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Review

Innovations in Minimally Invasive Management of Esophageal Atresia and Tracheoesophageal Fistula

by
Adrian Surd
1,
Rodica Muresan
2,
Carmen Iulia Ciongradi
3,
Lucia Maria Sur
4,
Lia Oxana Usatiuc
5,*,
Kriszta Snakovszki
2,
Camelia Munteanu
6 and
Ioan Sârbu
3
1
Pediatric Surgery and Orthopedics, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
2
Pediatric Surgery and Orthopedics, Emergency Children Hospital, 400370 Cluj-Napoca, Romania
3
Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700114 Iasi, Romania
4
Pediatrics 1, Department of Mother and Child, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
5
Pathophysiology, Department of Functional Sciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
6
Biology Section, Faculty of Agriculture, University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca, Romania
*
Author to whom correspondence should be addressed.
Gastrointest. Disord. 2025, 7(2), 39; https://doi.org/10.3390/gidisord7020039
Submission received: 15 April 2025 / Revised: 16 May 2025 / Accepted: 28 May 2025 / Published: 3 June 2025
(This article belongs to the Special Issue Pediatric Gastrointestinal Endoscopy and Surgery: Current Challenges and Future Directions)
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Abstract

:
Background and Aims: Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are rare but serious congenital anomalies requiring early surgical intervention. Over the past two decades, minimally invasive surgical (MIS) approaches—particularly thoracoscopic repair—have gained traction, aiming to reduce postoperative morbidity while maintaining surgical efficacy. Objective: This narrative review provides a comprehensive overview of the evolution and current status of MIS techniques for EA/TEF, assessing their clinical outcomes, technical challenges, and implications for patient care. Methods: A structured literature search was conducted to identify clinical studies, reviews, and reports on thoracoscopic, robotic-assisted, and endoscopic approaches to EA/TEF. Emerging adjuncts, including tissue engineering, botulinum toxin use, and magnet-assisted anastomosis, were also reviewed. Results: Thoracoscopic repair has demonstrated comparable anastomotic success rates to open surgery (approximately 85–95%) with significantly reduced rates of musculoskeletal complications, such as scoliosis and chest wall deformities (reported in less than 10% of cases, compared to up to 40% in open approaches). Robotic-assisted and endoscopic-assisted techniques have enabled improved visualization and precision in anatomically challenging cases, although their use remains limited to high-resource centers with specialized expertise. Common postoperative complications include anastomotic stricture (30–50%), gastroesophageal reflux disease (35–70%), and respiratory morbidity, necessitating long-term multidisciplinary follow-up. Recent innovations in simulation-based training and bioengineered adjuncts have facilitated safer MIS adoption in neonates. Conclusions: Minimally invasive techniques have improved the surgical management of EA/TEF, though challenges remain regarding technical complexity, training, and resource availability. Continued innovation and collaborative research are essential for advancing care and ensuring optimal outcomes for affected infants.

1. Introduction

The surgical management of esophageal atresia (EA) and its frequent companion, tracheoesophageal fistula (TEF), has undergone a remarkable transformation, moving from open procedures to increasingly sophisticated minimally invasive techniques. This shift towards MIS aims to reduce surgical morbidity, improve cosmesis, and potentially enhance long-term outcomes in this vulnerable patient population [1]. The estimated prevalence of EA is approximately 1 in 3000 to 4500 live births, with some studies reporting a prevalence of 2.44 per 10,000 births [2]. The frequent association of EA with multiple congenital anomalies presents significant challenges for pediatric surgeons. Given this complexity, a thorough evaluation for coexisting malformations is essential, and coordinated multidisciplinary care is often required to optimize outcomes.

1.1. Definition and Classification of Esophageal Atresia and Tracheoesophageal Fistula

EA, a birth defect affecting the esophagus, arises from the disrupted separation of the foregut during embryonic development. Often, EA occurs in conjunction with a TEF, which is an abnormal connection between one or both segments of the esophagus and the trachea. The presence and location of this fistula significantly influence the clinical presentation and classification of EA [1].
Several classification systems exist for EA, with the Gross classification (also known as the Vogt–Gross or Ladd–Gross classification) being the most widely used (Table 1, Figure 1). This system categorizes EA based on the anatomical configuration of the esophageal ends and the presence and location of any TEF.
A comparison between the Gross and Vogt–Ladd classification systems for EA/TA fistula, outlining anatomical subtypes, the presence and location of associated fistulas, and their approximate incidence, is presented in Table 1.

1.2. Advances in the Surgical Treatment of Esophageal Atresia

Surgical management of EA has evolved significantly since the first successful primary repair in the 1940s. Advances in neonatal intensive care, anesthesia, and surgical technique have raised survival rates from near 0% to roughly 90–95% in developed countries today [1]. Contemporary series confirm that operative mortality for EA/TEF has become very low (on the order of 2–10% in most centers) [6], with death largely limited to infants with severe comorbidities (such as complex cardiac defects or extreme prematurity) [1]. As a result, attention has shifted from survival to optimizing surgical approaches and reducing morbidities [7]. Improvements in perioperative care, including neonatal anesthesia, ventilation strategies, and nutrition, also have enhanced outcomes. In addition, the use of intraoperative endoscopy, improved suture materials, and enhanced imaging has refined surgical precision.

