Anastomotic Scar Tissue Terminology
The scar tissue that forms at the site of an anastomosis is called a cicatricial stricture or anastomotic stricture, characterized by intense fibrosis that develops during the healing process at the surgical connection site.
Terminology and Classification
Cicatricial strictures are specifically defined by their composition of thick, fibrous scar tissue that forms at anastomotic sites 1. These strictures are distinguished from other types of anastomotic narrowing by their characteristic intense fibrosis and unpredictable response to standard dilation therapy 1.
The World Journal of Emergency Surgery guidelines classify anastomotic strictures based on their mechanism of formation 1:
- Membranous strictures: Thin, easily treated with endoscopic balloon dilatation
- Cicatricial strictures: Characterized by intense fibrosis with unpredictable response to balloon dilation 1
- Granular strictures: Result from secondary intention healing or tissue necrosis 1
Pathophysiology
The formation of cicatricial tissue at anastomotic sites arises from several mechanisms 2:
- Ischemia at the anastomosis site due to compromised blood supply
- Anastomotic disruption during the healing process
- Leakage at the surgical connection, triggering excessive scar formation
- Chronic inflammation from conditions like marginal ulcers in gastrojejunal anastomoses 1
Clinical Significance
Cicatricial strictures require removal of scar tissue before definitive repair 1, 3. The key surgical principle is that anastomosis must be built upon healthy, non-ischemic, non-inflamed, and non-scarred tissue 4. When performing revision surgery, surgeons should remove the scar tissue from the bile duct or bowel stump after full exposure to ensure anastomosis with healthy tissue 3.
For colorectal anastomoses, cicatricial strictures manifest as tubular narrowing with thickened intestinal wall, often requiring specialized treatment beyond simple balloon dilation 5, 6. The strictures are resistant to standard dilation therapy and may require combination approaches including endoscopic incision of the scar tissue followed by balloon dilation 5.
Common Pitfall
A critical error is attempting to create an anastomosis without adequately excising the cicatricial tissue, which leads to high rates of re-stenosis and treatment failure 1, 3. Always ensure complete removal of fibrotic scar tissue and anastomose only to healthy, well-vascularized tissue with normal mucosa 4.