OBJECTIVES:Esophageal anastomotic stricture is a common complication following esophageal atresia (EA) repair. While multiple endoscopic therapies exist, predicting individual stricture response remains challenging. Existing classification systems focus primarily on luminal diameter and do not account for complex physical characteristics of the stricture. We developed and evaluated a novel endoscopic scoring tool, stricture classification of pediatric esophageal strictures (SCOPES), to determine if physical features are predictive of treatment response. In addition to its predictive utility, SCOPES aims to standardize the description of and improve communication of stricture morphology across providers and institutions. METHODS:A retrospective cohort study was conducted on EA patients treated at a tertiary referral center between 2019 and 2024. Patients with ≥2 endoscopies and documented SCOPES scores were included. The SCOPES tool categorizes strictures based on diameter, length, scar band intrusion, symmetry, and presence of diverticula. Multivariable mixed-effects regression models were used to analyze associations between SCOPES characteristics and the primary outcome of number of therapeutic endoscopies within 6 months. RESULTS:Seventy patients (238 endoscopies) met inclusion criteria. In multivariable analysis, symmetric strictures and those with highly intrusive scar bands were significantly associated with a greater number of therapeutic endoscopies within 6 months. Two complications were observed, both managed without long-term sequelae. CONCLUSIONS:The SCOPES classification tool identifies physical stricture features that significantly influence response to endoscopic therapy. Circumferential symmetry and scar tissue protuberance were associated with higher treatment burden, suggesting these characteristics may guide therapeutic decision-making. SCOPES may aid in individualizing endoscopic management of pediatric esophageal strictures and warrants prospective validation.

PURPOSE:Esophageal leaks in children are associated with significant morbidity. While they are traditionally managed with prolonged fasting and drains, endoluminal vacuum-assisted closure (EVAC) is a minimally invasive alternative. We evaluated outcomes and factors associated with EVAC success. METHODS:Retrospective single-center review of pediatric patients treated with EVAC for esophageal leaks (2019-2025). Leak episodes were analyzed independently. Data included leak characteristics, timing of EVAC initiation, procedural details, and outcomes. The primary outcome was leak resolution without surgery. RESULTS:Thirty-eight children with 40 leak events were included. Median age was 1.5 years (IQR 0.6-2.5). Etiologies included postsurgical (53%), endoscopic (45%), and perforation due to foreign body ingestion (2.5%); 78% were contained leaks. EVAC achieved leak resolution without surgery in 83% of cases (94% endoscopic vs 71% surgical). Median time to closure was 11 days (IQR 6-16). Median number of EVAC exchanges was 2 (IQR 1-3). During EVAC therapy, most patients maintained enteral post-pyloric feeding (65%), and drains were only required in 26%. No EVAC-related adverse events occurred. Strictures requiring surgery developed in 31%. CONCLUSION:EVAC is an effective treatment strategy for pediatric esophageal leaks, with high rates of leak resolution without surgery. Many patients were managed without pleural drainage while maintaining enteral nutrition, supporting EVAC as an active treatment option for selected pediatric esophageal leaks.

Acute food bolus impaction is frequently encountered in pediatric patients with underlying esophageal conditions. Traditional endoscopic methods for removing friable boluses, such as meat, are often time-intensive and challenging. This report explores the novel application of cryoadhesion, or freezing and adhering an object to a cryoprobe, for esophageal meat bolus extraction. A 25-year-old man with trisomy 21 and eosinophilic esophagitis presented with acute food bolus impaction. After unsuccessful conventional endoscopic maneuvers, a cryoprobe was externally attached to an endoscope and used to achieve cryoadhesion and extraction of the meat bolus. Within 10 minutes, the meat bolus was successfully removed attached to the cryoprobe without mucosal injury. The patient tolerated the procedure well and was discharged the next day without adverse events. Cryoadhesion via a flexible cryoprobe may offer a feasible alternative for removing challenging food impactions. Further investigation is warranted to evaluate its safety and efficacy.

