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.
DIAGNOSIS AND ENDOSCOPIC MANAGEMENT
1. High clinical suspicion of the presence of an anastomotic ulcer
2. Overt GI bleeding
3. Unexplained anemia
1. See Chapters 5 and 19 for esophagogastroduodenoscopy and colonoscopy for contraindications
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.
1. Upper GI tract surgery: use of either a single- or double-channel upper endoscope; if significant bleeding is suspected/encountered, should preferentially use a wide single-channel or a two-channel therapeutic upper endoscope to enhance aspiration.
2. Lower GI tract surgery: use of a colonoscope (see colonoscopy Chapter 19).
3. Use of CO2 insufflation.
4. Ancillary equipment for hemostasis such as epinephrine 1:10,000, hemostatic clips, bipolar cautery, or argon plasma coagulation.
5. Ancillary equipment for foreign material removal such as forceps, endoscopic scissors, or loop cutters.
1. Perform a complete examination of the upper and/or lower GI tract to exclude other causes of pain, anemia, or obstruction; if an anastomotic ulceration is encountered, do not pass beyond it as this can increase the risk of perforation.
2. Identify the location of the anastomotic ulcer and examine the ulcer for bleeding or stigmata of recent bleeding such as a visible vessel or pigmented red spot; if present, treat accordingly with injection and/or hemostatic clipping and/or cautery (see Chapters 35,36 and 37 on management of upper GI bleeding).
3. If no active bleeding or high-risk stigmata or recent bleeding, examine the area for foreign bodies such as staples or sutures. If present, use forceps to remove staples and sutures, and consider use of endoscopic scissors or loop cutters for refractory material.
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.
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.