1.2.1. Thoracoscopic Repair

One of the most notable developments is the introduction of minimally invasive surgery (MIS), particularly thoracoscopic repair, which has largely replaced traditional open thoracotomy in many centers. Thoracoscopic surgery was first successfully utilized to repair EA in a child, with the initial report appearing in 1999 [8]. Thoracoscopy offers the benefits of reduced postoperative pain, shorter hospital stays, better cosmetic results, and less musculoskeletal deformity, though it requires specialized training and expertise due to its technical demands [7,9].
Another major advancement is the development of techniques for managing long-gap EA, which historically posed a significant surgical challenge [10]. The Foker process, which uses tension-induced esophageal growth through traction sutures, allows preservation of the native esophagus even in cases with large gaps [11]. Other techniques include gastric pull-up, colonic or jejunal interposition, and, more recently, magnetic compression anastomosis, a novel non-surgical approach that facilitates esophageal continuity using magnetically guided tissue approximation [12].

1.2.2. Robotic-Assisted Surgery

Emerging fields such as robotic-assisted surgery hold future promise for less invasive and more individualized treatments [13]. Robotic surgery with the da Vinci system is a growing technique for minimally invasive repair of EA/TF in newborns. It provides surgeons with enhanced 3D vision, precise control, and wrist-like instrument movement, improving accuracy in delicate procedures. These advantages may lead to better suturing, reduced tissue damage, and less surgeon fatigue during long operations. While still uncommon due to challenges like limited space in newborns, lack of touch feedback, and high costs, early studies show the approach is safe and effective in selected cases. However, it remains limited to a few specialized, high-volume centers with experienced teams.

1.2.3. Tissue Engineering

Current options for esophageal replacement in children—using stomach, colon, or jejunum—lack consensus and are associated with high short- and long-term complication rates, including leaks, strictures, graft failure, and feeding issues. Allotransplantation is limited by donor availability, immune rejection, and the need for lifelong immunosuppression, making it less suitable for pediatric cases. As a result, tissue-engineered grafts are being explored as a promising alternative, combining biomaterials with stem cells to mimic native esophageal tissue. While most research has been in animals, early human applications are emerging [9,14,15].
Studies suggest that seeding scaffolds with mesenchymal or adipose-derived stem cells promotes better tissue integration than unseeded materials. However, the optimal scaffold material and ideal cell sources remain uncertain. Absorbable polymers and decellularized matrices show similar promise in preclinical models. While long-segment replacements still face major challenges, early successes in patch repairs offer hope. Esophageal transplantation, although less developed, could eventually play a role in selecting complex cases if future animal studies prove successful [9,16].

1.3. Comparative Advantages of MIS Compared to Open Surgery

Minimally invasive surgery (MIS) has become an increasingly adopted approach for the repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF), offering several advantages compared to traditional open surgery. One of the most notable benefits is the reduction in postoperative pain and quicker recovery. Patients undergoing MIS typically require less opioid analgesia and resume feeding earlier than those treated with open thoracotomy. Additionally, the minimally invasive approach avoids large thoracic incisions, resulting in superior cosmetic outcomes and potentially reducing long-term musculoskeletal complications such as scoliosis or shoulder dysfunction [17,18]. A study suggests that cosmetic outcome was better in the MIS group than in the open repair group (p = 0.00) [19].
Hospital stays are often shorter with MIS, with some studies reporting a reduction in one to three days, depending on patient complexity and institutional protocols. Operative time, however, is generally longer in MIS—especially early in the learning curve—but this difference decreases with surgical experience. Rozeik et al. conducted a study in which he compared open repair and MIS, and he concluded that there was no statistically significant difference between the two groups regarding operation time (p = 0.10) [19]. In terms of complications, anastomotic leak rates are similar between MIS and open surgery, typically ranging from 10 to 20% [20]. Anastomotic stricture remains a common issue, with some early MIS studies suggesting slightly higher rates (up to 50%), though recent data from experienced centers show comparable outcomes. Recurrent fistula occurs in approximately 5–15% of both MIS and open cases. Gastroesophageal reflux disease (GERD) is frequent in both groups, highlighting the need for long-term follow-up regardless of the surgical technique used. Importantly, long-term survival and functional outcomes, including swallowing and feeding ability, do not differ significantly between the two approaches [20,21].
These findings suggest that MIS, when performed by experienced teams in appropriately selected patients, can offer equivalent safety and effectiveness to open repair, with the added benefits of reduced recovery time, less pain, and improved cosmetic results.

