Therapeutic Intervention in Pediatric Endoscopy: Management of Postsurgical Complications and Bleeding

Authors: André Hoerning, Guido Seitz, Dominique Schluckebier, Jan de Laffolie

Abstract

Background

Pediatric surgical complications and their endoscopic treatment approaches share a unique challenge of small anatomy, highly volatile situations and the need to be flexible with instruments which have been designed for older and bigger patients. In the last few decades, endoscopic interventions have emerged as a minimally invasive alternative approach to standard open closure procedures for the treatment of postsurgical complications.

Summary

This review summarizes the most common situations and techniques in pediatric endoscopy taking on postsurgical complications, including opportunities to improve outcome and overcome barriers of individualized therapy as compared to adult strategies.

Key Message

Endoscopic management of postsurgical complications is highly effective and associated with high success rates, low mortality, and minimal recurrence of the underlying pathology.

Introduction

Pediatric Surgery and Pediatric Gastroenterology have grown to face a different patient population in the early 2020s compared to 20 years ago. The share of patients with more complex diseases and multidisciplinary approaches has grown, while the techniques in surgery and endoscopy have also advanced over time [1].

Children are not a smaller version of adults. Pediatric surgical complications and their endoscopic treatment approaches share a unique challenge of small anatomy, highly volatile situations and the need to be flexible with instruments which have been designed for much bigger and older patients. Notably, technological improvements in endoscope design and endoscopic devices have contributed to the evolution and success of pediatric endoscopy.

This review summarizes the most common postoperative situations in the first part, followed by applicable endoscopic techniques, including opportunities to improve such. We demonstrate that endoscopic management of postsurgical complications is highly effective and associated with high success rates, low mortality, and minimal recurrence of the underlying pathology.

Main Text

Potential complications following surgical interventions include bleeding, leakage, dehiscent anastomosis or the development of strictures or stenosis of the GI tract and adherent structures. Therapeutic endoscopy is applicable to both the upper and lower GI tract and can be performed already in early infancy, starting with a body weight of 2.5 kg with technical restrictions certainly needing to be faced.

Technical Difficulties Faced by the Endoscopist in Children

Endoscopes and techniques that are used in adults can only be used in children with a body weight >10–15 kg. Standard gastroscopes for pediatric use have an outer diameter of 4.9–6.0 mm and a working channel of 2.0–2.2 mm. They can accommodate needles for injection therapy (4–6 mm length) and bipolar and argon plasma coagulation probes, but no ligation devices. It should be noted that the diameter, and thus, the size of the working channel, is the limiting factor in the choice of interventional hemostasis techniques, but also other procedures described below. In addition, banding devices or over the scope clips (OTSC^®^) are attached to the endoscope with an additional device and add to the outer diameter, severely limiting its use in small children.

Bleeding Complications

Before the decision between an endoscopic or a surgical approach is made, it is essential that the patient has been resuscitated and stabilized. The required material and staff resources need to be available, and a clear management strategy should be discussed. The principles and methods to treat upper GI bleeding is summarized in Table 1. The following description of procedures are expert opinions and can differ between centers.

Upper and Lower GI-Tract Bleeding

Upper GI bleeding can occur as complication following surgery, but also in the critically ill child due to gastritis or recurrent vomiting and esophagitis. Variceal bleeding in children with portal hypertension is among the most severe sources of upper GIT bleeding and can be lethal. Endoscopy is diagnostic and therapeutic, bleeding sources and available age-dependent tools for their management are summarized in Table 1 [1–3].

Depending on the initial risk assessment, endoscopy is recommended within the first 6–12 h (up to 24 h in shock situations). Hemodynamically unstable patients should be stabilized before endoscopy, including the administration of blood products (red blood cell and possibly platelet concentrates if <50/nL) and the correction of coagulopathy (FFP, PPSB) via large lumen venous accesses. Endoscopy in children is usually performed under general anesthesia with endotracheal intubation. It is also indicated in children with low-grade bleeding that is unexplained and persistent or recurrent.

