Delayed thoracoscopic repair helps preserve native oesophagus in long-gap oesophageal atresia

Preservation of the native oesophagus is generally considered the preferred strategy for long-gap oesophageal atresia (LGOA). This study aimed to assess whether delayed thoracoscopic repair of LGOA was associated to increase rate of oesophageal preservation.

Retrospective single-centre cohort study including patients with Gross type A or B managed between January 2006 and December 2025. Patients undergoing delayed anastomotic attempt were grouped according to operative approach (open or thoracoscopic). The primary outcome was successful native oesophageal preservation. Secondary outcomes included postoperative morbidity, anastomotic leak, anastomotic stricture, dilatation requirements, ICU length of stay, and feeding outcomes and time to achievement of exclusive oral feeding.

Fifty patients with LGOA were identified. An attempt at oesophageal preservation was performed in 45/50 patients: 20 with open and 25 with thoracoscopic approach. Oesophageal preservation was significantly higher in the thoracoscopic group (88% vs 35%; p = 0.0004). On multivariable logistic regression analysis, thoracoscopic approach remained independently associated with successful native oesophageal preservation (OR 25.31, 95% CI 1.69-378.5; p = 0.019). ICU length of stay, complications, and leak rate did not differ significantly between groups. Thoracoscopic repair was associated with significantly higher rates of stricture (88% vs 55%; p = 0.018) and increased dilatation requirements (median 3.0 vs 2.0 procedures; p = 0.044). Kaplan-Meier analysis showed no significant difference in time to achieve exclusive oral feeding (log-rank p = 0.549).

Thoracoscopic delayed repair of LGOA was associated with higher rates of native oesophageal preservation, without increased ICU stay or complication rate. This benefit occurs at the cost of increased anastomotic stricture, although feeding outcomes at 36 months were comparable between groups.