esophageal Anastomotic Stricture

Background Postoperative anastomotic stenosis (AS) can cause poor oral intake and aspiration, hinder postoperative recovery, and impair long-term quality of life. Its incidence is reported to be between 10% and 40%, making it an unavoidable complication for esophageal surgeons. This study aims to evaluate our department’s treatment for AS and propose a treatment strategy. Methods Among 175 patients who underwent McKeown esophagectomy with gastric tube reconstruction between January 2017 and December 2024, 57 patients who developed postoperative AS were included in this study. AS was defined as the inability to pass an endoscope with a tip diameter of 9 mm and the ability to swallow only semi-solid or liquid food. Refractory AS was defined as cases that did not improve after three or more endoscopic balloon dilations (EBD). Patient characteristics, treatments for AS, efficacy, complications, and outcomes were investigated. Results Among 57 patients with AS (median age 67, male:female 44:13), most had retrosternal reconstruction (53/57), and 23 had anastomotic leakage (AL). Refractory AS occurred in 34 patients, with 91.3% of AL cases developing it (p < 0.0001). Excluding two spontaneous recoveries, 55 underwent endoscopic balloon dilation (EBD), curing 40 (median 4 sessions). Triamcinolone local injection (TLI) was effective in 19 of 27 patients. Stents in 9 patients resulted in 5 migrations and 4 cures. Radial incision and cutting (RIC) cured 1 of 5 patients. Surgery cured 2 patients (one for bony stenosis, one post-EBD perforation). Conclusion The proposed treatment strategy for AS is as follows: ① When performing EBD, actively use TLI in combination if there is no delayed postoperative healing of the anastomosis, ② Do not perform RIC considering the results of JCOG1207, ③ Stent placement is effective in 44% of cases and is worth trying, ④ For bony stenosis at the thoracic inlet, proceed with reoperation without delaying medical treatment. Persistent EBD + TLI is the fundamental treatment for postoperative AS, but it is also important to appropriately decide when to transition to stent placement or reoperation.