Rubber-band ligation (banding device) is primarily used for variceal bleeding which does usually not occur as a complication of surgery, but ligation in case of bleeding or a preemptive therapy can be necessary in the postoperative phase in patients with significant predisposing disease (Fig. 1). Small bowel or colonic varices can occur in pediatric patients with multiple intestinal surgeries such as serial transverse enteroplasty (STEP) used primarily in the treatment of short bowel syndrome and can also be treated by banding devices. Alternatives are radiological embolization e.g., by implementing coils or injection techniques as described below.

Modern ligation devices allow to deploy 4–7 bands, they need to be mounted on an adult scope and add 2–3 mm to the outer diameter (suitable for children over 1 year or 10 kg). Recurrence of bleeding by detachment of the ligature can typically happen within the first 5–14 days, but also at other time points of the healing process.

Injection therapy with epinephrine 10,000 or 100,000 is often used as an acute option to clarify a situation and identify the source. The effects of mechanical tamponade and vasoconstriction last 10–15 min so it needs to be combined with other techniques (Fig. 2).

In addition, injection can be performed with sclerosants, e.g., synthetic (Sodium tetradecyl sulfate, 1% and 3%, Polidocanol, 0.5–3%), fatty acid derivatives (Ethanolamine oleate, 5%, Sodium morrhuate, 5%), alcohols (Ethanol 99.5%, Phenol 3%), sugars (Hypertonic 50% dextrose solution) or glues (histoacryl, N-butyl-2-cyanoacrylate) [1].

Histoacryl is a sterile tissue adhesive glue licensed for sclerosing esophageal and fundal varices. Prior to its injection into the varix, Histoacryl is mixed with the diluent Lipiodol. Injection of glues carries a relevant risk for complications, including ulcers in 0.1–6.3%, perforation, peritonitis, systemic inflammation and infection [4, 5]. Also, there is a risk of embolizing other neighbored vessels or organs such as a pulmonary artery embolism as well as a substantial risk of systemic embolization in patients with veno-arterial shunt. However, sclerosants remain an important tool for variceal bleeding, especially in younger/smaller patients, where the small size of the esophagus is inaccessible to the increased diameter of scope with the banding device.

Hemoclips can be applied through different endoscopes and are manufactured in different sizes. The deployment mechanism allows to grasp a small area of tissue, compress the tissue with the clip and release the tissue-fixed material (Fig. 3).

Its main challenges are to position the clip in the right angle to the lesion and to anchor the surrounding tissue sufficiently. Multiple clips can be combined. After placement of the clip’s branches, tissue tension can be reduced by applying suction, allowing more material to be grasped. Modern clips can be opened and closed repeatedly and turned with the handle.

A convenient, easy-applicable method of hemostasis is the application of hemostatic spray which can be combined with other therapeutic procedures. Examples are Hemospray^®^ and EndoClot^®^, which are both applied through a catheter which is inserted through the working channel. They are easy to use and can potentially cover an extensive area within the GI tract.

Hemospray^®^ is an inert mineral powder causing coagulation through the increased activation of clotting and mechanical tamponade (Fig. 4). EndoClot^®^ is a starch-derived polysaccharide which also causes dehydration in contact with fluids leading to the concentration of platelets and coagulation factors which accelerates the clotting cascade. Both hemostatic powders have so far only been compared in the adult population with similar results in short- and long-term bleeding management [6]. As contact with any form of liquid will activate the agent, the working channel of the scope must be totally dry, as otherwise, the scope would not be usable anymore. Also, transitory adhesion of the gastroscope to surrounding GI mucosa has been described following its use in retroflexion which warrants particular caution [7].

Strictures and Stenosis

In principle, these can occur at any point of the GI tract and treatment is mostly endoscopically. Hydrostatic dilatation of the stenosis is a frequent procedure following surgery of esophageal atresia (EA) or anastomotic strictures following gut resection (Fig. 5).

he surgical therapy of EA is to anatomize the proximal and distal esophageal stump and closure of the tracheoesophageal fistula at the same time. As a rule, surgical treatment should be carried out within the first 72 h, particularly in the presence of a fistula. Interventions are performed thoracoscopically or by thoracotomy. Newer data show that there might be a higher rate of reinterventions in the minimal invasive surgery group [8]. However, the evidence for a clear recommendation is still limited and the literature shows varying results. Nevertheless, both concepts continue to be used [9].

