Comparative Analysis of Postoperative Outcomes and Complications of One-Stage Versus Staged Surgical Repair in Esophageal Atresia: A Retrospective Study from a Tertiary Pediatric Center

Comparative Analysis of Postoperative Outcomes and Complications of One-Stage Versus Staged Surgical Repair in Esophageal Atresia: A Retrospective Study from a Tertiary Pediatric Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Analysis of Postoperative Outcomes and Complications of One-Stage Versus Staged Surgical Repair in Esophageal Atresia: A Retrospective Study from a Tertiary Pediatric Center Rahman Khosravi, Hatef Alizadeh, Reyhaneh Aftabi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7077487/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background Esophageal atresia (EA) is a complex congenital anomaly requiring prompt surgical correction in neonates. The optimal approach between primary (one-stage) and staged (multi-stage) repair remains debated, especially in infants with comorbidities or long-gap defects. To compare postoperative outcomes and complications of one-stage versus staged surgical repair for EA in a tertiary pediatric center in Iran. Methods In this retrospective study, medical records of 115 neonates with EA treated between 2017 and 2024 at Motahari Pediatric Hospital were reviewed. Demographic features, associated anomalies, perioperative and postoperative complications, surgical duration, hospital stay, and survival rates were compared between the one-stage and two-stage repair groups using appropriate statistical tests. Results Of the 115 patients, 68 underwent primary repair and 47 staged repair. No significant differences were observed in postoperative complications, mortality, or hospital stay between the groups (p > 0.05). The mean operative time and hospitalization were longer in the two-stage group, but these differences did not reach statistical significance. Linear regression showed no significant association between chronological age and operative duration (B=-0.026, p = 0.570), nor between birth weight and operative duration (r=-0.040, p = 0.672). However, a significant inverse correlation between gestational age and surgical duration was observed (Spearman’s rho=-0.225, p = 0.016), suggesting that higher gestational age may be associated with shorter operative times. Conclusion One-stage and staged repairs provide comparable short-term outcomes in neonates with EA, supporting individualized surgical planning based on patient factors. The association between gestational age and operative duration warrants further investigation in prospective multicenter studies to optimize surgical decision-making and improve long-term results. Esophageal atresia Postoperative Outcomes Tracheoesophageal fistula Staged repair One-stage repair Introduction Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), represents one of the most challenging congenital anomalies in neonatal surgery. Characterized by a discontinuity of the esophagus, this condition prevents the normal passage of food from the oropharynx to the stomach and is often accompanied by a tracheoesophageal communication that can result in severe aspiration and respiratory compromise [ 1 ]. The incidence of EA/TEF is estimated at approximately 1 in 2,500 to 4,500 live births, with a slight male predominance, and nearly 50% of affected infants present with additional congenital anomalies, most commonly within the VACTERL spectrum (vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies) [ 2 , 3 ]. Surgical correction is the mainstay of treatment and is ideally performed within the first few days of life. The two principal surgical strategies are primary (one-stage) repair, where the esophageal continuity is restored in a single operation, and staged (multi-stage) repair, which involves initial gastrostomy or fistula ligation followed by delayed esophageal anastomosis [ 4 ]. While primary repair is generally preferred in cases with a short esophageal gap and stable physiology, a multi-stage approach is often chosen for infants with long-gap atresia, severe prematurity, low birth weight, or significant associated anomalies that preclude immediate definitive repair [ 5 , 6 ]. Despite being the cornerstone of neonatal surgical care, the optimal strategy for EA repair remains debated due to the wide variability in patient characteristics, institutional protocols, and surgical expertise. Primary repair offers benefits such as avoiding multiple surgeries, reduced hospital stays, and earlier enteral feeding. However, it may be associated with higher rates of intraoperative and early postoperative complications in high-risk neonates [ 7 ]. On the other hand, staged repair, while offering better perioperative stability, may prolong hospitalization and expose the infant to additional anesthesia-related risks and interstage complications such as feeding intolerance, sepsis, or deterioration of pulmonary status [ 8 , 9 ]. The postoperative outcomes of EA repair are influenced by a multitude of variables, including gestational age, birth weight, sex, comorbid anomalies, and timing of surgery. Surgical complications such as anastomotic leak, stricture formation, recurrent TEF, gastroesophageal reflux (GER), and tracheomalacia continue to pose significant clinical challenges [ 10 , 11 ]. Additionally, medical complications including sepsis, pneumonia, and long-term nutritional deficits further impact survival and quality of life in this vulnerable population [ 12 ]. There is a growing body of literature comparing the outcomes of different surgical strategies for EA, yet findings remain inconclusive. Some studies suggest that primary repair is associated with better survival and fewer complications, while others report no significant differences or even higher complication rates compared to staged repair, especially in neonates with long-gap EA or significant comorbidities [ 13 – 15 ]. Given these uncertainties, there is a compelling need for comprehensive, context-specific data comparing the demographic characteristics, surgical and medical complications, length of hospital stay, operative time, and associated anomalies between one-stage and multi-stage EA repairs. Such evidence is essential to guide clinical decision-making and develop tailored surgical approaches that balance risks and benefits for each individual patient. Most studies originate from high-resource settings; there is a lack of region-specific data from countries such as Iran, where resource limitations, neonatal care infrastructure, and patient characteristics may influence outcomes Therefore, this study aimed to compare the postoperative outcomes and complications of one-stage versus multi-stage surgical repair in neonates with EA in a tertiary Iranian center, to provide evidence-based guidance tailored to local practice. Materials and Methods Study Design and Setting This retrospective cohort study was conducted at Motahari Pediatric Hospital, a tertiary referral center in Urmia, Iran, between March 2017 and March 2024. Study Population All neonates diagnosed with esophageal atresia who underwent surgical repair during the study period were included. A census sampling strategy was employed, enrolling all eligible neonates without further sampling. Data Collection Data were extracted from medical records using a researcher-developed checklist that recorded demographic variables (gestational age, chronological age, sex, birth weight, weight at surgery), type of esophageal atresia, associated anomalies (vertebral, anal, cardiac, renal, limb), type of repair (one-stage or two-stage), perioperative complications (including sepsis and pneumonia), surgical complications (anastomotic leak, stricture, failed gastrostomy, gastroesophageal reflux), duration of surgery (minutes), length of hospital stay (days), and final discharge outcome (alive or deceased). Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics were reported as means ± standard deviation for continuous variables, and frequencies and percentages for categorical variables. The Shapiro–Wilk test assessed normality. The chi-square test or Fisher’s exact test was applied for categorical comparisons, and the independent-samples t-test or Mann–Whitney U test was used for continuous variables as appropriate. Linear regression, Pearson, and Spearman correlation analyses were used to assess relationships between gestational parameters and operative time. A p-value < 0.05 was considered statistically significant. Ethical Considerations This study was approved by the Ethics Committee of Urmia University of Medical Sciences (Approval code: IR.UMSU.REC.1403.085). All data were handled confidentially, and patient anonymity was preserved throughout data collection and analysis. Results A total of 115 neonates with esophageal atresia were included in this study. Among them, 68 underwent primary (one-stage) repair and 47 underwent staged (two-stage) repair. Demographic Characteristics Baseline characteristics were largely comparable between groups. The mean birth weight was higher in the one-stage group (2582.4 ± 588.9 g) compared to the two-stage group (2472.1 ± 555.8 g), though this difference was not statistically significant (p = 0.315). Gestational age also showed no significant difference between the two groups (p = 0.798), nor did chronological age at surgery (median rank 56.95 vs. 59.52, p = 0.683). However, a significant difference was observed in sex distribution, with a greater proportion of male neonates in the one-stage group (66.2%) versus the two-stage group (44.7%) (p = 0.022). Full details are presented in Table 1 . Table 1 Baseline Characteristics of Patients According to Surgical Approach Characteristic One-Stage Repair (n = 68) Staged Repair (n = 47) p-value Birth weight (g), mean ± SD 2582.4 ± 588.9 2472.1 ± 555.8 0.315 (Student’s t-test) Gestational age, n (%) : 0.798 (Chi-square test) 28–33 weeks 4 (5.9%) 4 (8.5%) 34–36 weeks 18 (26.5%) 9 (19.1%) 37–38 weeks 5 (7.4%) 4 (8.5%) 39–41 weeks 41 (60.3%) 30 (63.8%) Chronological age, mean ± SD 41.05 ± 127.9 39.75 ± 130.7 0.683 (Mann–Whitney U) Sex, n (%) : 0.022 (Chi-square test) Male 45 (66.2%) 21 (44.7%) Female 23 (33.8%) 26 (55.3%) Associated Anomalies The distribution of associated anomalies did not differ significantly between groups. Cardiac anomalies were the most prevalent, affecting 73.5% of patients in the one-stage group and 76.6% in the two-stage group (p = 0.828). Other anomalies—including anal, vertebral, renal, and limb anomalies—were evenly distributed between groups without significant differences (p = 0.138 to p = 1.000). Within the cardiac subgroup, the most common findings were patent foramen ovale (52.3%) and patent ductus arteriosus (41.9%). Tables 2 and 3 provide further details. Table 2 Associated Anomalies According to Surgical Approach Anomaly One-Stage Repair (n = 68) Staged Repair (n = 47) Total (n = 115) p-value (Fisher’s Exact) Vertebral anomaly 1 (1.5%) 2 (4.3%) 3 (2.6%) 0.566 Anal anomaly 5 (7.4%) 8 (17.0%) 13 (11.3%) 0.138 Tracheoesophageal fistula 12 (17.6%) 10 (21.3%) 22 (19.1%) 0.638 Renal anomaly 13 (19.1%) 7 (14.9%) 20 (17.4%) 0.624 Limb anomaly 2 (2.9%) 1 (2.1%) 3 (2.6%) 1.000 Cardiac anomaly 50 (73.5%) 36 (76.6%) 86 (74.8%) 0.828 Data are presented as number of patients (percentage of each group). Table 3 Detailed Distribution of Associated Anomalies System Specific Anomaly n % of All Responses % of Cases with Anomaly Cardiac Patent ductus arteriosus (PDA) 36 20.6% 41.9% Patent foramen ovale (PFO) 45 25.7% 52.3% Atrial septal defect (ASD) 29 16.6% 33.7% Tricuspid regurgitation (TR) 21 12.0% 24.4% Pulmonary hypertension 10 5.7% 11.6% Ventricular septal defect (VSD) 10 5.7% 11.6% Other minor lesions (including PI, MR, TOF, PS, etc.) 24 13.7% 27.9% Anorectal Anal stenosis 10 62.5% 76.9% Fistula 5 31.3% 38.5% Imperforate anus 1 6.3% 7.7% Limb General limb anomaly 47 94.0% 95.9% Other (thumb deformity, polydactyly, etc.) 3 6.0% 6.1% Renal Renal agenesis 4 20.0% 20.0% Severe hydronephrosis 4 20.0% 20.0% Other (hematoma, nephrocalcinosis, etc.) 12 60.0% 60.0% Multiple anomalies may occur in one patient (total exceeding 100%). Postoperative Complications Rates of postoperative complications were similar between the two surgical approaches. Anastomotic strictures were observed in 7.8% of all patients, with no significant difference between the one-stage (5.9%) and two-stage (10.6%) groups (p = 0.483). Other complications—including gastroesophageal reflux, anastomotic leakage, failed gastrostomy, wound infections, sepsis, and pneumonia—also showed no significant differences between groups (all p > 0.1). These findings are summarized in Table 4 . Table 4 Postoperative Complications by Surgical Approach Complication One-Stage (n = 68) Staged (n = 47) Total (n = 115) p-value (Fisher’s Exact) Anastomotic stricture 4 (5.9%) 5 (10.6%) 9 (7.8%) 0.483 Gastroesophageal reflux 1 (1.5%) 2 (4.3%) 3 (2.6%) 0.566 Anastomotic leak 3 (4.4%) 1 (2.1%) 4 (3.5%) 0.644 Failed gastrostomy 1 (1.5%) 4 (8.5%) 5 (4.3%) 0.157 Wound infection 0 (0.0%) 1 (2.1%) 1 (0.9%) 0.409 Sepsis 7 (10.3%) 3 (6.4%) 10 (8.7%) 0.524 Pneumonia 8 (11.8%) 6 (12.8%) 14 (12.2%) 1.000 Data are shown as number of patients (% of group). Clinical Outcomes Final survival rates were comparable between the groups (79.4% alive in the one-stage group versus 78.7% in the two-stage group; p = 0.929). The mean length of hospital stay was longer in the two-stage group (22.5 ± 16.4 days) compared to the one-stage group (17.8 ± 10.2 days), though this difference did not reach statistical significance (mean difference = − 4.65 days, 95% CI − 9.57 to 0.27; p = 0.064). Likewise, mean operative duration was longer in the two-stage group (146.8 ± 78.4 minutes) than in the one-stage group (125.0 ± 44.4 minutes), but this difference was also not statistically significant (mean difference = − 21.8 minutes, 95% CI − 44.6 to 0.96; p = 0.060). Refer to Table 5 for detailed information. Table 5 Comparison of Clinical Outcomes Outcome One-Stage Repair (n = 68) Staged Repair (n = 47) p-value Final outcome (alive) 54 (79.4%) 37 (78.7%) 0.929 (Chi-square) Length of stay (days) 17.8 ± 10.2 22.5 ± 16.4 0.064 (t-test) Surgery duration (min) 125.0 ± 44.4 146.8 ± 78.4 0.060 (t-test) Correlation Analyses Linear regression demonstrated no significant association between chronological age at admission and operative duration (B = − 0.026, SE = 0.046, p = 0.570), nor between birth weight and operative duration (r = − 0.040, p = 0.672). However, Spearman correlation revealed a significant inverse association between gestational age and operative time (rho = − 0.225, p = 0.016), suggesting that higher gestational age was associated with shorter operative duration. These findings are summarized in Table 6 . Table 6 Associations Between Gestational Parameters and Surgery Duration Variable Coefficient / Correlation (B / r / ρ) Standard Error (SE) p-value Chronological Age (linear regression) -0.026 0.046 0.570 Birth Weight (Pearson correlation) -0.040 — 0.672 Gestational Age (Spearman correlation) -0.225 — 0.016 Note: Linear regression was used for chronological age and surgery duration. Pearson correlation was applied for birth weight and surgery duration. Spearman correlation was used for gestational age and surgery duration due to its ordinal nature. Taken together, these results indicate no significant differences in early mortality, major complications, or length of hospitalization between one-stage and two-stage repair techniques. Nevertheless, the trend toward longer operative times and hospital stays in the staged group merits further investigation with larger cohorts. Discussion This study provides a comparative evaluation of one-stage versus staged surgical repair in neonates with esophageal atresia, focusing on postoperative outcomes and complications in a tertiary pediatric referral center. The results demonstrated no statistically significant differences between the two groups in terms of early postoperative mortality, major surgical complications, or medical morbidities such as sepsis and pneumonia. These findings are consistent with previous studies suggesting that the choice of surgical approach should be based on individual patient characteristics and perioperative stability rather than the assumption of superiority of either technique [ 1 , 16 , 17 ]. Although no significant differences were detected, the two-stage repair group demonstrated a trend toward longer operative times and prolonged hospital stays. This observation aligns with prior literature indicating that staged repair, while potentially beneficial in high-risk or unstable neonates, may be associated with higher cumulative surgical exposure, increased risk of interstage complications, and extended dependence on parenteral nutrition [ 7 , 18 , 19 ]. In contrast, primary repair offers the advantage of immediate