Engineering the esophagus: advances, challenges, and translational pathways in esophageal tissue reconstruction

Esophageal reconstruction is one of the most challenging procedures in gastrointestinal surgery. While conventional therapeutic approaches, such as gastric pull-up and intestinal interposition, can restore continuity, they often fail to replicate native physiology. This limitation frequently leads to long-term complications, including dysphagia, stricture, and reflux, which can significantly affect the patients' quality of life. Tissue engineering approaches offer promising alternatives aimed at developing esophageal constructs that restore both structure and function, addressing the shortcomings of current treatment methods. This review highlights recent progress in esophageal tissue engineering (ETE), focusing on the requirements for ideal ETE scaffolds and examining available biomaterials, including natural, synthetic, and hybrid. We discuss advances in fabrication techniques and various cell-based approaches, such as primary cells, stem cells, and organoids. Furthermore, we also review the steps necessary to transition ETE constructs from the laboratory to clinical settings (ongoing human trials), including preclinical studies conducted on rodent, rabbit, canine, and porcine models with the expected functional outcomes and regeneration capabilities. Early translational efforts in ETE are addressed, along with the regulatory and ethical considerations regarding good manufacturing practice (GMP) compliance, traceability, and long-term surveillance. While significant advancements in ETE have been made in preclinical models, the review also discusses the challenges of moving to clinical studies. Potential strategies to address these challenges, such as 4-dimensional printing, smart materials, artificial intelligence-driven scaffold optimization, and organoid-based models, are introduced to help bridge the gap from preclinical research to successful clinical trials. In summary, ETE is transitioning from an experimental advancement to a translational reality by integrating significant achievements in biomaterials, fabrication technologies, and cell biology while following health regulatory standards. These efforts aim to provide regenerative solutions that overcome the limitations of current therapeutic approaches in clinical settings, ultimately facilitating healing and improving the patients' quality of life.