In very low birth weight infants or long-gap EA, it might be indicated to first ligate the tracheoesophageal fistula, create a gastrostomy and then perform the anastomosis at a later stage. A correction 12 weeks after birth is particularly useful in the case of long gaps as the esophageal stumps might grow and become stronger during this time, so that an anastomosis is often possible. Other options for lengthening the esophagus are myotomies, the sequential extrathoracic esophageal elongation according to Kimura and the traction method according to Foker. Those approaches are accompanied by high complication rates. If no anastomosis is possible after 12 weeks, gastric pull-up appears to achieve the best results according to current data.

The most common early postoperative complications after EA are anastomotic strictures (up to 50%), anastomotic dehiscence and leakage (10–20%), recurrence of fistula (5–15%) but also cases of pneumothorax have been described [10, 11]. In case of anastomotic strictures, serial dilations are performed, either by endoscopic balloon dilatation or by bougienage (e.g., using a Bougie Cap©). In case of difficulties in stricture management with mechanical dilation alone other treatment modalities such as intralesional steroid injection (ISI), topical mitomycin C, endoscopic electrocautery incisional therapy (EIT) (Fig. 6 and online suppl. Video; for all online suppl. material, see https://doi.org/10.1159/000545893) and/or externally removable stents can be implemented as adjunct therapies all with the purpose to avoid a surgical resection [12–14]. A helpful algorithm for the evaluation and guidance for the management of esophageal strictures has recently been published [15]. While the success rates of ISI seem to be marginal and the reported study results of topical Mitomycin C application are controversial, endoscopic EIT targeting stricture incision to the most scarred site is successful according to Manfredi et al. [16] in over 60% of the patients with refractory esophageal strictures over a 2-year follow-up period with low complication rates in the hands of experienced endoscopists.

The extent of the anastomotic stricture as well as a dehiscence shows a clear association with the tension of the anastomosis which is more pronounced in long-gap situations. Risk factors for the development of an anastomotic stricture include anastomotic insufficiency, long-gap situations, a high-tension anastomosis, ischemic tissue ends, gastroesophageal reflux, and gestational age [17]. Hence, repetitive dilatation sessions are frequently required until symptoms resolve, with the goal of dilatations being the ability to enable an unrestricted oral diet [15].

An alternative for the endoscopically guided balloon dilatation is the fluoroscopic guidance performed in the hand of an experienced interventional radiologist. Marom et al. [18]. performed a retrospective review of the medical records of children (0–18 years) who were treated with balloon dilatations between 2010 and 2020. In their study, 46 patients underwent 174 dilatation sessions. While the success rates in the endoscopy and fluoroscopy groups were similar (62% versus 67%; p = 0.454) at 3 months and 57% versus 67%; p = 0.721) at 12 months) the complication rate was lower in the endoscopy group (0% vs. 15%, p < 0.001).

Esophageal dilatation is performed under general anesthesia, usually antibiotic prophylaxis is recommended as a single peri-interventional intravenous injection. Common balloons need a minimum working channel size of 2.8 mm and can be placed through the working channel of pediatric endoscopes with an outer diameter of 8–9 mm, in infants they can be placed next to the scope by using a guide wire. An alternative is depicted in Figure 5, where the balloon catheter is placed under endoscopic view via a transnasal tube placed in the proximal esophagus to protect the hypopharynx during the insertion of the catheter as well as the dilation procedure. Balloons are available in multiple sizes and diameters are indicated in mm and hydrostatic pressure, facilitating repetitive dilatation without changing the system. The effect on the mucosa is controlled under endoscopic view. X-ray and fluoroscopy provide supplementary information such as stricture imprinting. Once in position, the balloon is sequentially hydrostatically inflated. Balloon inflation time lasts generally 1–2 min, followed by a 1 min deflation time. This procedure needs to be repeated 3 times. In our own experience and others, dilating up to 4–5 mm above the initial stricture diameter, which can be assessed by comparing to the diameter of an open biopsy forceps, may not increase perforation risk [19].

