Physiopathology and treatment of anastomotic ulcer: An emerging pathology?

Anastomotic ulcer in the upper gastrointestinal tract is a relatively infrequent lesion which generally occurs in gastrojejunal anastomosis. Different alterations have been involved in its pathogenesis, which likely remains multifactorial. Several risk factors have been identified, including NSAID use and smoking habit, while postoperative proton pump inhibitor therapy exerts a protective effect. Data on the potential role of H. pylori are still controversial, and further well-designed studies are needed. Improvement of surgical technique (absorbable suture, small pouch, reinforced stapler, etc.) could reduce the incidence of marginal ulcer. Novel therapies based on perianastomotic injection with different stimulating factors showed promising results in experimental models. The marginal ulcer may remain asymptomatic or cause different symptoms requiring a prompt upper endoscopy. Prolonged proton pump inhibitor therapy seems to be the best medical approach, and the ulcer healing need to be confirmed. Indeed, some patients may experience an ulcer complication (bleeding, perforation, and stenosis) requiring either an endoscopic or a surgical approach in selected cases.