Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Renato Tambucci, Giulia Angelino, Paola De Angelis, Filippo Torroni, Tamara Caldaro, Valerio Balassone, Anna Chiara Contini, Erminia Romeo, Francesca Rea, Simona Faraci, Giovanni Federici di Abriola, Luigi Dall'Oglio, Renato Tambucci, Giulia Angelino, Paola De Angelis, Filippo Torroni, Tamara Caldaro, Valerio Balassone, Anna Chiara Contini, Erminia Romeo, Francesca Rea, Simona Faraci, Giovanni Federici di Abriola, Luigi Dall'Oglio

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.

Keywords: adjuvant treatments; anastomotic strictures; balloon dilators; bougie dilators; esophageal atresia; esophageal dilation; esophageal stenting; refractory and recurrent strictures.

Figures

Figure 1
Figure 1
Simplified algorithm for diagnosis and treatment of anastomotic strictures (ASs) after esophageal atresia (EA) repair. 1Symptoms suggestive of AS depend upon the age of the child and the type of food ingested (liquid or solid) and include feeding and swallowing difficulties, regurgitation and vomiting, mucus or food impaction, cough, drooling, recurrent respiratory infections, foreign body impaction, and poor weight gain. In EA patients, these symptoms may overlap with other pathologic conditions, and none of them alone is sensitive or specific enough to diagnose an AS (14). 2Other diagnosis includes esophageal dysmotility, recurrent tracheoesophageal fistula, gastroesophageal reflux disease, tracheomalacia, laryngeal clefts, and vocal cord dysfunction; these conditions may coexist and exacerbate AS symptoms. Patients with EA should be evaluated regularly by a multidisciplinary team (14). 3EA children in the first 2 years of life (with special attention during the introduction of solid food) and patients with long-gap EA and postoperative anastomotic leak need a closer follow-up (14). 4Recurrent AS: ≥3 episodes of clinically relevant stricture relapses after dilations (14) or inability to maintain a satisfactory luminal diameter for 4 weeks once the age-appropriate feeding diameter has been achieved (20). Refractory AS: inability to successfully remediate the anatomic problem to obtain age-appropriate feeding possibilities after a maximum of five dilation sessions (refractory) with maximal 4-week intervals (20). 5Potential adjuvant treatments may include intralesional and/or systemic steroids, topical application of mitomycin C (MMC), stents, and an endoscopic incisional therapy (14). Temporary stent placement or application of topical MMC following dilation is suggested as a first-line adjunctive treatment in children (20).

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