Abstract

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient’s age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Highlights

  • Since the original description of successful repair and primary anastomosis in 1943 [1] improved intensive care treatment, anesthetic techniques, and surgical techniques have dramatically raised survival rates in esophageal atresia (EA)

  • The pooled clinical success rate was 40.5% with no significant differences between patients treated with self-expandable plastic stents (SEPSs) and selfexpandable metal stents (SEMSs) ant those treated with biodegradable stents (BDSs)

  • Despite the efforts to identify possible pre, intra, and postoperative risk factors, incidence of Anastomotic strictures (ASs) does not seem to be changed over time

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Summary

Introduction

Since the original description of successful repair and primary anastomosis in 1943 [1] improved intensive care treatment, anesthetic techniques, and surgical techniques have dramatically raised survival rates in esophageal atresia (EA). Despite the identification of multiple risk factors for ASs, such as long-gap EA with consequent anastomotic tension, postoperative anastomotic leak, and gastroesophageal reflux disease (GERD) [3, 5–11], prevention strategies with intraoperative techniques and/or postoperative treatments have failed to decrease the incidence of ASs over time [12]. Traction and growth surgical techniques are considered a good system to induce esophageal growth and elongation, facilitating anastomosis with less tension [13]. The burden of ASs in the postoperative care of AE patients is still high and requires improvement of treatment strategies, especially for refractory and recurrent strictures

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