Discussion: stricture at the site of anastomosis is common and may require subsequent esophageal dilation.
The severity of complications after EA repair often is dictated by the extent of the repair required. Primary anastomosis and fistula closure has fewer complications than esophageal replacement. The length of the gap between the esophageal segments is directly related to possible complications; patients with longer gaps experience a higher complication rate. The most common complications include anastomotic leak, recurrent fistula, stricture,and gastroesophageal reflux (GER)
Anastomotic Esophageal strictures occur in 40% of children after surgical EA repair. Strictures result from natural healing and are caused by fibrosis, a difference in the sizes of the 2 anastomosed segments, tension, and GER. Leaks, as well as the use of a 2-layer anastomosis and/or silk sutures, enhance stricture formation. Strictures may be diagnosed with barium swallow examination or esophagoscopy. Although barium swallow studies aid in stricture reduction by dilating the anastomotic site, decreasing the size discrepancy between the 2 segments, and loosening the fibrosis of healing, they are not completely effective, and dilations are required for resolution. Dilation is 90% effective, but strictures that do not respond to dilation must be resected surgically.
leakage into the mediastinum occurs in 14-21% of children who have undergone surgical EA repair. Leaks can result from the small, friable lower segment, ischemia of the esophageal ends, excess anastomotic tension, sepsis, technically poor suturing techniques, and inaccurate mucosal apposition. Most leaks are small, occur later (after the first 48 h after surgery), and require only conservative management with cessation of oral intake (total parenteral nutrition [TPN]) and antibiotics. Spontaneous healing occurs in 95% of leaks when a mediastinal drain is present. More significant leaks occur early (within the first few days) and should be explored immediately. Major anastomotic disruptions occur in only 3-5% of leaks, but large leaks can be fatal and require surgical repair. Mediastinal leaks can lead to TEF recurrence; therefore, they should be monitored carefully.
Fistula recurrence between the esophagus and trachea is observed in 3-14% of patients treated for EA with TEF, EA without TEF, or H-type TEF. Fistulas usually recur within a few months, but they may recur as late as 2 years after surgery. An anastomotic leak with local inflammation and erosion at the previous repair site, ischemia, and surgical dissection too near the trachea may cause a recurrent fistula. This condition should be suspected when choking episodes occur during feeding and/or recurrent pneumonia is observed. The best methods of diagnosis are bronchoscopy and esophagography under videofluoroscopic guidance with the patient in the prone position and with bolus injections of contrast agent into a nasoesophageal tube. Fistulas do not close spontaneously and require surgical division and ligation. About 10-20% of cases recur after the first TEF recurrence.
Gastroesophageal reflux (GER) is a common complication, occurring in 40-70% of patients after EA repair. Symptoms of GER include coughing, apnea, recurrent pneumonia, failure to thrive, and stricture formation. A barium swallow examination may demonstrate GER, which is caused by tension, dysmotility of the lower esophagus, and an altered angle of Hiss resulting from distal esophageal mobilization. GER may be treated medically by keeping the patient in a prone head-up position after feeding; by thickening the food; and by giving smaller, more frequent meals. If problems persist, acid-reduction agents such as histamine H2 -receptor blockers and prokinetic agents may be administered. If medical therapy is unsuccessful, fundoplication may be considered. Fundoplications are required in about half of the patients with GER. GER tends to diminish with time, but long-term GER leads to mucosal changes such as esophagitis and Barrett esophagus