2. Preoperative Considerations and Preparation

2.1. Prenatal Diagnosis and Counseling

Prenatal detection of EA presents challenges, as direct visualization is uncommon. Suspicion often arises during second or third trimester ultrasound due to polyhydramnios and the absence or reduced size of the fetal stomach bubble, hinting at impaired fetal swallowing [22]. However, the presence of a distal TEF can lead to gastric filling via the trachea, resulting in a normal-appearing stomach and lowering diagnostic accuracy to approximately 40–50% [23].
Fetal magnetic resonance imaging (MRI) can enhance visualization by providing clearer imaging of the upper esophageal blind pouch and its separation from the lower segment [24]. When prenatal suspicion of EA exists, a comprehensive fetal anomaly ultrasound is advised given the frequent occurrence of associated anomalies. EA is frequently part of broader congenital syndromes, such as the VACTERL association, which encompasses vertebral, anal, cardiac, tracheoesophageal, renal, and limb anomalies. Other conditions, including CHARGE syndrome and Trisomy 18 (Edwards syndrome), are also frequently associated with EA and can significantly impact overall prognosis and clinical management, complicating both the surgical procedure and postoperative recovery [25]. In these situations, genetic counseling and testing, which may include amniocentesis, are often recommended.
Comprehensive prenatal counseling involving multiple specialists is crucial to prepare families for the necessity of neonatal surgery, potential co-occurring anomalies, and the need for extended follow-up care. Delivery should be strategically planned at a specialized center equipped with pediatric surgical and neonatal intensive care capabilities [26,27].

2.2. Patient Selection and Criteria for MIS

Minimally invasive surgery (MIS), particularly thoracoscopic repair, has become an increasingly preferred approach for the treatment of EA in selected patients. Despite its many benefits—such as reduced postoperative pain, lower risk of musculoskeletal complications, improved cosmetic outcomes, and faster recovery—it remains a technically demanding procedure that requires careful patient selection to ensure safety and effectiveness.
The ideal candidates for thoracoscopic repair are neonates diagnosed with type C EA, which is the most common anatomical variant, featuring a proximal esophageal pouch and a distal TEF. Several selection criteria are commonly considered in clinical practice. These include a birth weight over 2000–2500 g, hemodynamic and respiratory stability, and the absence of significant associated anomalies, particularly severe cardiac malformations or pulmonary hypoplasia [17,28]. Additionally, the length of the esophageal gap plays a crucial role; a short-gap EA allows for a tension-free anastomosis, making MIS feasible. In contrast, long-gap EA may require staged procedures or alternate surgical techniques better suited to open approaches.
Other important considerations include the surgical team’s experience and institutional resources. MIS for EA requires advanced neonatal anesthesia, specialized thoracoscopic instruments, and high-definition imaging systems. Surgical proficiency and proper training are essential due to the narrow operative field and delicate tissue handling required in neonates [29].
In summary, while thoracoscopic EA repair offers significant advantages in terms of recovery and long-term outcomes, it should be limited to carefully selected patients who meet clinical, anatomical, and institutional criteria. Individualized evaluation and the involvement of a multidisciplinary team are key to achieving safe and successful outcomes [28].
A summary of the key criteria for selecting suitable candidates for MIS in EA/TEF patients is presented in Table 2.

2.3. Preoperative Paraclinical Evaluation

Preoperative evaluation for EA/TEF is crucial to guide surgical planning and manage associated anomalies. A thorough assessment includes imaging, endoscopic evaluation, genetic testing, and input from a multidisciplinary team.
Imaging studies should include a chest and abdominal X-ray to help detect gas patterns and identify the presence of a blind-ending upper esophageal pouch. A contrast esophagram could provide more detailed anatomical information, including the location of the esophageal ends and the gap between them. Echocardiography is essential, as congenital heart defects are common in infants with EA/TEF. In addition, spinal and renal ultrasound should be performed to identify any associated vertebral or renal anomalies.
Endoscopy, particularly bronchoscopy, may be indicated in selected cases to locate the fistula and assess the anatomy of the tracheobronchial tree. This can be particularly useful in complex or unclear anatomical presentations.
Genetic testing and syndromic assessment should also be taken into consideration. All patients should be evaluated for features of the VACTERL association, which includes vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies. In infants with dysmorphic features or other indicators of a genetic syndrome, further testing such as chromosomal microarray or exome sequencing should be considered.
Finally, a multidisciplinary evaluation is essential to ensure comprehensive care. Teams typically involved include pediatric surgery, neonatology, cardiology, genetics, and anesthesiology. This collaborative approach helps tailor the surgical strategy, anticipate complications, and ensure optimal perioperative management.
Together, these steps form a structured preoperative workup that supports safer and more effective treatment of EA/TEF in neonates.

2.4. Anesthetic Considerations and Intraoperative Management

Anesthesia for neonates undergoing EA and TEF repair presents unique challenges due to their delicate physiology, frequent associated anomalies, and complex airway/ventilation management. A major concern is gastric insufflation through a distal TEF, necessitating preoperative Replogle tube placement to prevent aspiration [30]. Careful endotracheal intubation below the fistula but above the carina, sometimes with intentional endobronchial intubation, is crucial, potentially guided by preoperative bronchoscopy [22,31]. Anesthetic maintenance uses volatile agents (e.g., sevoflurane), opioids (e.g., fentanyl), and neuromuscular blockers, with invasive monitoring (arterial blood pressure, temperature, and end-tidal CO2) recommended [17]. Thoracoscopic repair adds challenges with CO2 insufflation, requiring low pressures (≤5 mmHg) and ventilation adjustments [8]. Postoperative care involves monitoring airway, breathing, and pain, with potential use of regional anesthesia (e.g., caudal epidural) [32]. Successful outcomes require careful planning and close collaboration.

