Management of postoperative leaks and infections in patients with esophageal atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) remains a common, complex congenital anomaly with high survival but significant postoperative morbidity. Despite advances in surgical technique and neonatal care, one of the main contributors to postoperative morbidity is infection with anastomotic leakage occurring in up to 25 % of cases. Leakage of the esophageal anastomosis is associated with mediastinal and thoracic infection, prolonged hospitalization, and long-term sequelae. Prompt recognition and management can minimize short- and long-term complications for these patients. Here we present a narrative review of contemporary literature incorporating retrospective cohort studies, multicenter analyses, and guideline statements to summarize the clinical presentation and management strategies of anastomotic leaks following surgical intervention for EA. We highlight the symptoms specific to infections following EA repair and diagnostic modalities such as contrast esophagram. Treatment requires an individualized approach based on clinical status ranging from conservative management utilizing chest drainage, antibiotics, and parenteral nutrition, to large or uncontained leaks that necessitate endoscopic interventions or surgical re-exploration. Endoscopic stenting and vacuum therapy are increasingly employed modalities that may reduce the need for invasive revisional surgery, although pediatric data remain limited. Long-term follow-up demonstrates children who experience anastomotic leaks are more likely to develop late complications including esophageal strictures, dysmotility, reflux, and chronic respiratory issues. Vigilant surveillance and multidisciplinary care are therefore essential to optimize outcomes and preserve esophageal function.