restoration of esophageal continuity, which may facilitate earlier enteral feeding and reduced hospitalization in appropriately selected patients with favorable anatomy and physiology [ 20 , 21 ]. An important secondary observation of this study was the relationship between gestational parameters and operative duration. While chronological age and birth weight did not significantly affect operative time, a modest but significant inverse correlation was found between gestational age and surgical duration. This may reflect improved tissue resilience, easier tissue handling, and reduced technical challenges in more mature neonates [ 22 , 23 ]. However, the relatively small effect size suggests that gestational age alone cannot predict surgical complexity and should be interpreted alongside other clinical factors such as esophageal gap length, comorbid anomalies, and ventilatory status Furthermore, the distribution of associated anomalies, particularly cardiac anomalies, was similar across both groups. As previous studies have shown, cardiac anomalies are the most common associated conditions in neonates with EA, highlighting the necessity for comprehensive preoperative cardiac evaluation and multidisciplinary perioperative management [ 2 , 24 ]. This supports the importance of individualized surgical planning to optimize outcomes in this complex patient population. Despite providing meaningful comparative data on short-term outcomes, this study is limited by its exclusive focus on early postoperative results. Long-term functional outcomes such as feeding difficulties, growth patterns, neurodevelopment, and quality of life were not evaluated, limiting comprehensive assessment of the true clinical impact of each surgical approach. Future longitudinal studies with standardized follow-up are necessary to better understand these critical endpoints. Moreover, while gestational age and cardiac anomalies were found to influence operative duration, the complex interaction of these factors with intraoperative challenges and postoperative recovery remains insufficiently explored. A deeper analysis of these relationships would enhance understanding of surgical complexity and patient prognosis. The noted trend toward longer hospitalization and operative time in staged repairs may also be influenced by confounding variables such as institutional protocols, surgeon experience, and perioperative care differences that were not controlled for in this retrospective study. Addressing these factors in future research would strengthen the validity and generalizability of findings. Overall, these findings reinforce that a tailored, patient-centered approach should be the standard of care when selecting between one-stage and staged repairs for esophageal atresia. Neither surgical strategy showed definitive superiority in this study, emphasizing the need for flexible decision-making based on the infant’s risk profile, anatomical factors, and institutional resources. Limitations of this study include its retrospective single-center design, which may limit generalizability and introduce potential selection and information bias. Additionally, the sample size might have been insufficient to detect subtle differences in rare complications. Moreover, long-term functional outcomes such as feeding difficulties, gastroesophageal reflux–related respiratory symptoms, and neurodevelopmental sequelae were not assessed, which should be addressed in future research. Prospective, multicenter studies with larger sample sizes and standardized follow-up protocols are strongly recommended to better define long-term outcomes and to establish evidence-based guidelines for optimal surgical management. In conclusion, this study suggests that one-stage and staged repair techniques offer comparable early postoperative outcomes in neonates with esophageal atresia. However, the observed association between greater gestational maturity and shorter operative duration, along with the trend toward longer hospital stays in staged repairs, warrants further investigation. Future multicenter and prospective studies will be critical to validate these findings and to optimize care pathways for this vulnerable patient population. Conclusion In this retrospective comparative study of neonates undergoing one-stage versus staged surgical repair for esophageal atresia, no significant differences were identified in early postoperative outcomes, including mortality, major surgical complications, or medical morbidities. Both approaches demonstrated comparable short-term safety profiles, supporting the feasibility of individualized surgical selection based on patient-specific factors and anatomical considerations. Although the two-stage repair group showed a tendency toward longer operative duration and hospital stay, these differences did not reach statistical significance, underlining the need for larger, adequately powered studies to fully evaluate their clinical relevance. Furthermore, the observed inverse association between gestational age and operative time suggests that higher gestational maturity may modestly facilitate surgical handling and reduce procedural complexity, although this relationship requires further prospective validation. Ultimately, this study highlights the importance of a patient-centered, multidisciplinary approach to the surgical management of esophageal atresia, integrating gestational age, birth weight, associated anomalies, and perioperative stability into decision-making. Future multicenter, prospective investigations with standardized follow-up are essential to establish robust, evidence-based guidelines and to assess long-term functional and quality-of-life outcomes for this vulnerable neonatal population. Declarations Acknowledgment 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. Author’s Contribution 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 Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Conflict of interest The authors declare no competing interests. Ethics Statement 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 Decleration and its later amendments or comparable ethical standards. All data were anonymized before analysis, and no identifiable patient information or images are included in this article. Human Ethics and Consent to Participate declarations Not applicable (retrospective study with anonymized data, waived consent). Clinical Trial Registration Clinical trial number: not applicable. Consent to publish declaration Not applicable. References Van Lennep M, Singendonk MM, Dall’Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SW et al. (2019) Oesophageal atresia. Nature Reviews disease primers; 5(1): 26. Shaw-Smith C. Oesophageal atresia, tracheo-oesophageal fistula, and the VACTERL association: review of genetics and epidemiology. J Med Genet. 2006;43(7):545–54. Stoll C, Alembik Y, Dott B, Roth MP. Associated anomalies in cases with esophageal atresia. Am J Med Genet A. 2017;173(8):2139–57. El-Gohary Y, Gittes GK, Tovar JA, editors. Congenital anomalies of the esophagus. Seminars in pediatric surgery. Elsevier; 2010. Sulkowski JP, Cooper JN, Lopez JJ, Jadcherla Y, Cuenot A, Mattei P, et al. Morbidity and mortality in patients with esophageal atresia. Surgery. 2014;156(2):483–91. Okuyama H, Tazuke Y, Uenoa T, Yamanaka H, Takama Y, Saka R, et al. Long-term morbidity in adolescents and young adults with surgically treated esophageal atresia. Surg Today. 2017;47:872–6. Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2017;52(8):1245–51. Galazka P, Skinder D, Styczynski J. Use of Staged vs. Primary Repair in Thoracoscopic Esophageal Atresia Repair. J Pediatr Surg. 2024;59(3):357–62. Dimitrov G, Aumar M, Duhamel A, Wanneveich M, Gottrand F. Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis. J Pediatr Gastroenterol Nutr. 2024;78(3):457–70. Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, et al. Posterior tracheopexy for severe tracheomalacia associated with esophageal atresia (EA): primary treatment at the time of initial EA repair versus secondary treatment. Front Surg. 2018;4:80. Legrand C, Michaud L, Salleron J, Neut D, Sfeir R, Thumerelle C, et al. Long-term outcome of children with oesophageal atresia type III. Arch Dis Child. 