Systemic steroid application for treatment of edematous anastomotic stenosis following delta-shaped anastomosis in laparoscopic distal gastrectomy: a case report

Background Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation. Case presentation We present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment. Conclusion Systemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.


Background
Surgical resection is the mainstay treatment for gastric cancer. Billroth-I is considered a simple reconstruction procedure, as it requires only one anastomosis in distal gastrectomy. Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy (Additional file 1) [1].
Anastomotic stenosis is a well-known postoperative complication associated with delta-shaped anastomosis [2], and endoscopic balloon dilatation (EBD) is a major remedy for such a complication [3]. In case of unsuccessful EBD, additional surgical management is required, resulting in a great burden on patients undergoing the procedure. To date, a solid alternative therapy for such surgical procedures has not been established, necessitating the development of non-surgical treatments for anastomotic stenosis. Here, we present a case where systemic steroid application was effective in sustained anastomotic stenosis after EBD.

Case presentation
In March 2018, a 72-year-old man was referred to our department for surgical treatment of early-stage gastric cancer. Laparoscopic distal gastrectomy was performed by the Billroth-I producer using delta-shaped anastomosis. The posterior walls of both the stomach and the duodenum were joined using a 45-mm linear stapler in delta-shaped anastomosis. The enterotomy was closed with a 60-mm linear stapler. The patient consumed food and water between postoperative days 4 and 9. On postoperative day 9, the patient experienced left abdominal pain. Computed tomography (CT) scans revealed that the luminal continuity of the anastomotic part was wide enough for the passage of food (Fig. 1a). However, on postoperative day 19, an endoscopic investigation revealed anastomotic stenosis with severe edema (Fig. 1b,  c). Contrast-enhanced CT scans also revealed that the anastomotic part was narrower compared to that observed in previous CT scans (Fig. 1d). Fluoroscopy clearly showed the presence of anastomotic stenosis (Fig.  1e). EBD was performed with 10 mm, 12 mm, and 15 mm-balloons approximately every week to treat the anastomotic stenosis. The stenosis sustained even after the injection of steroids into the anastomosis section during the third EBD (Fig. 1f). Consequently, we started systemic steroid treatment on postoperative day 56. For the first 4 days, the steroid (prednisolone) was injected intravenously at a dose of 40 mg/day. Stenosis started to improve soon after the onset of steroid treatment (Fig. 2a). Hence, for the next 3 and 8 days, the systemic steroid treatment was continued at a lower dosage of 20 mg/day and 10 mg/day, respectively. Thereafter, we started oral administration of steroids (5 mg/day). Although oral steroid administration was temporally increased (10 mg/day for 3 weeks) due to reappearance of nausea, fluoroscopy on postoperative day 93 showed improvement of anastomotic stenosis (Fig. 2b). Steroid treatment was discontinued for 3 months after completion of systemic steroid treatment. Endoscopic analysis approximately 1 month after completion of systemic steroid treatment showed improvement in anastomotic stenosis. (Fig. 2c, d). A summary of the EBD and steroid treatments is shown in Fig. 3. No dietary restrictions were required for 6 months following the completion of systemic steroid treatment. Moreover, no adverse events were found to be associated with steroid treatment.

Discussion and conclusion
To the best of our knowledge, this case report is the first in PubMed to show that systemic steroid treatment could improve edematous anastomotic stenosis following gastrectomy with delta-shaped anastomosis. This  case report also showed that multi-dose administration of systemic steroids could improve stenosis after EBD.
A previous study showed that local steroid injection in combination with EBD was effective in treating stenosis after esophagectomy [4], and in our case, we adapted the same methodology to treat stenosis after gastrectomy. However, in our case, local steroid injection was not effective in treating edematous anastomotic stenosis. This could be due to the fact that the edema was severe and, consequently, it was impossible to inject sufficient levels of steroids. A previous study reported that systemic steroid application was more effective than local steroid injection in treating stenosis after large endoscopic submucosal dissection of the stomach [5]. Systemic steroid administration immediately improved edematous anastomotic stenosis in 6 patients reported from Japan [6][7][8].
We have summarized the details of these cases, including ours in Table 1. Based on this evidence, we hypothesized that systemic steroid administration could be effective in treating edematous anastomotic stenosis, and consequently, we used steroid therapy as a secondary option along with EBD. The stenosis started to improve soon after the onset of steroid treatment. Such an observation is in line with a previously published report that showed steroids can not only inhibit collagen synthesis, but also enhance collagen degradation, thereby inhibiting stenosis formation [9]. Such a mechanism could induce long-term benefits by expanding the stenotic part after the completion of systemic steroid treatment.
The edematous stenosis could have resulted from several factors such as tension created during anastomosis, local tissue ischemia, subclinical leakage, injury from acid exposure, and submucosal hematoma created during suturing [10]. In the present case, endoscopic and CT investigations showed that the main cause of anastomotic stenosis was not structural (such as the small lumen or twists in the anastomotic part) but primarily the formation of edema. While the mechanism of the observed edematous change remained unclear, the improvement of the edema was important in treating stenosis in this case. Based on these conditions, systemic steroid treatment could be safer with a more immediate effect than surgical re-approach. In this case, the extremely edematous remnant stomach increased the risk of re-anastomotic stenosis or leakage in gastrojejunostomy. Moreover, in the rhinoplasty, a meta-analysis concluded that multi-dose steroid administration was more effective in reducing edema than single-dose steroid application [11,12]. Previous Japanese case reports have also mentioned the use of multi-dose steroid therapy in all cases (Table 1). Although even a single-dose of steroids may reduce edema compared with controls (no steroid administration), we employed multi-dose steroid therapy in the present case based on previous evidence.
However, several issues need to be considered. First, it should be noted that multi-dose steroid administration could lead to adverse events [13]. As such, the dosage of steroids should be as low as possible to prevent such events. Fortunately, in our case, we did not observe any side effects of steroid therapy. Second, it is necessary to have experience regarding single-dose steroid administration for anastomotic stenosis. Based on these issues, further studies are required with a large number of cases to determine the adequate dosages and time-periods for systemic steroid application to treat anastomotic stenosis. Third, although the prediction of anastomotic strictures is difficult, we may need to consider the earlier use of steroids to prevent worsening of anastomotic stenosis before EBD.
In conclusion, anastomotic stenosis is one of the postoperative complications associated with delta-shaped anastomosis in gastrectomy. Systemic steroid application could be useful in treating edematous anastomotic stenosis.