Long-term Outcomes of Esophageal Replacement in Children: A Multicenter Study by the Indian Association of Pediatric Surgeons

A BSTRACT Introduction: Esophageal replacement (ER) remains a challenging but essential reconstructive procedure in pediatric surgery when the native esophagus cannot be preserved, most often in long-gap esophageal atresia (EA) and corrosive strictures. Data from India are limited, with most reports representing single-center experiences. This multicenter study by the Indian Association of Pediatric Surgeons (IAPS) aimed to analyze national patterns, outcomes, and long-term results of pediatric ER. Materials and Methods: A retrospective, multicenter observational study was conducted across eight IAPS-affiliated institutions. Children under 18 years who underwent ER were included. Data regarding demographics, indications, conduit type, surgical route, timing of cervical anastomosis, complications, and outcomes were analyzed. Statistical tests included Chi-square/Fisher’s exact for group comparisons and penalized regression for exploratory assessment of risk factors for anastomotic complications. Results: Ninety-nine children (69 males, 30 females; mean age 22 months, mean weight 9.9 kg) were analyzed. EA was the indication in 89.9% and corrosive stricture in 10.1%. Gastric conduits were used in 98.9% – isoperistaltic gastric tube (48.5%), gastric transposition (GT) (24.2%), and reverse gastric tube (17.2%) – with only one colonic interposition. The posterior mediastinal route was used in 53 (53.5%) and the retrosternal in 46 (46.5%) children. Overall mortality was 4.04%, all in GT, with a mortality of 16.7% in transmediastinal GT in patients with EA, while nil in transmediastinal GT for corrosive injury, which were significantly bigger children. Early complications occurred in 30.3% and late in 25.3%, with anastomotic leak (13.1%) and stricture (13.1%) being the most common. Leak and stricture rates were higher after staged than primary anastomosis (19% vs. 8.8% and 19% vs. 7%, respectively; P > 0.05). Penalized regression suggested that leak was more likely with higher weight, major comorbidities, and retrosternal route, while stricture risk was greater with comorbidities and retrosternal routing. Mean parental satisfaction and child quality-of-life scores were 4.25 ± 0.94 and 4.03 ± 0.94, respectively. Conclusion: Pediatric esophageal replacement in India is most commonly performed for long-gap esophageal atresia using gastric conduits and is associated with acceptable mortality and satisfactory long-term quality of life. Anastomotic complications remain common and appear influenced by patient comorbidities and conduit route, emphasizing the need for standardized approaches and multicenter collaboration to improve outcomes. Discussion: Stomach-based conduits predominated in Indian practice due to their simplicity, vascular reliability, and adaptability to resource-limited settings. Retrosternal routing, though less anatomical, was often favored for its perceived safety and avoidance of mediastinal dissection. Leak and stricture rates were comparable to global data and appeared influenced more by comorbidities and conduit route than by staging or weight. The strong correlation between leak and later stricture underscores the importance of meticulous anastomotic technique and vigilant follow-up.