An alternative represents the functional lumen imaging probe for dilatation (ESOFLIP©) which offers simultaneous real-time impedance measurement of luminal diameter while doing dilation with a range from 6 to 30 mm. However, so far the system is only approved for dilatation therapy in adults [20, 21]. Predictors of dilation failure requiring surgical stricture resection include long-gap esophageal atresia, a stricture length ≥10 mm, a prior anastomotic leak, and ≥7 repetitive balloon dilations [22].

A novel treatment option in patients with refractory postoperative anastomotic stricture in esophageal atresia may represent in future an autologous oral mucosa-derived epithelial cell sheet transplantation therapy [23]. However, its application has only be reported in a few cases and confirmatory larger RCT studies are not available so far to evaluate safety and efficacy.

When dilating stenosis in the colon or ileum, beyond the rectum only through-the-scope balloons can be used. The risk for complications, namely, perforation is low, around 2%. Endoscopy using carbon oxide insufflation is recommended at all age levels to minimize luminal distension and facilitate early respiratory extubation [15].

A setting where this is most significant is anastomotic stenosis in children after necrotizing enterocolitis (NEC) or extensive atresia of small bowel with short bowel syndrome and ileocolonic anastomosis. The situation can be especially challenging since it is often associated with bleeding or failure to wean from parenteral nutrition. A surgical approach would imply additional bowel loss that should be avoided [24].

Recurrent tracheoesophageal fistula can be detected using methylene blue application either from the esophageal or the tracheal access (Fig. 7). Surgical occlusion is highly invasive while endoscopic therapy has been shown to be a safe and effective approach with lower morbidity and mortality. They are successfully occluded via endoscopic techniques with an overall success rate of 70.0% to prevent reconstruction by open surgery with a greater risk of damage to the surrounding tissues, nerves, and blood vessels during reopening or another thoracoscopic surgical approaches. Ling et al. [25] reported in a systematic review illustrating that no obvious severe intra- or postinterventional complications occurred during the follow-up period. Only mild esophageal strictures were noticed in 6 of 170 patients and grade II tracheal stenosis in one patient.

Endoscopic techniques for occlusion of small-sized fistulas (e.g., 2–4 mm lumen) comprise de-epithelialization mainly including endoscopic diathermy coagulation (EDC), or an argon plasma coagulation (APC) probe for cauterization, or mechanical abrasion using bronchial brush or biopsy forceps, and chemical abrasion (silver nitrate, 50% TCA) [26]. Endoscopic de-epithelialization is technically easier to perform, and helps avoid the risk of injury to other important structures and should be used preferentially in the pediatric population. However, severe side effects have also been reported e.g., respiratory distress in patients following extended diathermy time, possibly caused by an edema or even necrosis of the adjacent tracheal wall [27, 28].

Chemical sealants such as fibrin glue (FG), histoacryl (n-butyl-cyanoacrylate) or histoacryl blended with lipiodol, can be used for injection into the fistula (see Table 1). The most common sealant is FG, which consists of a fibrinogen/FXIII concentrate and thrombin concentrated from human plasma causing tissue adhesion, especially in combination with EDC which is necessary to induce necrosis and mucosal inflammation to sufficiently and permanently seal the fistula. As an alternative, sclerosing agents such as DuraSeal, Dx/HA, or aethoxysklerol can be submucosally injected, causing de-epithelialization and concomitant inflammation and leading to a closure of the fistula when combined with a sealant [29, 30].

The combination of de-epithelialization with chemosealant occlusion therapy seems to further improve the sealing effect in tracheoesophageal fistulae as the success rate of the combined therapy is reported higher (77%) in a systematic review by Ling et al. [25]. However, to date no prospective RCTs are available on this topic [31].