3. Thoracoscopic Repair of Esophageal Atresia

3.1. Surgical Technique and Instrumentation

Minimally invasive repair of EA typically requires general anesthesia and positioning the infant in a left lateral decubitus or semi-prone position to best visualize the right chest cavity. Surgeons usually insert three small ports: a 3- or 5-millimeter camera port along the midaxillary line (typically in the 4th or 5th intercostal space) and two 3-millimeter working ports positioned anteriorly and posteriorly. Carbon dioxide (CO2) is used to gently inflate the chest cavity to create working space and collapse the lung, with pressure kept low (3–5 mmHg) to avoid affecting the baby’s breathing and circulation [8].
To improve the view, the azygos vein might be divided. The TEF is carefully separated and closed using small endoscopic clips or sutures. The upper and lower ends of the esophagus are then freed, and the surgeon performs a direct, internal connection (end-to-end anastomosis) using very fine absorbable sutures (5-0 or 6-0). This delicate step demands significant surgical expertise due to the tiny size of the baby’s esophagus and the limited space within the chest. High-definition cameras, fine endoscopic instruments for holding needles, and gentle grasping tools are crucial for precise surgery [33,34].

3.2. Primary Anastomosis via Thoracoscopy

Thoracoscopic primary anastomosis is the favored surgical method for suitable EA with distal TEF, especially with short esophageal gaps allowing tension-free repair. This minimally invasive approach mirrors open surgery principles but reduces trauma and improves recovery and cosmesis [35,36].
The infant is positioned left lateral or semi-prone, and three small ports (3- or 5-millimeter camera port and two 3-millimeter working parts) are placed. Low-pressure CO2 insufflation (3–5 mmHg) creates working space. After careful dissection, the distal TEF is identified, isolated, and closed with endoscopic sutures or clips. The upper esophageal pouch is then mobilized. Both esophageal ends are freed enough for tension-free approximation [36]. The direct connection (primary anastomosis) is created internally using fine (5-0 or 6-0) absorbable sutures, often interrupted. This requires advanced thoracoscopic skills in the small space. A Replogle tube may aid alignment, and twisting/tension are avoided. Leak testing with air insufflation and saline submersion may be performed. If no leaks occur, the chest is irrigated, a drain is placed, and ports are removed [36].
Experienced surgeons achieve comparable outcomes with thoracoscopic primary anastomosis versus open surgery, with less pain and better musculoskeletal development. However, it is technically demanding and best for specialized centers.

3.3. Challenges and Technical Pitfalls

Thoracoscopic EA repair, while less invasive, is technically demanding due to the small surgical field, fragile neonatal tissues, and limited thoracic space. Precise dissection of the TEF near critical nerves (vagus and recurrent laryngeal nerves) requires delicate handling and clear visualization to prevent complications like vocal cord paralysis [8]. Mobilizing short or retracted esophageal pouches for tension-free anastomosis is challenging, and excessive traction risks leaks or strictures. Intracorporeal suturing of delicate neonatal esophageal tissue in a confined space demands advanced skills to avoid tearing and ensure secure, well-aligned connections. Careful CO2 insufflation management is also vital to prevent cardiopulmonary compromise. Other risks include injury to the azygos vein, airway perforation, and misidentification of esophageal ends, which can lead to postoperative obstruction [8].
Conversion rate is variable and depends on multiple factors, such as hemodynamic stability, hypercapnia levels, associated risk factors, comorbidities, the experience of the surgeon, and also the experience anesthesiologist. Lin et al. compared conversion rates between his study and the current literature and obtained a result of 4–44% [37].

4. Minimally Invasive Techniques in Long-Gap Esophageal Atresia

4.1. Definition and Challenges of Long-Gap EA

Long-gap esophageal atresia (LGEA) is a type of EA where the esophageal segments are too far apart (over 2–3 vertebral bodies or preventing tension-free connection). It affects 10–15% of EA cases and often involves pure atresia (Type A) [38,39]. The main issue is the inability for direct connection, risking leaks and strictures if forced. Management involves staged repair, lengthening techniques (like Foker), esophageal replacement, or magnetic anastomosis. LGEA often leads to longer hospital stays, feeding problems, reflux, and respiratory infections, requiring long-term specialized care. LGEA is a unique challenge needing tailored treatment and follow-up [39].

4.2. Minimally Invasive Foker Technique (Internal Traction Approach)

The Foker technique is a key advancement for LGEA, progressively lengthening the native esophagus. Initially open surgery, it is now adapted as a minimally invasive (thoracoscopic) approach using internal traction.
This involves placing traction sutures on esophageal ends via thoracoscopy, anchored externally or internally under continuous gentle tension. This stimulates tissue growth (mechanotransduction), elongating both segments. The staged procedure requires intubation and sedation in the NICU, with repeated thoracoscopic adjustments until the gap closes for primary anastomosis.
Thoracoscopic Foker aims for less trauma, pain, scarring, and faster recovery than open surgery but is technically demanding, needing high expertise and careful monitoring. Challenges include prolonged ventilation, infection risks, traction injury, and difficult internal suturing. Despite this, it shows promise for achieving esophageal continuity and function in specialized centers experienced in both thoracoscopy and staged reconstruction.

