Surgical Decision-Making for the Difficult to Manage Peptic Esophageal Stricture

Esophageal strictures are often managed with PPIs and endoscopic dilation, achieving favorable outcomes in most patients. However, some remain refractory to medical and endoscopic therapy, necessitating a rigorous diagnostic workup and individualized surgical planning. We describe a stepwise approach trying to ascertain the optimal surgical approach based on data. Additional evaluations require ruling out conditions such as medication-induced injury, Zollinger-Ellison syndrome, and CYP2C19 phenotype. Nutritional optimization and pharmacologic acid suppression are critical prior to definitive surgical intervention. Laparoscopic fundoplications are effective in patients with preserved motility and dilation-responsive strictures. Patients with esophageal shortening may require Collis gastroplasty. In refractory cases with poor motility or transmural fibrosis, esophagectomy with gastric, colonic or jejunal reconstruction is indicated. Segmental esophageal resection with jejunal interposition (Merendino procedure) is an alternative to preserve the gastric reservoir.