For larger fistulas exceeding several mm, endoscopic stent placement can also be implemented as an attempt to occlude recurrent tracheoesophageal fistulas alone or in combination with an OTSC with varying success rates. These devices and others such as vacuum therapy can also be considered and will be discussed below. Accessibility to material, experience of the endoscopist should always be put into balance with the potential requirement of surgical closure. However, in particular in multi-operated patients less invasive endoscopic management might be the preferable option [32].

Endoscopic Treatment of Achalasia in Children

For achalasia in children, there are two endoscopic techniques besides the classic laparoscopic Heller myotomy (LHM). Pneumatic dilation is effective; however, relapses occur frequently in some patients, so most require more than one dilation (34–90%) [33]. It is usually performed with a pneumatically inflated balloon specifically designed to relieve lower esophageal sphincter pressure under endoscopic and/or radiological guidance. LHM is associated with a higher complication rate but is effective long term in over 80% of patients [34].

Peroral endoscopic myotomy (POEM) – the second endoscopic technique – is a myotomy of the LES performed endoscopically in adults and older children with high efficacy in 80–94% of the patients [35]. A incision is made on the posterior wall of the esophageal mucosa and a submucous layer as well as the circular muscle are carefully detached from the muscle. followed with the endoscope, transecting muscular circular fibers.

Leakage and Perforation

Gastroesophageal leaks and fistula can either occur spontaneously related to a GI pathology or can be iatrogenic due to increasingly complex interventional endoscopic procedures or surgical procedures. Smaller perforations (<10 mm) can be closed with clips (abovementioned), but OTSC^®^ (described below) can be used in a variety of settings besides in the esophagus and duodenum, especially for perforation, closing of fistula, anastomotic leakage, and bleeding (Fig. 2). Compared to hemoclips, a larger piece of tissue is grasped with stronger jaws. The smallest size currently available has an outer diameter for intubation of 14.6 mm that can hardly be used in small children.

EndoVac or comparable devices consist of a drain with an open polyurethane sponge (OPD) wrapped around the distal part of an aspiration tubing (Fig. 8). They can be used for larger perforation defects in esophageal and rectal locations [36, 37]. The sponge is equipped with suture loops to allow better grasping and positioning by the endoscopist. After placement of the sponge in the extraluminal cavity or intraluminally, a negative pressure is applied. Endoscopic control, debridement and cleaning as well as changes of the sponge are performed every 3–5 days.

Placement can be achieved via a push technique with a grasper, a pull technique, by which a distal sponge is pulled back via the tube in position, a pull through technique with a preplaced wire or suture from the distal side, in a modified Seldinger technique on a preplaced wire or piggyback, on top of the endoscope by firmly grasping the distal suture.

Specialist Work and Advanced Endoscopic Techniques

Over the Scope Clips

OTSC^®^ is an established tool in adult endoscopy for the management of non-variceal bleeding, perforations, anastomotic leaks, and fistula closure [1, 38–41]. The OTSC^®^ is attached to the tip of the endoscope (Fig. 2d), similar to variceal banding devices and deployed likewise by a combination of suction and turning the wheel for its deployment. Other than the grasper/clip device, the system includes a twin grasper which allows approaching borders of the defect and a stiff tissue brush. Compared to conventional hemostatic clips, the OTSC strikes with a combination of increased tensile grasping strength of the clip jaws, an improved tissue bite with the additional positive effect of persistent blood flow through the grasped tissue which prevents necrosis and supports the healing process [1, 38]. Different clip sizes are available; however, even the smallest, 8.5–9.8 mm in diameter, with its loading device on the tip of the endoscope increases the overall diameter by up to 14.65 mm, which limits its use especially in younger children [1, 39]. Removal of the clip in case of its improper application can be easily performed with the aid of a specifically designed endoscopic cutting device.

Kobara et al. [40] recently reviewed OTSC use in 1,517 adult patients, with an overall success rate of 78%, 85% for bleeding and perforation, 52% for fistula and 66% for anastomotic dehiscence with prevention of rebleeding in 85%. Two tertiary pediatric centers from the UK and the USA recently published their data about 24 OTSC procedures in 20 patients over a 3-year period. Mean age was 12 years with the youngest patient at 5 years with a weight of 18 kg. Indications included persistent gastro-cutaneous fistula after gastrostomy insertion, acute non-variceal bleeding and non-healing ulcers as well as a mucocutaneous fistula of the esophagus. Technical success was achieved in all but 1 case (95%), and clinical success was achieved in 18 cases (90%) [39].

