Endoscopic Management of Postsurgical Adverse Events

Endoscopic Management of Postsurgical Adverse Events

Amar Mandalia, MD

Allison R. Schulman, MD, MPH

Gastrointestinal surgery is commonly performed for a variety of indications in the upper and lower gastrointestinal (GI) tract. There are a number of unique adverse events that can develop in this patient population and are managed endoscopically. This chapter will focus on endoscopic procedural considerations for common adverse events following surgery and will include a brief overview of the epidemiology, pathophysiology, and management of each adverse event.


Anastomotic ulceration, also known as marginal ulceration, is reported in up to 8.6% of patients who have undergone partial or total gastrectomy, 5% to 27% of patients with pancreaticoduodenectomy, 0.6% to 16% of patients who have undergone Roux-en-Y gastric bypass (RYGB), and 0.8% of patients following ileocectomy.1,2,3,4,5,6,7 These ulcerations occur at the resection margin of the intestinal wall. The mechanism of development is multifactorial, with a variety of proposed risk factors including but is not limited to ischemia and tension at the anastomosis, tissue irritants such as smoking, various medications, diabetes mellitus, and the presence of foreign material (such as staples or sutures). When symptoms occur, they include pain, obstruction, GI bleeding, perforation, or anemia. Diagnosis is made endoscopically by either upper endoscopy or colonoscopy, depending on location.



  • 1. Obtain informed consent which includes a detailed discussion with the patient about indications for the procedure and possible adverse events.

  • 2. The patient should be nil per os (NPO) for at least 4 to 6 hours prior to endoscopic evaluation; if a colonoscopy is planned, bowel preparation is required (see Chapter 3 for details).

  • 3. Patients with GI bleeding should be appropriately managed and adequately resuscitated prior to pursuing endoscopic evaluation.

Postprocedure Care

  • 1. Observe the patient for signs of bleeding, fever, and/or perforation. Pain medication may be indicated.

  • 2. Use acid-suppressing medication in open capsule or soluble form for upper GI anastomotic ulcers; consider use of liquid sucralfate.8

  • 3. Repeat the procedure in 8 to 12 weeks to evaluate for healing of the ulcer.

Adverse Events

  • 1. Cardiopulmonary: The most common adverse events during colonoscopic examinations are related to the cardiopulmonary system, with bradycardia, hypotension, and reactions to various sedation medications.

  • 2. Perforation: More serious adverse events such as perforation occur in <1% of examinations, but the risk is increased in the setting of a deep-cratered anastomotic ulceration and during therapeutic intervention. See Chapters 5 and 19 on upper endoscopy and colonoscopy for management.

  • 3. Rebleeding: See Chapters 35,36 and 37 on management of upper GI bleeding.

  • 4. Infection: Rare, see Chapters 5 and 19 on upper endoscopy and colonoscopy for more information.


Anastomotic luminal stenosis may form after esophagectomy (9.1% to 65.8%), partial or total gastrectomy (1.1% to 8.0%), pancreaticoduodenectomy, RYGB (2% to 23%), sleeve gastrectomy (0.1% to 3.9%), and colorectal surgery (0% to 30%).9,10,11,12,13,14,15,16,17,18 Anastomotic biliary strictures can occur after liver transplantation (14.2%) and are covered in detail in the Chapter 28.19 Etiologies of stricture formation include ischemia, anastomotic tension, inflammation, surgical technique, and recurrence of malignancy. Luminal strictures can present as obstructive symptoms and inability to tolerate meals. The strictures are typically benign but can also be due to a recurrence of malignancy at the anastomoses. Endoscopic management varies by location and by complexity of stricture. This subsection will outline the various endoscopic tools that can be used to treat anastomotic strictures and stenoses.

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May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Endoscopic Management of Postsurgical Adverse Events

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