From the Research
Ulcers at the esophagojejunostomy anastomosis should be treated with a combination of proton pump inhibitors (PPIs) and mucosal protective agents, prioritizing high-dose PPI therapy and sucralfate suspension for 8-12 weeks, as supported by the most recent evidence 1. The treatment approach should focus on reducing acid reflux, bile reflux, and ischemia at the surgical site, while also addressing potential complications such as malignancy or other conditions that may have arisen from gastric surgery for cancer. Key considerations in managing these ulcers include:
- Starting with high-dose PPI therapy, such as omeprazole 40mg twice daily or pantoprazole 40mg twice daily, for 8-12 weeks 2.
- Adding sucralfate suspension 1g four times daily, taken at least 30 minutes before meals and at bedtime, to provide direct mucosal protection.
- Endoscopic evaluation to rule out malignancy or other complications, especially in patients with a history of gastric surgery for cancer.
- For refractory ulcers, considering the addition of misoprostol 200mcg four times daily with meals and at bedtime.
- Implementing supportive measures such as smoking cessation, avoiding NSAIDs, limiting alcohol consumption, and providing nutritional support with a soft diet and small, frequent meals to reduce mechanical trauma to the anastomosis. If medical therapy fails after 8-12 weeks, endoscopic interventions like argon plasma coagulation or hemostatic clips may be necessary, particularly for bleeding ulcers, as indicated by studies on anastomotic leakage and its management 3, 4. Surgical revision is typically reserved for severe, refractory cases with significant complications, emphasizing the importance of a multidisciplinary approach in the management of ulcers at the esophagojejunostomy anastomosis 5, 1.