However, this device should only be used by experienced endoscopist with specific OTSC training, and the type and size of the OTSC device should be carefully considered, along with any comorbidities of the patient that may preclude success and/or lead to potential adverse events such as esophageal perforation.

Endoscopic Vacuum-Assisted Closure for Esophageal Leakage and Perforation

Esophageal perforation and leakage are serious, potentially life-threatening complications in adults and in children [36, 42–55]. Etiologies vary according to age, including trauma (e.g., nasogastric tube, intubation), foreign body or caustic ingestion and iatrogenic causes such as surgical repair of esophageal atresia or endoscopic interventions in the esophagus. In the adult population, anastomotic leaks occur between 5.7 and 14.3% [42], while leakage following esophageal atresia repair in children has been reported even up to 44% [43].

While surgical repair used to be the first-line management in the past, the initial conservative approach (gut rest, broad-band antibiotics, nasogastric tube, parenteral nutrition, etc.) has now been widely adapted. If conservative management fails, surgical repair might be required; however, endoscopic procedures such as the endoscopic vacuum-assisted closure system (EVAC) are an attractive minimal invasive alterative for these often-complex patients who often underwent multiple surgeries beforehand.

EVAC is a treatment method that uses negative pressure (vacuum) applied endoscopically to promote wound healing, particularly in gastrointestinal defects such as anastomotic leaks, perforations, and fistulas. EndoVac is a term often used synonymously with EVAC but sometimes specifically refers to vacuum-assisted therapy applied inside the lumen of the gastrointestinal tract, particularly for esophageal or colorectal anastomotic leaks.

EVAC was first described by Weidenhagen in 2003 who derived this technique from vacuum-assisted closure therapy for external the application of negative pressure (between −75 and −125 mm Hg according to different studies) at the perforation site induces a compartment providing drainage of fluids, decreasing tissue edema and infection and induces healing by debriding wounds and encouraging tissue reperfusion and angiogenesis [44–46]. The majority of EVAC treatment cases in the esophagus are performed as part of complication management due to postoperative anastomotic insufficiencies. The second main indication for use is spontaneous and iatrogenic perforations.

EVAC can be either be provided by self-fabricated sponge material (in general, polyurethane) attached around a suction tube, or prefabricated sponge material (e.g., EsoSPONGE™, Braun B Melsungen, Germany) is now also available but usually limited to older patients. The sponge body (up to 12 cm long) is placed directly in the esophageal lumen. The sponge is best positioned so that the defect zone is in the middle of the foam. The pressure can be either applied continuously or in an intermittent setting (e.g., 5 min on, 5 min off). Animal models have shown that a negative pressure around −125 mm Hg shows the highest efficacy for inducing wound adaptation, granulation, and induction of angiogenesis, and this has been successfully applied even in younger infants. It is important that the diameter of the sponge is cut to the size of the esophagus based on fluoroscopic images. The sponge dressing is then attached to a suction tube, e.g., a 10, 12, 14, or 16Fr Salem Sump tube as described by Manfredi et al. [46], depending on the size of the patient. The sponge is soaked in water-soluble contrast for fluoroscopic assisted placement in the correct position. The tube can be either pushed or pulled in case the patient has a gastrostomy in situ. Once in position, the suction tube is connected to an external pressure system with intermittent or continuous pressure depending on center experience.

In adults, EVAC is now a standard procedure and has replaced self-expanding fully covered metallic stents as first-line management of esophageal perforation. Results are indeed promising, showing an excellent healing rate of between 83 and 100% in the adult population with therapy duration between 5 and 14 days. Complications are scarce, including stricture formation, bleeding during insertion and retrieval as well as sponge ingrowth [44, 45].