Background and Aims:This case details an 8-year-old female patient with a type C tracheoesophageal fistula and esophageal atresia who developed a symptomatic diverticulum proximal to an anastomotic scar band. This patient underwent diverticular-peroral endoscopic tunneling stricturotomy (D-POETS), a novel procedure for management of symptomatic postoperative diverticula refractory to incisional therapy and balloon dilation. Methods:Before the D-POETS procedure, an intraoperative esophagram showed an anastomotic diameter of 18 mm and a proximal diverticulum extending 1 cm below the anastomotic scar band. A mucosal bleb was formed 3 cm proximal to the diverticulum using a methylene blue and saline solution. A mucosotomy was created for submucosal hydrodissection and tunneling using a Hybrid T-type knife (Erbe, Tübingen, Germany). As the endoscope approached the scar band, the easily dissectible submucosal connective tissue transitioned to disorganized scar fibers and a difficult dissection plane. Results:At its conclusion, the tunnel length measured 3.5 cm and extended 5 mm distal to the scar band. After the stricturotomy, the scar band had an improved diameter (21 mm) with improved esophageal contour. At 8 months postoperatively, the patient's solid food dysphagia remained resolved. Conclusions:To our knowledge, the D-POETS technique is the first reported use of endoscopic third-space submucosal tunneling for stricturotomy of an anastomotic diverticulum.

Background: Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery.Materials and methods: This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher's exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay.Results: Twenty children, median age 2 years (IQR 1-11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (+/- SD) scores decreasing (improvement in symptoms) from 19.9 (+/- 9.3) to 2.4 (+/- 2.5) p = 0.001, and 8.7 (+/- 4.7) to 2.8 (+/- 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1).Conclusion: Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.

OBJECTIVES:In pediatric patients with intestinal failure (IF) due to short bowel syndrome (SBS), we hypothesized that young children, those with shorter residual small bowel and those with congenital malrotation of the bowel would be more likely to undergo pan-enteroscopy. We aimed to determine the feasibility and diagnostic yield of pan-enteroscopy in this cohort. METHODS:We performed a single-center, retrospective study of pediatric patients with IF due to SBS who had undergone at least one GI endoscopic evaluation between January 1, 2018 and January 1, 2023. RESULTS:A pan-enteroscopy might have been possible in 381 of the 431 procedures (206 patients) reviewed. Forty-four (21%) patients underwent 54 pan-enteroscopies. Children with a residual bowel length <35 cm had higher odds of undergoing pan-enteroscopy (odds ratio [OR] 3.72, 95% confidence interval [CI] [1.32, 10.48], p = 0.01), as did patients with periprocedural glucagon-like peptide 2 (GLP-2) analog use (OR 4.30, 95% CI [1.24, 14.95], p = 0.02). Patients with diagnoses other than necrotizing enterocolitis (NEC) tended to be more likely to achieve a pan-enteroscopy (OR 2.73, 95% CI [0.95,7.88], p = 0.06). Evidence of gross and histopathologic abnormalities were found in 77.8% and 78% of the procedures, respectively. No complications were identified. CONCLUSION:In a large cohort of children with SBS, pan-enteroscopy was successfully performed in 14.2% of the procedures and microscopic abnormalities were common. Shorter residual bowel length, underlying diagnoses of non-NEC, and GLP-2 analog use were generally associated with successful pan-enteroscopy, independent of age and several other factors. These data suggest that pan-enteroscopy is feasible and of high-yield in a subset of patients with SBS.

Diagnostic and therapeutic endoscopic procedures in children are fundamental to the subspecialty of pediatric gastroenterology. This review highlights significant advancements and trends in pediatric endoscopy, emphasizing the transformative impact of technological innovations in the field. The advent of ultra-thin endoscopes and the development of minimally-invasive techniques have markedly enhanced both diagnostic and therapeutic capabilities, leading to safer and more effective procedures for pediatric patients. Key advancements include transnasal endoscopy, endoscopic ultrasound, and per-oral endoscopic myotomy.