2012;97(9):808–11. Ten Kate CA, Rietman AB, Van de Wijngaert Y, van Gils-Frijters A, Gischler SJ, Keyzer-Dekker CM, et al. Longitudinal health status and quality of life after esophageal atresia repair. J Pediatr Gastroenterol Nutr. 2021;73(6):695–702. Chen H, Chen Z-X, Shi G-Q. Risk factors and prevention and treatment methods of anastomotic stricture after esophageal atresia repair: a literature review. Pediatr Surg Int. 2025;41(1):99. Wu Y, Kuang H, Lv T, Wu C. Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis. Pediatr Surg Int. 2017;33:1147–57. Beasley SW. Oesophageal atresia and tracheo-oesophageal fistula. Surg (Oxford). 2022;40(11):708–12. Kapapa M, Weber D, Serra A. Oesophageal atresia: Clinical outcome after surgical treatment. J Surg Res. 2023;6:401–10. Davenport M, Jawaid WB, Losty PD. UK paediatric surgical academic output (2005–2020): A cause for concern? J Pediatr Surg. 2021;56(12):2142–7. Bagolan P, Valfrè L, Morini F, Conforti A. Long-gap esophageal atresia: traction-growth and anastomosis–before and beyond. Dis Esophagus. 2013;26(4):372–9. Chakraborty P, Roy S, Mandal KC, Halder PK, Jana G, Paul K. Esophageal atresia and tracheoesophageal fistula: a retrospective review from a tertiary care institute. J West Afr Coll Surg. 2022;12(3):30–6. Baird R, Levesque D, Birnbaum R, Ramsay M. A pilot investigation of feeding problems in children with esophageal atresia. Dis Esophagus. 2015;28(3):224–8. Tambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V et al. (2017) Anastomotic strictures after esophageal atresia repair: incidence, investigations, and management, including treatment of refractory and recurrent strictures. Frontiers in pediatrics; 5: 120. Parsons A, Netsanet A, Seedorf G, Abman SH, Taglauer ES. Understanding the role of placental pathophysiology in the development of bronchopulmonary dysplasia. Am J Physiology-Lung Cell Mol Physiol. 2022;323(6):L651–8. Samraj P, Chakraborty G, Sugandhi N, Shoor G, Acharya SK, Jadhav A, et al. Primary anastomosis in difficult cases of type C esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome. J Pediatr Surg. 2021;56(5):1076–81. Rahman NA, Abdullah MY, Abidin MAZ, Nah SA. Burden and mortality of congenital gastrointestinal anomalies: insights from a nationwide cohort study. Pediatr Surg Int. 2024;40(1):270. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 04 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviews received at journal 31 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers agreed at journal 25 Jul, 2025 Reviewers invited by journal 24 Jul, 2025 Editor invited by journal 16 Jul, 2025 Editor assigned by journal 11 Jul, 2025 Submission checks completed at journal 11 Jul, 2025 First submitted to journal 08 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7077487","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491441713,"identity":"21e093c1-789d-4bf7-b041-6eeec9e3b4f7","order_by":0,"name":"Rahman Khosravi","email":"","orcid":"","institution":"Urmia University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rahman","middleName":"","lastName":"Khosravi","suffix":""},{"id":491441715,"identity":"e3181f85-ccc2-4cab-8baf-c20ddb76acae","order_by":1,"name":"Hatef Alizadeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYBACAxBRwcAgw8bAfADIlJAhQgszA8MZBgYeNga2BJAWHuK1ABHYRsJazNnPH3xwgMGOh4//zOdXN2oseBjYDx/dgE+LZU8ys8EBhmSgw85us845BnQYT1raDbwOO5DMJv2BgZmHjbF3m3EOG1CLBI8Zfi3nH7P/OMBQz8PGzPPMOOcfMVpuJLMxHGA4zMPGxsP8OLeNKC2PjSUOGBznYeNhM2PO7ZMAMgj55Xziww8HKqrl5PsPP/6c861Ojp/98DG8WqAawSSbBJgkrBwBmD+QonoUjIJRMApGDgAAyFo/luDS2m8AAAAASUVORK5CYII=","orcid":"","institution":"Urmia University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Hatef","middleName":"","lastName":"Alizadeh","suffix":""},{"id":491441718,"identity":"24b1927f-52d7-4e59-9269-d7b70d1ccfbc","order_by":2,"name":"Reyhaneh Aftabi","email":"","orcid":"","institution":"Urmia University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Reyhaneh","middleName":"","lastName":"Aftabi","suffix":""}],"badges":[],"createdAt":"2025-07-08 18:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7077487/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7077487/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03300-1","type":"published","date":"2025-11-19T15:58:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96650213,"identity":"2eb920fe-4ffa-42dd-b2a8-19229d512aeb","added_by":"auto","created_at":"2025-11-24 16:09:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":935381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7077487/v1/9f5db4a0-b04f-44b2-ac5c-fcf5242e38c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Analysis of Postoperative Outcomes and Complications of One-Stage Versus Staged Surgical Repair in Esophageal Atresia: A Retrospective Study from a Tertiary Pediatric Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEsophageal atresia (EA), with or without tracheoesophageal fistula (TEF), represents one of the most challenging congenital anomalies in neonatal surgery. Characterized by a discontinuity of the esophagus, this condition prevents the normal passage of food from the oropharynx to the stomach and is often accompanied by a tracheoesophageal communication that can result in severe aspiration and respiratory compromise [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The incidence of EA/TEF is estimated at approximately 1 in 2,500 to 4,500 live births, with a slight male predominance, and nearly 50% of affected infants present with additional congenital anomalies, most commonly within the VACTERL spectrum (vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgical correction is the mainstay of treatment and is ideally performed within the first few days of life. The two principal surgical strategies are primary (one-stage) repair, where the esophageal continuity is restored in a single operation, and staged (multi-stage) repair, which involves initial gastrostomy or fistula ligation followed by delayed esophageal anastomosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While primary repair is generally preferred in cases with a short esophageal gap and stable physiology, a multi-stage approach is often chosen for infants with long-gap atresia, severe prematurity, low birth weight, or significant associated anomalies that preclude immediate definitive repair [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite being the cornerstone of neonatal surgical care, the optimal strategy for EA repair remains debated due to the wide variability in patient characteristics, institutional protocols, and surgical expertise. Primary repair offers benefits such as avoiding multiple surgeries, reduced hospital stays, and earlier enteral feeding. However, it may be associated with higher rates of intraoperative and early postoperative complications in high-risk neonates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. On the other hand, staged repair, while offering better perioperative stability, may prolong hospitalization and expose the infant to additional anesthesia-related risks and interstage complications such as feeding intolerance, sepsis, or deterioration of pulmonary status [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe postoperative outcomes of EA repair are influenced by a multitude of variables, including gestational age, birth weight, sex, comorbid anomalies, and timing of surgery. Surgical complications such as anastomotic leak, stricture formation, recurrent TEF, gastroesophageal reflux (GER), and tracheomalacia continue to pose significant clinical challenges [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, medical complications including sepsis, pneumonia, and long-term nutritional deficits further impact survival and quality of life in this vulnerable population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere is a growing body of literature comparing the outcomes of different surgical strategies for EA, yet findings remain inconclusive. Some studies suggest that primary repair is associated with better survival and fewer complications, while others report no significant differences or even higher complication rates compared to staged repair, especially in neonates with long-gap EA or significant comorbidities [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Given these uncertainties, there is a compelling need for comprehensive, context-specific data comparing the demographic characteristics, surgical and medical complications, length of hospital stay, operative time, and associated anomalies between one-stage and multi-stage EA repairs. Such evidence is essential to guide clinical decision-making and develop tailored surgical approaches that balance risks and benefits for each individual patient. Most studies originate from high-resource settings; there is a lack of region-specific data from countries such as Iran, where resource limitations, neonatal care infrastructure, and patient characteristics may influence outcomes\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to compare the postoperative outcomes and complications of one-stage versus multi-stage surgical repair in neonates with EA in a tertiary Iranian center, to provide evidence-based guidance tailored to local practice.