The use of EVAC is still a relatively new procedure in the pediatric population. Manfredi et al. [46] reported a case series of 17 children managed with EVAC with complications following esophageal atresia with a success rate of 88%. Further pediatric studies varied in success rates as well as age; Kaczmarek et al. [47] reported the youngest population so far with a case series of 4 patients between 24 and 161 days of age with the lowest weight of 1,500 g. EVAC was inserted transorally and remained in place between 7 and 39 days with a success rate of 100% [48–51]. While intraluminal EVAC leads to a temporary therapeutic esophageal closure, enteral feeding can be carried out using a feeding tube which is passed through the sponge body.

As intraluminal EVAC is very common in small iatrogenic esophageal perforations in which it is not possible to pass through the transmural defect into a cavity behind it, intracavity EVAC involves inserting a small sponge body through the transmural wall defect into a wound cavity behind it. After negative pressure is applied, the wound cavity collapses with and around the sponge body. At the same time, permanent suction closes the defect around the drainage. With this variant, the esophageal passage remains intact and enteral nutrition can be provided via an additional naso-gastrointestinal tube.

In summary, EVAC combines the two main surgical treatment principles for treating gastrointestinal closure of the defect with simultaneous (internal) drainage. Therefore, EVAC can be used to treat not only small defects but also longer defects. At the same time, septic wound secretions are simultaneously treated by drainage [56].

Stenting

Endoscopic stent placement is mostly used after anastomotic dehiscence, severe esophageal lesions following caustic ingestion, anastomotic strictures, esophageal perforation, as an attempt to occlude recurrent tracheoesophageal fistulas, or even therapy refractory bleeding from esophageal varices. Common plastic or coated metal stents are available in various sizes, mostly self-expanding and are easy to place endoscopically or radiologically. Esophageal stents are relatively safe, but it requires the technical expertise for proper placement and removal [15]. To avoid dislocation, longer stents should be used when in doubt. In the future, biodegradable stents may combine the strengths of common metal or plastic stents with less complication and no need to remove the stent, applying less trauma to the tissue [57].

In addition, stents can also be applied in cases of refractory anastomotic stenosis after esophageal atresia. They continuously apply centrifugal forces to the esophagus, aiming to avoid repetitive anesthesia and endoscopic interventions. However, treatment duration for this indication should not exceed 14 days and regular monitoring of the stent’s position with chest x-rays is recommended to exclude stent migration. In cases of anastomotic insufficiencies, stents should be removed after 3–6 weeks; earlier control endoscopies and adequate drainage of the leakage are mandatory. In a recent retrospective single-center study on esophageal stenting after esophageal atresia, Baghdadi et al. [58] described a moderate success rate of about 40% in preventing esophageal stenosis in a relatively large cohort of 42 pediatric patients. Other groups with smaller cohort sizes reported variable outcomes in stenting of esophageal strictures, with success rates ranging from 0% to 86% [17, 59–63].

The most common adverse events reported in the cohort of Baghdadi et al. [58] were erosions and ulcerations at the edge of the stents (29%), followed by granulation tissue formation (27%) and choking/vomiting (26%). Stent migration was described in 9% of the cases. Esophageal leaks caused as a result of the stent were seen in 3% of patients.

Conclusion

In this review, we have highlighted and discussed state-of-the-art endoscopic procedures for the management of postsurgical complications. It is important to emphasize that the role of endoscopy in the overall management of surgical complications always depends on a number of factors, including specific clinical patient-related ones, the availability/appropriateness of these endoscopic approaches, and, of course, the experience and skills of the endoscopist.

Conflict of Interest Statement

A.H. has received research grants for clinical studies, speaker’s fees, honoraria or travel expenses from AbbVie, Astellas, Danone, Dr. Falk Pharma, MSD, Mirum, Ipsen, Novartis, Nutricia, Sanofi and Shire/Takeda. J.L. received research grants, speaker’s fees and honoraria from AbbVie, Sanofi, Takeda, Danone, MSD, Mirum, Dr. Falk Pharma.

Funding Sources

The authors received no funding.

Author Contributions

A.H. and J.L. drafted and wrote the manuscript. D.S. and G.S. contributed in writing and editing. A.H., J.L., and D.S provided figures.