Abstract
Background
Esophageal atresia (EA) is a life-threatening congenital anomaly requiring surgical repair. The choice between primary (one-stage) and staged repair remains debated, particularly in neonates with long-gap EA or comorbidities. Evidence from resource-limited settings is scarce.
Methods
We retrospectively reviewed 115 neonates with EA who underwent surgical repair at Motahari Pediatric Hospital, Iran (2017–2024). Patients were classified into one-stage or staged repair groups. Demographics, associated anomalies, complications, operative time, hospital stay, and survival were analyzed using appropriate statistical tests.
Results
Of 115 patients, 68 underwent one-stage repair and 47 staged repair. Baseline characteristics were comparable, though Type A EA was more frequent in staged cases. Postoperative complication rates, including anastomotic stricture, leak, pneumonia, and sepsis, were similar between groups. Failed gastrostomy was significantly higher in staged repair (p = 0.01). Survival rates were comparable (79.4% vs. 78.7%). Mean operative time and hospital stay were longer in the staged group but not statistically significant. Gestational age showed a significant inverse correlation with operative duration (ρ = − 0.225, p = 0.016).
Conclusion
One-stage and staged repairs demonstrated comparable short-term outcomes in EA. Individualized surgical planning, considering gestational age, gap length, and comorbidities, is essential. These findings highlight that acceptable outcomes can be achieved even in resource-limited settings, supporting tailored decision-making rather than universal preference for either technique.
Keywords: Esophageal atresia, Tracheoesophageal fistula, Primary repair, Staged repair, Neonatal surgery
Introduction
Esophageal atresia (EA), often associated with tracheoesophageal fistula (TEF), is a life-threatening congenital anomaly with an incidence of 1 in 2,500–4,500 live births [1]. Nearly half of affected infants present with additional malformations, frequently within the VACTERL spectrum [2]. Despite advances in neonatal surgery, EA repair remains challenging, particularly in resource-limited settings.
Two main surgical approaches are employed: primary (one-stage) repair and staged repair. Primary repair is generally preferred in stable neonates with short-gap EA, while staged repair is considered in infants with long-gap EA, low birth weight, prematurity, or major comorbidities [3, 4]. Although primary repair offers the advantage of early esophageal continuity and reduced hospitalization, staged procedures may provide greater perioperative stability in high-risk neonates [5].
Reported outcomes vary widely, with some studies favoring primary repair for improved survival, while others highlight comparable complication rates between approaches [6, 7]. However, most data originate from high-resource countries, and limited evidence exists from low-resource settings. Evaluating surgical outcomes in such contexts is essential to inform decision-making and optimize care.
This study aimed to compare short-term outcomes of one-stage versus staged EA repair in a tertiary pediatric center in Iran.
Materials and methods
This retrospective audit was conducted at Motahari Pediatric Hospital, a tertiary referral center in Urmia, Iran, between March 2017 and March 2024. Medical records of all neonates diagnosed with esophageal atresia (EA) and undergoing surgical repair were reviewed.
Patients were classified into two groups:
One-stage repair: direct primary anastomosis during the initial surgery.
Staged repair: initial gastrostomy and/or fistula ligation followed by delayed anastomosis within the same hospitalization.
The surgical approach was determined by clinical status, gap length (short < 2 vs. long ≥ 3 vertebral bodies), birth weight, and associated anomalies, based on multidisciplinary team consensus.
Data collected included demographic features, associated anomalies, type of EA, perioperative and postoperative complications, operative time, hospital stay, and final outcome.
Statistical analysis was performed using IBM SPSS v.26. Continuous variables were analyzed with Student’s t-test or Mann–Whitney U test, while categorical variables were compared using chi-square or Fisher’s exact test. Correlations between gestational parameters and operative time were examined with regression and correlation analyses. A p < 0.05 was considered significant.
Ethical approval was obtained from the Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1403.085).
Results
A total of 115 neonates with esophageal atresia (EA) were included: 68 underwent primary (one-stage) repair and 47 staged repair. Baseline demographics, including birth weight and gestational age, were similar between groups. However, Type A EA was more frequent in the staged group, while Type C predominated overall.
Postoperative complications showed no significant differences. Anastomotic stricture occurred in 7.8% of patients (5.9% one-stage vs. 10.6% staged, p = 0.48). Rates of anastomotic leak, sepsis, pneumonia, and gastroesophageal reflux were comparable. Failed gastrostomy was significantly higher in the staged group (p = 0.01).
Survival was similar (79.4% one-stage vs. 78.7% staged, p = 0.93). The mean hospital stay was longer in the staged group (22.5 ± 16.4 vs. 17.8 ± 10.2 days), and operative time was also greater (146.8 ± 78.4 vs. 125.0 ± 44.4 min), though neither difference reached statistical significance.
Correlation analysis revealed no association between chronological age or birth weight and operative duration. A significant inverse correlation was observed between gestational age and operative time (ρ = − 0.225, p = 0.016), indicating shorter procedures in more mature neonates.
Discussion
In this audit, one-stage and staged esophageal atresia (EA) repairs showed comparable short-term outcomes, with no significant differences in mortality or major complications. This aligns with prior studies reporting similar early survival and complication rates between both approaches [1, 3].
Although staged repair was associated with longer operative time and hospital stay, these differences were not statistically significant, likely reflecting our practice of completing definitive anastomosis within the same admission. In contrast, longer interstage intervals reported in high-resource countries may contribute to higher morbidity in staged patients [4, 5].
Primary repair provides immediate esophageal continuity and earlier feeding [6], while staged repair may benefit neonates with long-gap EA, severe anomalies, or instability [7]. Our finding of higher failed gastrostomy rates in staged repair is consistent with previous observations that additional procedures increase complication risks [8].
A novel observation in this study was the inverse association between gestational age and operative time, suggesting improved tissue handling in more mature neonates. Similar findings have been noted in studies highlighting the influence of neonatal maturity on surgical complexity and outcomes [3, 7].
Importantly, most existing data come from high-resource settings, while our study demonstrates that comparable outcomes can be achieved in resource-limited environments when surgical expertise and careful patient selection are applied [5, 9].
Conclusion
Both primary and staged EA repairs are feasible and safe, with individualized selection based on anatomical and clinical factors. Our findings support tailoring surgical strategy rather than assuming superiority of either approach. Further prospective multicenter studies are needed to validate these results and assess long-term outcomes.
Acknowledgements
We would like to express our gratitude to Urmia University of Medical Sciences for their support in conducting this research. We also thank all those who contributed to the successful completion of this study.
Authors’ contributions
R. K. was involved in the conceptualization of the study, oversight of the research process, and critical revision of the manuscript drafts. H. A. had a leading role in the development of the study concept and design, supervision of its implementation, drafting of the manuscript, and final revisions. R. A. contributed to the initial design of the study, data acquisition, and statistical analysis. All authors have reviewed and approved the final version of the manuscript.
Funding
No funding was received for this work.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.1403.085). The study was conducted in accordance with the ethical standards of 1964 Helsinki Declaration and its later amendments or comparable ethical standards. As this was a retrospective audit using anonymized medical records, the need for individual informed consent was waived by Ethics Committee of Urmia University of Medical Sciences, in accordance with national regulation. No identifiable patient information was collected, and all data were analysed anonymously.
Consent to publish declaration
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.