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective cohort study was conducted at Motahari Pediatric Hospital, a tertiary referral center in Urmia, Iran, between March 2017 and March 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll neonates diagnosed with esophageal atresia who underwent surgical repair during the study period were included. A census sampling strategy was employed, enrolling all eligible neonates without further sampling.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData were extracted from medical records using a researcher-developed checklist that recorded demographic variables (gestational age, chronological age, sex, birth weight, weight at surgery), type of esophageal atresia, associated anomalies (vertebral, anal, cardiac, renal, limb), type of repair (one-stage or two-stage), perioperative complications (including sepsis and pneumonia), surgical complications (anastomotic leak, stricture, failed gastrostomy, gastroesophageal reflux), duration of surgery (minutes), length of hospital stay (days), and final discharge outcome (alive or deceased).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics were reported as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables, and frequencies and percentages for categorical variables. The Shapiro\u0026ndash;Wilk test assessed normality. The chi-square test or Fisher\u0026rsquo;s exact test was applied for categorical comparisons, and the independent-samples t-test or Mann\u0026ndash;Whitney U test was used for continuous variables as appropriate. Linear regression, Pearson, and Spearman correlation analyses were used to assess relationships between gestational parameters and operative time. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study was approved by the Ethics Committee of Urmia University of Medical Sciences (Approval code: IR.UMSU.REC.1403.085). All data were handled confidentially, and patient anonymity was preserved throughout data collection and analysis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 115 neonates with esophageal atresia were included in this study. Among them, 68 underwent primary (one-stage) repair and 47 underwent staged (two-stage) repair.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDemographic Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBaseline characteristics were largely comparable between groups. The mean birth weight was higher in the one-stage group (2582.4\u0026thinsp;\u0026plusmn;\u0026thinsp;588.9 g) compared to the two-stage group (2472.1\u0026thinsp;\u0026plusmn;\u0026thinsp;555.8 g), though this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.315). Gestational age also showed no significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.798), nor did chronological age at surgery (median rank 56.95 vs. 59.52, p\u0026thinsp;=\u0026thinsp;0.683). However, a significant difference was observed in sex distribution, with a greater proportion of male neonates in the one-stage group (66.2%) versus the two-stage group (44.7%) (p\u0026thinsp;=\u0026thinsp;0.022). Full details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics of Patients According to Surgical Approach\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-Stage Repair (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStaged Repair (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth weight (g), mean\u003c/b\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2582.4\u0026thinsp;\u0026plusmn;\u0026thinsp;588.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2472.1\u0026thinsp;\u0026plusmn;\u0026thinsp;555.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.315 (Student\u0026rsquo;s t-test)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational age, n (%)\u003c/b\u003e:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.798 (Chi-square test)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e28\u0026ndash;33 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (5.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e34\u0026ndash;36 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (26.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e37\u0026ndash;38 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (7.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e39\u0026ndash;41 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (60.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (63.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChronological age, mean\u003c/b\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.05\u0026thinsp;\u0026plusmn;\u0026thinsp;127.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.75\u0026thinsp;\u0026plusmn;\u0026thinsp;130.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.683 (Mann\u0026ndash;Whitney U)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.022 (Chi-square test)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (66.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (33.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (55.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAssociated Anomalies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe distribution of associated anomalies did not differ significantly between groups. Cardiac anomalies were the most prevalent, affecting 73.5% of patients in the one-stage group and 76.6% in the two-stage group (p\u0026thinsp;=\u0026thinsp;0.828). Other anomalies\u0026mdash;including anal, vertebral, renal, and limb anomalies\u0026mdash;were evenly distributed between groups without significant differences (p\u0026thinsp;=\u0026thinsp;0.138 to p\u0026thinsp;=\u0026thinsp;1.000). Within the cardiac subgroup, the most common findings were patent foramen ovale (52.3%) and patent ductus arteriosus (41.9%). Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provide further details.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociated Anomalies According to Surgical Approach\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnomaly\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-Stage Repair (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStaged Repair (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value (Fisher\u0026rsquo;s Exact)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVertebral anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.566\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnal anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (7.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13 (11.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTracheoesophageal fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (17.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (21.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.638\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRenal anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (14.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20 (17.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.624\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (2.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardiac anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50 (73.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36 (76.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86 (74.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.828\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eData are presented as number of patients (percentage of each group).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDetailed Distribution of Associated Anomalies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpecific Anomaly\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% of All Responses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% of Cases with Anomaly\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCardiac\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatent ductus arteriosus (PDA)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e41.