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Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long-term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one-fifth have Barrett's metaplasia. Close to 100%, GER of pure and long-gap cases require fundoplication. In the long run, these patients have 50-fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long-gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.

Background and Aims: esophageal atresia (ea) with or without tracheo-esophageal fistula (tef) is a rare condition that can be nowadays succesfully treated. the current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results.Methods: the current strategies for the difficult or impossible anastomoses in pure and long-gap ea, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (ger) are reviewed.Results: methods of esophageal elongation and multi-staged repair of pure and longgap ea allow anastomosis but with functional results that are often poor. esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. ger is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates.Conclusions: ea with or without tef can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.