4.3. Delayed Primary Anastomosis and the Role of Gastrostomy

In cases of long-gap esophageal atresia (LGEA) where a tension-free anastomosis is not feasible at birth, delayed primary anastomosis is a widely accepted and effective strategy. This approach aims to preserve the native esophagus by allowing time for spontaneous esophageal growth or with assistance from techniques like internal or external traction prior to surgical reconnection [40].
The initial step typically includes the placement of a gastrostomy tube, which plays a dual role in providing enteral nutrition and gastric decompression. This intervention supports neonatal growth, avoids parenteral nutrition, and reduces the risk of aspiration pneumonia due to pooled secretions in the upper pouch [41]. Gastrostomy also facilitates postoperative recovery and contributes to better long-term outcomes, especially when the definitive repair is delayed for weeks or months.
During the waiting period, serial imaging or endoscopy may be used to monitor the position and growth of the esophageal ends. Once the gap is reduced to a manageable length, a second surgery is performed to create an end-to-end anastomosis. In some cases, additional procedures such as esophagostomy may be used alongside gastrostomy to divert secretions and protect the airway [39].
Though delayed repair may result in longer hospitalization and multiple interventions, it avoids the complications associated with esophageal substitution and preserves the native esophagus, which remains functionally superior in terms of swallowing, motility, and sensation [42].

4.4. Alternative Minimally Invasive Approaches

4.4.1. Thoracoscopic Esophageal Elongation

Thoracoscopic esophageal elongation is based on the Foker principle, where gentle pulling (traction) on the esophageal pouches stimulates them to lengthen. By using small 3-millimeter ports and a high-definition camera, surgeons place special traction sutures on the upper and lower esophageal pouches. Over several days or weeks, the sutures are gradually tightened, either inside or outside the baby’s body. The slow, steady tension helps the esophageal segments grow longer until they are close enough to be sewn together directly (end-to-end anastomosis). Throughout this lengthening period, the baby is kept sedated and on a breathing machine, and surgeons regularly check the progress with the thoracoscope, adjusting the sutures as needed [43].
A major benefit of this technique is that it allows the baby to use their own esophagus, avoiding the need for a replacement. Compared to traditional open surgery, this minimally invasive approach causes less surgical trauma, results in less pain after the operation, and leaves smaller scars. However, it requires highly skilled surgeons experienced in advanced minimally invasive surgery in newborns, specialized tiny surgical tools, and intensive medical care before, during, and after the procedure. In carefully chosen babies with LGEA, thoracoscopic esophageal elongation has shown good results, making it an important tool in how doctors now treat this challenging condition [11,43].

4.4.2. Endoscopic and Combined Thoracoscopic–Endoscopic Techniques

Endoscopic and combined thoracoscopic–endoscopic methods have become increasingly vital in EA surgery, especially for complex cases. These techniques improve visualization and anatomical understanding, leading to safer and more accurate dissection, particularly when locating the TEF is difficult [44].
Before surgery, endoscopy can confirm the diagnosis, find the TEF, and assess the esophageal pouches. During the operation, it helps place feeding tubes and confirm pouch positions. Using light or inserting a guidewire under endoscopic guidance further improves orientation during the minimally invasive dissection [45].
These combined techniques are particularly helpful in cases with unusual anatomy or TEF locations, where precise and safe dissection is crucial. Endoscopic assistance can also shorten surgery time and lower the risk of damaging nearby structures like the vagus and recurrent laryngeal nerves [46]. Although technically complex and requiring teamwork, these combined approaches are being used more often in specialized centers and are likely to become a standard addition to minimally invasive EA repair.

4.4.3. Magnetic Compression Anastomosis (Magnamosis)

Magnetic compression anastomosis (MCA), or magnamosis, is a novel technique for connecting the esophagus in LGEA without traditional surgery. It uses two biocompatible magnets placed in the separated esophageal pouches. These magnets slowly attract each other, compressing the tissue and eventually creating a connection (anastomosis).
The magnets are usually inserted using endoscopic or X-ray guidance. One goes through a feeding tube into the lower pouch, and the other through the mouth into the upper pouch. Over several days, the magnetic pull brings the esophageal ends together, causing controlled tissue breakdown and eventual fusion. The magnets then pass naturally through the digestive system or are removed endoscopically after the connection is complete [12].
Magnamosis offers potential benefits like avoiding open or keyhole surgery, shorter operation times, and no need for difficult suturing in the chest. Early results suggest good healing with low leak and narrowing rates, although long-term data are still limited. This method may be especially useful for patients with very long gaps and suitable anatomy who are not ideal for immediate surgery [47].
However, MCA is still a new technique, mainly used in a few specialized centers and ongoing research studies. More research is needed to fully understand its safety, effectiveness, and long-term results compared to standard surgical approaches.

