Surgical Treatment of Esophageal Anastomotic Stricture after Repair of Esophageal Atresia

• Published in: Journal of pediatric surgery 2023-12, Vol.58 (12), p.2375-2383
• Main Authors: Kamran, Ali, Smithers, Charles J., Izadi, Shawn N., Staffa, Steven J., Zurakowski, David, Demehri, Farokh R., Mohammed, Somala, Shieh, Hester F., Ngo, Peter D., Yasuda, Jessica, Manfredi, Michael A., Hamilton, Thomas E., Jennings, Russell W., Zendejas, Benjamin
• Format: Article
• Language: English
• Subjects: Anastomotic stricture; Esophageal anastomotic stricture; Esophageal atresia; Esophageal stricture; Stricture surgical repair
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/j.jpedsurg.2023.07.014

Anastomotic strictures (AS) after esophageal atresia (EA) repair are common. While most respond to endoscopic therapy, some become refractory and require surgical intervention, for which the outcomes are not well established. All EA children with AS who were treated surgically at two institutions (2011–2022) were retrospectively reviewed. Surgical repair was performed for those with AS that were either refractory to endoscopic therapy or clinically symptomatic and undergoing surgery for another indication. Anastomotic leak, need for repeat stricture resection, and esophageal replacement were considered poor outcomes. 139 patients (median age: 12 months, range 1.5 months to 20 years; median weight: 8.1 kg) underwent 148 anastomotic stricture repairs (100 refractory, 48 non-refractory) in the form of stricturoplasty (n=43), segmental stricture resection with primary anastomosis (n=96), or stricture resection with a delayed anastomosis after traction-induced lengthening (n=9). With a median follow-up of 38 months, most children (92%) preserved their esophagus, and the majority (83%) of stricture repairs were free of poor outcomes. Only one anastomotic leak occurred in a non-refractory stricture. Of the refractory stricture repairs (n=100), 10% developed a leak, 9% required repeat stricture resection, and 13% required esophageal replacement. On multivariable analysis, significant risk factors for any type of poor outcome included anastomotic leak, stricture length, hiatal hernia, and patient's weight. Surgery for refractory AS is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes. Level III. •Surgical treatment for refractory strictures can achieve a high rate of esophageal preservation; however, this carries an inherent but low risk of anastomotic leak, need for repeat stricture resection, or eventual esophageal replacement.•Children with co-existent refractory stricture and a hiatal hernia are at an increased risk of poor anastomotic outcomes.