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatent foramen ovale (PFO)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e52.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAtrial septal defect (ASD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTricuspid regurgitation (TR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePulmonary hypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVentricular septal defect (VSD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther minor lesions (including PI, MR, TOF, PS, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnorectal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnal stenosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e76.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e38.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImperforate anus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLimb\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral limb anomaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e94.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e95.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther (thumb deformity, polydactyly, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRenal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRenal agenesis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere hydronephrosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther (hematoma, nephrocalcinosis, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eMultiple anomalies may occur in one patient (total exceeding 100%).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostoperative Complications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRates of postoperative complications were similar between the two surgical approaches. Anastomotic strictures were observed in 7.8% of all patients, with no significant difference between the one-stage (5.9%) and two-stage (10.6%) groups (p\u0026thinsp;=\u0026thinsp;0.483). Other complications\u0026mdash;including gastroesophageal reflux, anastomotic leakage, failed gastrostomy, wound infections, sepsis, and pneumonia\u0026mdash;also showed no significant differences between groups (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.1). These findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative Complications by Surgical Approach\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-Stage (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStaged (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value (Fisher\u0026rsquo;s Exact)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnastomotic stricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (5.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (10.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (7.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.483\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastroesophageal reflux\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.566\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnastomotic leak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (4.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (3.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.644\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailed gastrostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWound infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (0.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSepsis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (10.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (6.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10 (8.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.524\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (12.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14 (12.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eData are shown as number of patients (% of group).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFinal survival rates were comparable between the groups (79.4% alive in the one-stage group versus 78.7% in the two-stage group; p\u0026thinsp;=\u0026thinsp;0.929). The mean length of hospital stay was longer in the two-stage group (22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4 days) compared to the one-stage group (17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 days), though this difference did not reach statistical significance (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;4.65 days, 95% CI \u0026minus;\u0026thinsp;9.57 to 0.27; p\u0026thinsp;=\u0026thinsp;0.064). Likewise, mean operative duration was longer in the two-stage group (146.8\u0026thinsp;\u0026plusmn;\u0026thinsp;78.4 minutes) than in the one-stage group (125.0\u0026thinsp;\u0026plusmn;\u0026thinsp;44.4 minutes), but this difference was also not statistically significant (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;21.8 minutes, 95% CI \u0026minus;\u0026thinsp;44.6 to 0.96; p\u0026thinsp;=\u0026thinsp;0.060). Refer to Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e for detailed information.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Clinical Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-Stage Repair (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStaged Repair (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinal outcome (alive)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54 (79.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (78.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.929 (Chi-square)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.064 (t-test)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e125.0\u0026thinsp;\u0026plusmn;\u0026thinsp;44.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146.8\u0026thinsp;\u0026plusmn;\u0026thinsp;78.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.060 (t-test)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCorrelation Analyses\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLinear regression demonstrated no significant association between chronological age at admission and operative duration (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.026, SE\u0026thinsp;=\u0026thinsp;0.046, p\u0026thinsp;=\u0026thinsp;0.570), nor between birth weight and operative duration (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.040, p\u0026thinsp;=\u0026thinsp;0.672). However, Spearman correlation revealed a significant inverse association between gestational age and operative time (rho\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.225, p\u0026thinsp;=\u0026thinsp;0.016), suggesting that higher gestational age was associated with shorter operative duration. These findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociations Between Gestational Parameters and Surgery Duration\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoefficient / Correlation (B / r / ρ)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard Error (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronological Age (linear regression)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.570\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth Weight (Pearson correlation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.672\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational Age (Spearman correlation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003eNote: Linear regression was used for chronological age and surgery duration. Pearson correlation was applied for birth weight and surgery duration. Spearman correlation was used for gestational age and surgery duration due to its ordinal nature.\u003c/p\u003e\u003cp\u003eTaken together, these results indicate no significant differences in early mortality, major complications, or length of hospitalization between one-stage and two-stage repair techniques. Nevertheless, the trend toward longer operative times and hospital stays in the staged group merits further investigation with larger cohorts.