5. Robotic-Assisted Surgery in EA and TEF

Robotic surgery, notably using the da Vinci system, marks a significant step in minimally invasive pediatric surgery for EA and TEF. This system offers surgeons improved dexterity, 3D vision, and precise control. Initially for adults, its use in pediatric chest surgery is growing due to smaller instruments and increased surgeon experience, potentially overcoming the challenges of limited space in newborns during EA/TEF repair [48,49].
Robotic platforms offer benefits over traditional keyhole surgery. Their 3D high-definition imaging and tremor reduction enhance precision in delicate tasks like esophageal dissection and connection. Robotic arms with a wide range of motion mimic the human wrist, improving maneuverability in the tight neonatal chest. Furthermore, the ergonomic console can reduce surgeon fatigue, leading to more stable and longer operations. These advantages may result in better suturing, alignment of the connection, and less tissue damage during EA/TEF repair [49].
While robotic surgery in newborns for EA/TEF is still complex and not common, initial reports and small studies show it is possible and safe in select cases. Procedures like fistula closure, esophageal mobilization, and direct connection have been conducted successfully in specialized centers [50]. Early results are similar to standard keyhole surgery, with some suggesting improved precision and fewer complications. However, larger studies and long-term data are still needed.
Despite its potential, robotic EA/TEF surgery has limitations. The size of robotic tools and the space needed for the ports can be challenging in small newborns, making careful patient selection important. Also, the lack of touch feedback can make tissue handling more difficult during delicate dissection. Robotic systems are also expensive and require significant investment. Finally, it takes time for surgeons to become skilled in both pediatric keyhole surgery and robotic techniques to ensure safety. As a result, robotic EA/TEF repair is currently limited to a few specialized, high-volume centers [50].

6. Postoperative Management and Complications After Minimally Invasive Surgery

Despite the advantages of thoracoscopic techniques, complications can still arise and must be promptly identified and treated.
Anastomotic leak represents an early complication occurring in 5–10% of cases [17]. Clinical signs include fever, increased oxygen requirement, and drainage of saliva or enteric content from chest tubes. Small leaks may heal with conservative management, while significant leaks may require surgical revision or diversion [51]. Recurrent fistula develops in 5–15% of cases and may require re-intervention [52].
Anastomotic stricture is among the most frequent late complications, seen in up to 40% of patients [53]. Feeding difficulties and dysphagia, often related to strictures or esophageal dysmotility, are reported in 20–40% of patients and are diagnosed via contrast studies or endoscopy [52]. Rozeik et al. conducted a study to compare outcomes of MIS and the traditional approach. His findings suggested that MIS has a lower stricture rate than open technique, but in the literature, the complication rate between these two groups is similar [19]. Endoscopic dilatation—either with balloon or bougie—remains the first-line therapy, often repeated over several sessions.
Recurrent TEF occurs in approximately 5–15% of cases, often manifesting as coughing or aspiration during feeds [54]. Diagnosis is confirmed via bronchoscopy or contrast swallow studies. Surgical reclosure is typically necessary, and in select cases, thoracoscopic revision is feasible [45].
GERD is a common postoperative complication in EA patients, affecting up to 30–60% of the cases. It is a consequence of the impaired esophageal motility and the absence of a functional lower esophageal sphincter. Clinical manifestations include vomiting, failure to thrive, and recurrent pulmonary infections. First-line treatment is medical management with acid suppression, but surgical intervention (e.g., Nissen fundoplication) may be indicated in severe or refractory cases [42].
Studies suggest that complication rates of MIS are almost similar to conventional repair, but the data are heterogenous. More studies are needed with a larger number of subjects to determine the real complication rates.
Long-term surveillance is critical given the risk of delayed complications. Follow-up includes regular clinical assessments, growth monitoring, and periodic imaging such as contrast esophagograms. Endoscopy and 24-hour pH monitoring may be used to evaluate esophagitis or GERD. A multidisciplinary approach involving pediatric surgery, gastroenterology, pulmonology, and speech therapy is often required to optimize functional outcomes [55,56].

7. Long-Term Outcomes After Minimally Invasive Repair

Preservation of esophageal function remains a key long-term goal. Most children achieve satisfactory swallowing after MIS repair, although many experience early feeding difficulties, often requiring temporary tube feeding or gastrostomy support. Esophageal dysmotility is common due to congenital neuromuscular abnormalities, regardless of the surgical approach. However, growth trajectories and nutritional status are typically normal by early childhood with appropriate feeding interventions [53]. Long-term follow-up may reveal persistent issues such as food aversion, strictures, and GERD, which require multidisciplinary care.
Children with repaired EA frequently suffer from recurrent respiratory infections, chronic cough, and aspiration, especially in the presence of associated tracheomalacia or vocal cord paresis. These issues are not specific to the surgical technique but are inherent to the congenital defect. However, MIS has shown a lower risk of postoperative pulmonary complications compared to open repair, possibly due to less chest wall trauma and faster recovery [57]. Long-term pulmonary function testing may reveal mild restrictive or obstructive patterns, warranting ongoing surveillance in some patients.
Studies evaluating quality of life (QoL) in children after EA repair have shown reassuring results, with most children leading normal lives. Functional impairments tend to be mild, and the impact on daily activities diminishes over time. Parental satisfaction is generally high, especially in cases managed with MIS, due to shorter recovery times and better cosmetic outcomes [57]. Psychological support and counseling may benefit families managing chronic symptoms or feeding issues in early childhood.

