Predicting need for step-up approach and recurrence in endoscopic management of anastomotic strictures after esophagectomy: results from a 10-year multicenter retrospective study

Background and aims Anastomotic stricture (AS) is a common late complication after esophagectomy. Evidence guiding endoscopic escalation ("step-up") and the risk of post-treatment recurrence remains limited. We assessed clinical, surgical, and procedural determinants of (i) need for step-up therapy and (ii) recurrence after initial endoscopic success. Methods We conducted a multicenter retrospective study at two tertiary centers in Milan (2014-2024). Adults with na & iuml;ve post-esophagectomy AS underwent standardized endoscopic management (bougie or pneumatic dilatation with predefined step-up options: incision therapy, stenting, steroid injection). Outcomes included technical (TS) and clinical success (CS), safety, rates of step-up and recurrence, and uni/multivariable predictors of change of strategy and recurrence. Results Among 1729 esophagectomies, 61 patients (3.5%) developed benign AS. Initial therapy was bougie in 54.1% and pneumatic in 45.9%. TS was achieved in 100% and CS in 93.4%. Safety was favorable (1/61, 1.6%). Overall, 39.3% required a change of strategy, typically early: the first switch occurred at a median of 35 days, and in 62.5% within 30 days, most often for failure to achieve a >= 2-mm lumen gain (66.7%). On multivariable analysis, higher BMI (OR 0.81 per 1 kg/m(2), p = 0.022) and baseline dysphagia < 2 (OR 0.13, p = 0.006) independently reduced the likelihood of step-up. Among patients with CS, recurrence occurred in 24.6% (14/57). In models restricted to surgical variables, stapled versus hand-sewn anastomosis was protective (OR 0.11, p = 0.022), whereas procedure type (McKeown vs Ivor-Lewis) and caliber <= 25 mm were not significant. Conclusions Endoscopic treatment of post-esophagectomy AS is highly effective and safe, yet step-up intervention is required in nearly 40% and recurrence occurs in one quarter of patients. Nutritional status and baseline dysphagia help identify patients at higher risk of escalation, while stapled anastomoses appear to reduce recurrence. These findings support a risk-adapted, personalized endoscopic strategy and warrant prospective validation.