Outcomes of Early Extubation Following Fontan Surgery in Children: A Systematic Review and Meta-Analysis

Children with single-ventricle physiology undergo the Fontan procedure but remain at risk of postoperative complications. Whether early extubation (EE) is safe and beneficial in this population is uncertain. The objective of this study was to assess the safety and effectiveness of EE compared with delayed extubation after Fontan surgery in children. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review and meta-analysis registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251083062). We searched PubMed, Scopus, and Web of Science from January 1, 2005, to June 2025. Eligible studies compared EE (within six to 12 hours) versus delayed extubation in patients aged zero to 18 years undergoing the Fontan procedure. Outcomes included reintubation (primary), ICU and hospital length of stay, ventilation time, mortality, and postoperative complications. Risk of bias was assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I); certainty of evidence was rated using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Four retrospective cohort studies met the inclusion criteria. EE was not associated with a higher risk of reintubation. EE was associated with a shorter ICU stay. There were no significant differences in hospital length of stay or pleural effusion. Mortality did not differ significantly between groups (pooled RR 0.30, 95% CI 0.08-1.18; p = 0.09). Across outcomes, statistical heterogeneity was low. Overall certainty of evidence was low, primarily due to observational designs and imprecision. In pediatric Fontan patients, EE appears safe and is associated with a shorter ICU stay without increased reintubation or mortality. These findings support EE within structured fast-track pathways for appropriately selected patients, while highlighting the need for prospective, higher-quality studies.