Background: The management of neonates with long-gap esophageal atresia (LGEA) combined with distal congenital esophageal strictures (CES) is challenging. We sought to review our approach for this rare set of anomalies. Methods: We reviewed children with LGEA + CES surgically treated at two institutions (2018-2024). LGEA repair was performed using the Foker technique (traction-induced esophageal lengthening). A CES strategy was chosen based on preoperative evaluations and intraoperative findings. The configuration and length of the CES were assessed using retrograde flexible esophagoscopy via gastrostomy with contrast fluoroscopy. Results: Eight patients (75% male) with LGEA + CES were treated: Four had type A and four had type B EA. Median gap length was 3.5 cm. Three underwent thoracoscopic esophageal lengthening. After a median follow-up of 18 months (IQR: 9-25), all retained their native esophagus. However, those who had CES resection concurrent with the lengthening process or at the time of EA anastomosis had more challenging perioperative courses: one required additional time on traction and another required esophageal anastomotic stricture resection. Conclusions: Our experience with LGEA and distal CES emphasizes tailoring surgical approaches to each patient's unique condition, avoiding a one-size-fits-all strategy. However, if the esophageal tissue above the distal CES is in good condition, our preference has shifted towards retaining the CES during traction, performing gentle dilation at anastomosis time, and conducting definitive endoscopic management subsequently. We would caution against making the assumption that salvage of the native esophagus is not possible or that resection of the CES is always needed. Level of Evidence: Level III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Individuals with esophageal atresia (EA) have lifelong increased risk for mucosal and structural pathology of the esophagus. The use of surveillance endoscopy to detect clinically meaningful pathology has been underexplored in pediatric EA. We hypothesized that surveillance endoscopy in pediatric EA has high clinical yield, even in the absence of symptoms.STUDY DESIGN:The medical records of all patients with EA who underwent at least 1 surveillance endoscopy between March 2004 and March 2023 at an international EA referral center were retrospectively reviewed. The primary outcomes were endoscopic identification of pathology leading to an escalation in medical, endoscopic, or surgical management. Logistic regression analysis examined predictors of actionable findings. Nelson-Aalen analysis estimated optimal endoscopic surveillance intervals.RESULTS:Five hundred forty-six children with EA underwent 1,473 surveillance endoscopies spanning 3,687 person-years of follow-up time. A total of 770 endoscopies (52.2%) in 394 unique patients (72.2%) had actionable pathology. Esophagitis leading to escalation of therapy was the most frequently encountered finding (484 endoscopies, 32.9%), with most esophagitis attributed to acid reflux. Barrett's esophagus (intestinal metaplasia) was identified in 7 unique patients (1.3%) at a median age of 11.3 years. No dysplastic lesions were identified. Actionable findings leading to surgical intervention were found in 55 children (30 refractory reflux and 25 tracheoesophageal fistulas). Significant predictors of actionable pathology included increasing age, long gap atresia, and hiatal hernia. Symptoms were not predictive of actionable findings, except dysphagia, which was associated with stricture. Nelson-Aalen analysis predicted occurrence of an actionable finding every 5 years.CONCLUSIONS:Surveillance endoscopy uncovers high rates of actionable pathology even in asymptomatic children with EA. Based on the findings of the current study, a pediatric EA surveillance endoscopy algorithm is proposed.

Purpose: The purpose of this study was to analyze the management and outcomes of primary button battery ingestions and their sequelae at a single high-volume center, and to propose a risk score to predict the likelihood of a severe outcome. Methods: The medical record was queried for all patients under 21 years old evaluated at our institution for button battery ingestion from 2008 to 2021. A severe outcome was defined as having at least one of the following: deep/circumferential mucosal erosion, perforation, mediastinitis, vascular or airway injury/fistula, or development of esophageal stricture. From a selection of clinically relevant factors, logistic regression determined predictors of a severe outcome, which were incorporated into a risk model. Results: 143 patients evaluated for button battery ingestion were analyzed. 24 (17%) had a severe outcome. The independent predictors of a severe outcome in multivariate analysis were location of battery in the esophagus on imaging (96%), battery size >/ 1/4 2 cm (95%), and presence of any symptoms on presentation (96%), with P < 0.001 in all cases. Predicted probability of a severe outcome ranged from 88% when all three risk factors were observed, to 0.3% when none were present. Conclusion: We report the presentation, management, and complication profiles of a large cohort of BB ingestions treated at a single institution. A risk score to predict severe outcomes may be used by pro-viders initially evaluating patients with button battery ingestion in order to allocate resources and expedite transfer to a center with pediatric endoscopic and surgical capabilities. Level of evidence: Level IV. Type of study: Clinical Research Paper.(c) 2022 Elsevier Inc. All rights reserved.

Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.

Harvard Medical School, USA; The Children's Hospital of Philadelphia, USA; Johns Hopkins All Children's Hospital, USA; Boston Children's Hospital, USA.

Background: 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.Methods: 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.Results: 139 patients (median age: 12 months, range 1.5 months-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 followup 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.Conclusions: 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 of Evidence: Level III.(c) 2023 Elsevier Inc. All rights reserved.

Background: Left-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheo-bronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process.Methods: We retrospectively reviewed patients who underwent Foker process for LGEA at two in-stitutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed. Results: 71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2-8) operations and median 13.5 (IQR 11-21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5-31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0-13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement. Conclusions: For multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch. Level of evidence: Level IV Treatment Study.(c) 2022 Elsevier Inc. All rights reserved.

