What are the recommendations for Esophagogastrointestinal (EEA) anastomosis?

Recommendations for Esophagogastrointestinal (EEA) Anastomosis

Triangular linear stapling (TLS) with 60-mm staplers is strongly recommended for esophagogastrointestinal anastomosis as it significantly reduces stricture rates compared to other techniques. 1

Anastomotic Technique Selection

• TLS with 60-mm staplers demonstrates the lowest stricture rate (3.2%) compared to manual sewing (22.2%), circular stapling (14.5%), and hybrid linear stapling (16.1%) 1
• When TLS is not available, the CDH circular stapler shows better outcomes with lower leakage rates than the EEA stapler 2
• For intrathoracic anastomosis between upper esophagus and gastric tube, proper technical procedures must be followed when using EEA staplers to ensure safety 3

Risk Factors for Anastomotic Complications

• Chronic obstructive pulmonary disease significantly increases risk of stricture formation (HR 1.726) 1
• Anastomotic leakage is a major risk factor for subsequent stricture development (HR 2.502) 1
• Smaller diameter staplers (25-29mm) are associated with significantly higher stricture rates compared to larger diameter staplers (30-33mm) 4

Management of Anastomotic Complications

Strictures

• Use 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 5
• Consider needle knife incision for anastomotic strictures as an alternative to dilatation 5
• Inform patients that chest pain after dilatation is common 5
• Repeat dilatation if needed, as symptom response after dilatation usually lasts up to 1 year 5

Leakage

• Minor anastomotic leakage can be managed with total parenteral nutrition for approximately 2 weeks 3
• Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory 5
• Consider treatment of concurrent delayed gastric emptying to reduce the need for redilatations 5

Special Considerations

• For completely obstructed esophagus, consider a combined anterograde and retrograde dilatation (CARD) or rendezvous approach under general anesthetic as an alternative to surgery 5
• Use fluoroscopic guidance to assist with rendezvous procedures 5
• For refractory strictures, consider discussion with and/or referral to centers with expertise in treatment and follow-up 5

Technical Recommendations

• Consider the use of special techniques such as EndoFLIP and Balloon pull-through to judge the optimal caliber and position of dilatation 5
• After gaining luminal patency using the CARD procedure, perform subsequent dilatation using either balloon or bougie 5
• 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 5
• Use fluoroscopic guidance during dilatation of refractory esophageal strictures 5

Pitfalls to Avoid

• Avoid using smaller diameter staplers (25-29mm) when possible, as they significantly increase stricture risk 4
• Consider alternative neuromuscular causes in patients with ongoing dysphagia despite a seemingly adequate esophageal diameter 5
• 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 5
• Be aware that while stapling techniques reduce leakage rates, they may be associated with higher stricture rates, particularly with smaller stapler sizes 6