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comparative evaluation of one-stage versus staged surgical repair in neonates with esophageal atresia, focusing on postoperative outcomes and complications in a tertiary pediatric referral center. The results demonstrated no statistically significant differences between the two groups in terms of early postoperative mortality, major surgical complications, or medical morbidities such as sepsis and pneumonia. These findings are consistent with previous studies suggesting that the choice of surgical approach should be based on individual patient characteristics and perioperative stability rather than the assumption of superiority of either technique [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough no significant differences were detected, the two-stage repair group demonstrated a trend toward longer operative times and prolonged hospital stays. This observation aligns with prior literature indicating that staged repair, while potentially beneficial in high-risk or unstable neonates, may be associated with higher cumulative surgical exposure, increased risk of interstage complications, and extended dependence on parenteral nutrition [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In contrast, primary repair offers the advantage of immediate restoration of esophageal continuity, which may facilitate earlier enteral feeding and reduced hospitalization in appropriately selected patients with favorable anatomy and physiology [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAn important secondary observation of this study was the relationship between gestational parameters and operative duration. While chronological age and birth weight did not significantly affect operative time, a modest but significant inverse correlation was found between gestational age and surgical duration. This may reflect improved tissue resilience, easier tissue handling, and reduced technical challenges in more mature neonates [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the relatively small effect size suggests that gestational age alone cannot predict surgical complexity and should be interpreted alongside other clinical factors such as esophageal gap length, comorbid anomalies, and ventilatory status\u003c/p\u003e\u003cp\u003eFurthermore, the distribution of associated anomalies, particularly cardiac anomalies, was similar across both groups. As previous studies have shown, cardiac anomalies are the most common associated conditions in neonates with EA, highlighting the necessity for comprehensive preoperative cardiac evaluation and multidisciplinary perioperative management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This supports the importance of individualized surgical planning to optimize outcomes in this complex patient population.\u003c/p\u003e\u003cp\u003eDespite providing meaningful comparative data on short-term outcomes, this study is limited by its exclusive focus on early postoperative results. Long-term functional outcomes such as feeding difficulties, growth patterns, neurodevelopment, and quality of life were not evaluated, limiting comprehensive assessment of the true clinical impact of each surgical approach. Future longitudinal studies with standardized follow-up are necessary to better understand these critical endpoints.\u003c/p\u003e\u003cp\u003eMoreover, while gestational age and cardiac anomalies were found to influence operative duration, the complex interaction of these factors with intraoperative challenges and postoperative recovery remains insufficiently explored. A deeper analysis of these relationships would enhance understanding of surgical complexity and patient prognosis.\u003c/p\u003e\u003cp\u003eThe noted trend toward longer hospitalization and operative time in staged repairs may also be influenced by confounding variables such as institutional protocols, surgeon experience, and perioperative care differences that were not controlled for in this retrospective study. Addressing these factors in future research would strengthen the validity and generalizability of findings.\u003c/p\u003e\u003cp\u003eOverall, these findings reinforce that a tailored, patient-centered approach should be the standard of care when selecting between one-stage and staged repairs for esophageal atresia. Neither surgical strategy showed definitive superiority in this study, emphasizing the need for flexible decision-making based on the infant\u0026rsquo;s risk profile, anatomical factors, and institutional resources.\u003c/p\u003e\u003cp\u003eLimitations of this study include its retrospective single-center design, which may limit generalizability and introduce potential selection and information bias. Additionally, the sample size might have been insufficient to detect subtle differences in rare complications. Moreover, long-term functional outcomes such as feeding difficulties, gastroesophageal reflux\u0026ndash;related respiratory symptoms, and neurodevelopmental sequelae were not assessed, which should be addressed in future research. Prospective, multicenter studies with larger sample sizes and standardized follow-up protocols are strongly recommended to better define long-term outcomes and to establish evidence-based guidelines for optimal surgical management.\u003c/p\u003e\u003cp\u003eIn conclusion, this study suggests that one-stage and staged repair techniques offer comparable early postoperative outcomes in neonates with esophageal atresia. However, the observed association between greater gestational maturity and shorter operative duration, along with the trend toward longer hospital stays in staged repairs, warrants further investigation. Future multicenter and prospective studies will be critical to validate these findings and to optimize care pathways for this vulnerable patient population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this retrospective comparative study of neonates undergoing one-stage versus staged surgical repair for esophageal atresia, no significant differences were identified in early postoperative outcomes, including mortality, major surgical complications, or medical morbidities. Both approaches demonstrated comparable short-term safety profiles, supporting the feasibility of individualized surgical selection based on patient-specific factors and anatomical considerations.\u003c/p\u003e\u003cp\u003eAlthough the two-stage repair group showed a tendency toward longer operative duration and hospital stay, these differences did not reach statistical significance, underlining the need for larger, adequately powered studies to fully evaluate their clinical relevance. Furthermore, the observed inverse association between gestational age and operative time suggests that higher gestational maturity may modestly facilitate surgical handling and reduce procedural complexity, although this relationship requires further prospective validation.\u003c/p\u003e\u003cp\u003eUltimately, this study highlights the importance of a patient-centered, multidisciplinary approach to the surgical management of esophageal atresia, integrating gestational age, birth weight, associated anomalies, and perioperative stability into decision-making. Future multicenter, prospective investigations with standardized follow-up are essential to establish robust, evidence-based guidelines and to assess long-term functional and quality-of-life outcomes for this vulnerable neonatal population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR. 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis 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 Decleration and its later amendments or comparable ethical standards. All data were anonymized before analysis, and no identifiable patient information or images are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable (retrospective study with anonymized data, waived consent).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVan Lennep M, Singendonk MM, Dall\u0026rsquo;Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SW et al. (2019) Oesophageal atresia. Nature Reviews disease primers; 5(1): 26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShaw-Smith C. Oesophageal atresia, tracheo-oesophageal fistula, and the VACTERL association: review of genetics and epidemiology. J Med Genet. 2006;43(7):545\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStoll C, Alembik Y, Dott B, Roth MP. Associated anomalies in cases with esophageal atresia. Am J Med Genet A. 2017;173(8):2139\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl-Gohary Y, Gittes GK, Tovar JA, editors. Congenital anomalies of the esophagus. Seminars in pediatric surgery. Elsevier; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSulkowski JP, Cooper JN, Lopez JJ, Jadcherla Y, Cuenot A, Mattei P, et al. Morbidity and mortality in patients with esophageal atresia. Surgery. 