8. Emerging Techniques and Innovations in Minimally Invasive EA/TEF Surgery

Tissue engineering offers promising alternatives for esophageal reconstruction in cases where native tissue preservation is not feasible, particularly in long-gap EA. Recent experimental studies have focused on the development of biodegradable scaffolds, stem cell-seeded grafts, and 3D-printed esophageal segments aimed at regenerating functional esophageal tissue. These approaches, though still in preclinical stages, may one day replace or complement traditional esophageal substitution techniques, minimizing complications associated with grafts from the stomach or colon [14].
Adjunctive pharmacological therapies are being explored to optimize surgical outcomes. Botulinum toxin injections into the esophageal muscular layer have shown potential to reduce anastomotic tension by relaxing the muscle, potentially lowering the risk of leaks and strictures [58]. Similarly, growth factors such as VEGF and EGF are under investigation for their roles in enhancing wound healing and reducing inflammation post-repair. These agents may be delivered locally to the anastomotic site or integrated into bioengineered materials.
Endoscopic technology continues to evolve, enabling new therapeutic possibilities. Transluminal endoscopic approaches, such as internal septotomy for strictures or endoscopic closure of small recurrent fistulas, are minimally invasive alternatives to surgery in select cases. Advances in endoscopic imaging, such as narrow-band imaging and high-definition endoscopy, improve tissue visualization and guide precise interventions. Combined thoracoscopic–endoscopic techniques are also being refined to enhance safety and anatomical accuracy during primary repairs [59].
As minimally invasive techniques become standard in EA/TEF management, the need for specialized training and surgical simulation has increased. High-fidelity virtual reality (VR) simulators, 3D-printed models, and animal labs now support the acquisition of technical skills in a risk-free environment. These tools allow trainees to practice complex procedures like thoracoscopic suturing, fistula ligation, and esophageal anastomosis, thereby reducing the learning curve and improving outcomes in clinical practice [60].

9. Challenges, Limitations, and Future Directions

Despite its growing acceptance, MIS for EA and TEF continues to face significant technical barriers. Neonatal thoracoscopy is limited by restricted working space, delicate tissue handling, and the need for fine intracorporeal suturing, especially during esophageal anastomosis. The small thoracic cavity and proximity to vital structures like the vagus and recurrent laryngeal nerves increase the risk of intraoperative complications. Additionally, complex anatomical variations and long-gap cases may still necessitate open or staged procedures in many centers [61].
MIS in neonates is technically demanding and associated with a long learning curve. Surgeons require extensive training in pediatric laparoscopy, thoracoscopy, and advanced suturing techniques. However, formalized training programs and credentialing standards specific to neonatal MIS are still limited in many regions. Simulation-based training and mentorship models are critical to ensure competency while maintaining patient safety [60]. In our center, 3-4 MIS repairs are performed each year. We believe that a proper number of cases to maintain and develop these complex surgical skills is 10 cases per year.
Technologies like 3D printing (3DP), artificial intelligence (AI), and virtual reality (VR) are increasingly transforming minimally invasive surgery (MIS), especially in complex pediatric cases such as esophageal atresia (EA) and tracheoesophageal fistula (TEF). 3DP has been successfully used to create patient-specific thoracic models that allow surgeons to plan port placement and rehearse the procedure in realistic anatomical contexts. For example, 3D-printed models have helped in simulating thoracoscopic EA/TEF repairs, improving operative precision, and reducing intraoperative surprises [62].
AI and VR also offer significant advances in surgical training and decision support. VR platforms, such as the Fundamentals of Laparoscopic Surgery and custom pediatric simulators, have been shown to improve trainee performance before entering the operating room [63]. AI-powered video analysis tools, used in centers of excellence, can assess surgical techniques in real time and provide predictive insights into potential complications. These applications demonstrate how integrating emerging technologies can enhance both the safety and effectiveness of MIS in pediatric surgery [64].
The adoption of MIS techniques is also influenced by institutional resources and financial constraints. High costs associated with specialized instruments, robotic systems, and maintenance of advanced operating environments may limit accessibility in low- and middle-income settings. Moreover, the need for multidisciplinary expertise—including experienced anesthesiologists, neonatologists, and postoperative care teams—makes successful implementation feasible only in well-equipped, high-volume centers [44]. By default, MIS requires more financial resources than the open approach. We believe that with technological advances, the costs will reduce and MIS will become more affordable. Further research is needed to define best practices, outcome benchmarks, and long-term functional results of MIS in EA/TEF. Randomized controlled trials comparing thoracoscopic versus open repair are scarce due to the rarity of the condition and ethical considerations. Future priorities should include prospective multicenter registries, evaluation of quality-of-life outcomes, development of bioengineered esophageal substitutes, and validation of emerging technologies like robotic surgery and magnet-assisted anastomosis. Integration of personalized surgical planning using 3D imaging and artificial intelligence may also shape the next generation of EA/TEF management strategies [60,61].