Background:Estimation of the dimensions of endoscopic findings such as stricture diameter is largely subjective. Accurate assessment of stricture dimensions has multiple benefits including facilitating the choice of appropriately sized endoscopic therapies for treating stricture, properly tracking response to endoscopic therapies between procedures, and potentially even predicting outcomes of endoscopic therapy. Methods:Endoscopies performed in children with repaired esophageal atresia between August 2019 and August 2021 for which both (1) an endoscopic estimate of esophageal stricture diameter obtained by visual comparison with the known dimensions of the biopsy forceps and (2) an intraoperative esophageal fluoroscopy study were performed were included for analysis. Fluoroscopic stricture diameter measurements were manually obtained using a software ruler tool calibrated to the known dimensions of the intraluminal endoscope. Statistical concordance was calculated between the visual diameter estimates and the standard fluoroscopic stricture measurements. Results:One hundred ninety-one endoscopies were included for analysis. Lin's concordance correlation coefficient was 0.92 (95% confidence interval: 0.89-0.94) between the visual diameter estimates and the fluoroscopic stricture measurements. Correlation was strongest for smaller to mid-sized stricture diameters. Conclusions:Use of the biopsy forceps as a visual reference of known dimensions enables accurate visual estimation of esophageal stricture diameter during endoscopy using commonly available tools, with high concordance with standard fluoroscopic measurement techniques.

Background: Indocyanine green (ICG) is commonly used to assess perfusion, but quality defining features are lacking. We sought to establish qualitative features of esophageal ICG perfusion assessments, and develop an esophageal anastomotic scorecard to risk-stratify anastomotic outcomes. Methods: Single institution, retrospective analysis of children with an intraoperative ICG perfusion as-sessment of an esophageal anastomosis. Qualitative perfusion features were defined and a perfusion score developed. Associations between perfusion and clinical features with poor anastomotic outcomes (PAO, leak or refractory stricture) were evaluated with logistic and time-to-event analyses. Combining signifi-cant features, we developed and tested an esophageal anastomotic scorecard to stratify PAO risk. Results: From 2019 to 2021, 53 children (median age 7.4 months) underwent 55 esophageal anasto-moses. Median (IQR) follow-up was 14 (10-19.9) months; mean (SD) perfusion score was 13.2 (3.4). Fif-teen (27.3%) anastomoses experienced a PAO and had significantly lower mean perfusion scores (11.3 (3.3) vs 14.0 (3.2), p = 0.007). Unique ICG perfusion features, severe tension, and primary or rescue traction-induced esophageal lengthening [Foker] procedures were significantly associated with PAO on both lo-gistic and Cox regression. The scorecard (range 0-7) included any Foker ( + 2), severe tension ( + 1), no arborization on either segment ( + 1), suture line hypoperfusion > twice expected width ( + 2), and seg-mental or global areas of hypoperfusion ( + 1). A scorecard cut-off >3 yielded a sensitivity of 73% and specificity of 93% (AUC 0.878 [95%CI 0.777 to 0.978]) in identifying a PAO. Conclusions: A scoring system comprised of qualitative ICG perfusion features, tissue quality, and anasto-motic tension can help risk-stratify esophageal anastomotic outcomes accurately. Levels of Evidence: Diagnostic -II & COPY; 2022 Elsevier Inc. All rights reserved.

ABSTRACT Background and Aims: Anastomotic strictures following surgical repair is one of the most common complications in esophageal atresia (EA). The utility of esophageal stenting to treat anastomotic esophageal strictures in pediatrics is unclear. Our primary aim was to evaluate whether esophageal stenting, in conjunction with dilation and other endoscopic therapies, prevented surgical stricture resection (SR). Our secondary aims were to evaluate predictors of successful esophageal stenting and evaluate adverse events from stent placement. Methods: A retrospective review of pediatric patients with EA complicated by esophageal strictures was performed. The change in stricture diameter in millimeters from the time of stent removal to subsequent endoscopy was defined as delta diameter (Δ D ). A receiver operating characteristic (ROC) curve analysis was performed to determine the discriminatory ability of Δ D . Youden J index was used to identify optimal cutoff‐point in predicting stent success. A univariate and multivariate analysis were done to assess predictors of success. Result: Forty‐nine esophageal anastomoses were stented to treat esophageal strictures. Stents prevented SR in 41% of patients. ROC curve analysis utilizing Youden J index identified Δ D of ⩽4 mm (area under the curve = 0.790; 95% confidence interval: 0.655–0.924; P < 0.001) as the optimal cutoff point in differentiating stent success. The most common adverse events were erosions/ulcerations, granulation tissue formation, and vomiting/retching. Conclusion: Stent therapy in preventing SR at the site of EA repair was successful in 41% in our population with good long term follow‐up. The most significant predictor of success in this study was the change in luminal diameter (⩽4 mm) at initial poststent follow‐up.