2014;156(2):483\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOkuyama H, Tazuke Y, Uenoa T, Yamanaka H, Takama Y, Saka R, et al. Long-term morbidity in adolescents and young adults with surgically treated esophageal atresia. Surg Today. 2017;47:872\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2017;52(8):1245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGalazka P, Skinder D, Styczynski J. Use of Staged vs. Primary Repair in Thoracoscopic Esophageal Atresia Repair. J Pediatr Surg. 2024;59(3):357\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDimitrov G, Aumar M, Duhamel A, Wanneveich M, Gottrand F. Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis. J Pediatr Gastroenterol Nutr. 2024;78(3):457\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, et al. Posterior tracheopexy for severe tracheomalacia associated with esophageal atresia (EA): primary treatment at the time of initial EA repair versus secondary treatment. Front Surg. 2018;4:80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLegrand C, Michaud L, Salleron J, Neut D, Sfeir R, Thumerelle C, et al. Long-term outcome of children with oesophageal atresia type III. Arch Dis Child. 2012;97(9):808\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTen Kate CA, Rietman AB, Van de Wijngaert Y, van Gils-Frijters A, Gischler SJ, Keyzer-Dekker CM, et al. Longitudinal health status and quality of life after esophageal atresia repair. J Pediatr Gastroenterol Nutr. 2021;73(6):695\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen H, Chen Z-X, Shi G-Q. Risk factors and prevention and treatment methods of anastomotic stricture after esophageal atresia repair: a literature review. Pediatr Surg Int. 2025;41(1):99.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu Y, Kuang H, Lv T, Wu C. Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis. Pediatr Surg Int. 2017;33:1147\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeasley SW. Oesophageal atresia and tracheo-oesophageal fistula. Surg (Oxford). 2022;40(11):708\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKapapa M, Weber D, Serra A. Oesophageal atresia: Clinical outcome after surgical treatment. J Surg Res. 2023;6:401\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavenport M, Jawaid WB, Losty PD. UK paediatric surgical academic output (2005\u0026ndash;2020): A cause for concern? J Pediatr Surg. 2021;56(12):2142\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBagolan P, Valfr\u0026egrave; L, Morini F, Conforti A. Long-gap esophageal atresia: traction-growth and anastomosis\u0026ndash;before and beyond. Dis Esophagus. 2013;26(4):372\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChakraborty P, Roy S, Mandal KC, Halder PK, Jana G, Paul K. Esophageal atresia and tracheoesophageal fistula: a retrospective review from a tertiary care institute. J West Afr Coll Surg. 2022;12(3):30\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaird R, Levesque D, Birnbaum R, Ramsay M. A pilot investigation of feeding problems in children with esophageal atresia. Dis Esophagus. 2015;28(3):224\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V et al. (2017) Anastomotic strictures after esophageal atresia repair: incidence, investigations, and management, including treatment of refractory and recurrent strictures. Frontiers in pediatrics; 5: 120.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParsons A, Netsanet A, Seedorf G, Abman SH, Taglauer ES. Understanding the role of placental pathophysiology in the development of bronchopulmonary dysplasia. Am J Physiology-Lung Cell Mol Physiol. 2022;323(6):L651\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSamraj P, Chakraborty G, Sugandhi N, Shoor G, Acharya SK, Jadhav A, et al. Primary anastomosis in difficult cases of type C esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome. J Pediatr Surg. 2021;56(5):1076\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahman NA, Abdullah MY, Abidin MAZ, Nah SA. Burden and mortality of congenital gastrointestinal anomalies: insights from a nationwide cohort study. Pediatr Surg Int. 2024;40(1):270.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Esophageal atresia, Postoperative Outcomes, Tracheoesophageal fistula, Staged repair, One-stage repair","lastPublishedDoi":"10.21203/rs.3.rs-7077487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7077487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEsophageal atresia (EA) is a complex congenital anomaly requiring prompt surgical correction in neonates. The optimal approach between primary (one-stage) and staged (multi-stage) repair remains debated, especially in infants with comorbidities or long-gap defects. To compare postoperative outcomes and complications of one-stage versus staged surgical repair for EA in a tertiary pediatric center in Iran.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e In this retrospective study, medical records of 115 neonates with EA treated between 2017 and 2024 at Motahari Pediatric Hospital were reviewed. Demographic features, associated anomalies, perioperative and postoperative complications, surgical duration, hospital stay, and survival rates were compared between the one-stage and two-stage repair groups using appropriate statistical tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 115 patients, 68 underwent primary repair and 47 staged repair. No significant differences were observed in postoperative complications, mortality, or hospital stay between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The mean operative time and hospitalization were longer in the two-stage group, but these differences did not reach statistical significance. Linear regression showed no significant association between chronological age and operative duration (B=-0.026, p\u0026thinsp;=\u0026thinsp;0.570), nor between birth weight and operative duration (r=-0.040, p\u0026thinsp;=\u0026thinsp;0.672). However, a significant inverse correlation between gestational age and surgical duration was observed (Spearman\u0026rsquo;s rho=-0.225, p\u0026thinsp;=\u0026thinsp;0.016), suggesting that higher gestational age may be associated with shorter operative times.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOne-stage and staged repairs provide comparable short-term outcomes in neonates with EA, supporting individualized surgical planning based on patient factors. The association between gestational age and operative duration warrants further investigation in prospective multicenter studies to optimize surgical decision-making and improve long-term results.\u003c/p\u003e","manuscriptTitle":"Comparative Analysis of Postoperative Outcomes and Complications of One-Stage Versus Staged Surgical Repair in Esophageal Atresia: A Retrospective Study from a Tertiary Pediatric Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 10:22:06","doi":"10.21203/rs.3.rs-7077487/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T12:07:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T02:40:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T10:29:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242314726898172251887208620627367153209","date":"2025-07-27T08:59:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177348375313263697566874642625486497378","date":"2025-07-25T11:13:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-24T19:45:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T12:39:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T04:55:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-11T04:54:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-07-08T18:30:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f96e190-5a56-4dce-8faa-76dd1d43e532","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:03:32+00:00","versionOfRecord":{"articleIdentity":"rs-7077487","link":"https://doi.org/10.1186/s12893-025-03300-1","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-11-19 15:58:36","publishedOnDateReadable":"November 19th, 2025"},"versionCreatedAt":"2025-07-28 10:22:06","video":"","vorDoi":"10.1186/s12893-025-03300-1","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03300-1","workflowStages":[]},"version":"v1","identity":"rs-7077487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7077487","identity":"rs-7077487","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}