10. Conclusions

MIS has shown significant promise in the treatment of EA/TEF, offering benefits such as reduced postoperative pain, faster recovery, and improved cosmetic outcomes. However, the technique remains technically demanding, requiring careful patient selection based on defined thresholds such as birth weight, gestational age, and comorbidities. Continued focus should be placed on advancing surgical training through simulation technologies, refining tissue engineering strategies for esophageal replacement, and generating robust long-term outcome data.
As the field evolves, priority must also be given to the development of standardized protocols, investment in surgical innovation, and equitable access to high-volume centers with specialized expertise. Above all, progress in the management of EA/TEF will depend on strong multidisciplinary and international collaboration—bringing together surgeons, neonatologists, researchers, engineers, and policymakers to ensure every child receives the safest and most effective care possible.

Author Contributions

A.S.: writing—original draft, investigation, and conceptualization; R.M.: writing—original draft, investigation, and conceptualization; K.S.: writing—original draft and investigation; C.M.: writing—review, editing, and investigation; L.M.S.: writing—original draft, investigation, and conceptualization; L.O.U.: writing—review, editing, and investigation; C.I.C.: writing—review and editing, investigation, and conceptualization; I.S.: writing—original draft, investigation, and conceptualization. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

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Gastrointestdisord 07 00039 g001
Figure 1. Esophageal atresia/tracheoesophageal fistula classification (adapted after [3,4]).
Figure 1. Esophageal atresia/tracheoesophageal fistula classification (adapted after [3,4]).
Gastrointestdisord 07 00039 g001
Table 1. Esophageal atresia/tracheoesophageal fistula classification (adapted after [3,4,5]).
Table 1. Esophageal atresia/tracheoesophageal fistula classification (adapted after [3,4,5]).
Gross TypeVogt/Ladd
Type		Esophageal AnatomyTracheoesophageal Fistula (TEF)Approximate Incidence (%)
-Type 1/-Esophageal agenesia--
Type AType 2/IUpper and lower esophagus are blind-ended pouchesAbsent5–10
Type BType 3A/IIUpper pouch with blind lower esophagusProximal (to trachea)1–2
Type CType 3B/III, IVUpper pouch with lower esophagus connected to the tracheaDistal (to trachea)80–90
Type DType 3C/VUpper and lower pouches with separate connections to tracheaProximal and distal<1
Type EType 4 or H-type/-Esophagus is continuousPresent (between trachea and esophagus)4–8
Table 2. Criteria for MIS candidacy in EA/TEF.
Table 2. Criteria for MIS candidacy in EA/TEF.
CriterionThreshold
Birth Weight>2.500 g
Gestational Age>34–36 weeks
Cardiac StatusAbsence of severe congenital heart anomalies
Respiratory StabilityStable; no need for high-frequency ventilation or significant oxygen support
Gap LengthShort to moderate; primary anastomosis possible without significant tension
Associated AnomaliesNo major anomalies requiring immediate surgery (e.g., abdominal wall defects)
Surgical and Institutional FactorsAvailability of an experienced MIS team and neonatal intensive care resources
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Surd, A.; Muresan, R.; Ciongradi, C.I.; Sur, L.M.; Usatiuc, L.O.; Snakovszki, K.; Munteanu, C.; Sârbu, I. Innovations in Minimally Invasive Management of Esophageal Atresia and Tracheoesophageal Fistula. Gastrointest. Disord. 2025, 7, 39. https://doi.org/10.3390/gidisord7020039

AMA Style

Surd A, Muresan R, Ciongradi CI, Sur LM, Usatiuc LO, Snakovszki K, Munteanu C, Sârbu I. Innovations in Minimally Invasive Management of Esophageal Atresia and Tracheoesophageal Fistula. Gastrointestinal Disorders. 2025; 7(2):39. https://doi.org/10.3390/gidisord7020039

Chicago/Turabian Style

Surd, Adrian, Rodica Muresan, Carmen Iulia Ciongradi, Lucia Maria Sur, Lia Oxana Usatiuc, Kriszta Snakovszki, Camelia Munteanu, and Ioan Sârbu. 2025. "Innovations in Minimally Invasive Management of Esophageal Atresia and Tracheoesophageal Fistula" Gastrointestinal Disorders 7, no. 2: 39. https://doi.org/10.3390/gidisord7020039

APA Style

Surd, A., Muresan, R., Ciongradi, C. I., Sur, L. M., Usatiuc, L. O., Snakovszki, K., Munteanu, C., & Sârbu, I. (2025). Innovations in Minimally Invasive Management of Esophageal Atresia and Tracheoesophageal Fistula. Gastrointestinal Disorders, 7(2), 39. https://doi.org/10.3390/gidisord7020039

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