Outcomes of Esophageal Atresia at University Tertiary Hospital of Kigali, Rwanda

Outcomes of Esophageal Atresia at University Tertiary Hospital of Kigali, Rwanda | 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 Outcomes of Esophageal Atresia at University Tertiary Hospital of Kigali, Rwanda Chioma Moneme, Kimberley Duru, Owen Selden, Shaina Twardus, Jordan Gooding, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7678868/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : Mortality associated with EA/TEF has declined in HICs with advances in multidisciplinary care. However, it remains as high as 80% in LMICs. This study examines the current clinical outcomes of neonates with EA/TEF at a tertiary-level hospital in Rwanda following the implementation of care by fellowship-trained pediatric surgeons. Methods : A retrospective cohort study of neonates with EA/TEF from January 2015 to December 2023. Patient data were collected from medical logbooks for all patients who received surgical treatment at Centre Hospitalier Universitaire de Kigali, Rwanda. Univariable logistic regression was used to identify factors associated with higher 30-day mortality. Results : 56 patients were included. All infants were born at term and, on average, arrived 7 days after birth (6.98 ±5.18). Type C was the most common anomaly (68%). Mortality data were only available for 82.1% of patients. Of this subset, the 30-day mortality was 52.2%. Increased odds of mortality were associated with the presence of any congenital anomaly (p <0.05) and specifically a cardiac congenital anomaly (p<0.05). Conclusion : This study provides insights into infants with EA/TEF after implementing specialized surgical care, which has helped reduce mortality compared to other LMICs. Targeted quality improvement initiatives for infants with additional associated congenital anomalies could further improve outcomes. Rwanda tracheoesophageal fistula esophageal atresia low- and middle-income countries access to care pediatric surgical care Figures Figure 1 Introduction Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) is the most common congenital anomaly of the esophagus, estimated to affect 1 of every 2,500 to 4,000 live births, and results from the failure of separation of the foregut. (1–4). EA/TEF is known to occur in isolation but often occurs in association with other congenital and chromosomal anomalies including VACTERL association (vertebral, anal, cardiac, tracheoesophageal, renal and limb anomalies), CHARGE association (coloboma, heart anomalies, choanal atresia, retarded growth, genital anomalies, and ear anomalies), cardiac defects, trisomy 18 and trisomy 21 with additional anomalies seen in up to 55% of congenital EA/TEF cases. (2,3,5). It confers an elevated risk of mortality and morbidity during the early neonatal period due to aspiration, respiratory failure, and failure to thrive (6). Congenital disorders are one of the leading causes of death in children under the age of 5 worldwide. (7) Over 90% of deaths associated with congenital anomalies occur in low -and middle-income countries (LMICs). (8) Evolution in management of EA/TEF has been well described, and early surgical intervention remains the mainstay of management. (9) With advances in pediatric surgery expertise and operative techniques, mortality rates in high-resource settings are as low as 5%. (6)(10) Conversely, management of infants with EA/TEF in low-resource settings continues to present a significant challenge, with mortality rates up to 80%. (11) Whereas mortality in high-resource settings in infants with EA/TEF is highly associated with additional congenital anomalies, delays in care delivery, sub-optimal health infrastructure, and lack of skilled health care providers significantly affect mortality rates in LMICs(10)(12). Nonetheless, healthcare delivery is not static in low-resource settings, and recruitment of skilled providers, relevant training, and infrastructure improvement may alter outcomes. Few studies exist in the literature that describe outcomes in infants with EA/TEF in LMICs where fellowship-trained pediatric surgeons are available. This study aimed to evaluate the surgical management, anatomic classification distribution, and outcomes of infants with EA/TEF at Centre Hospitalier Universitaire de Kigali (CHUK), a high-volume tertiary center and teaching hospital in Rwanda, with fellowship-trained pediatric surgeons. Methods IRB ethical approval This study received Institutional Review Board approval from the CHUK Office of Clinical Education and Research and the University of Virginia (UVA) Health Sciences Research Institutional Review Board (#HSR230210). Patient identifiers were not collected and were only used to identify patient medical files. Patient selection This is a single-center, retrospective cohort study of neonates who presented to CHUK with esophageal atresia, with or without a tracheoesophageal fistula, from 2015 to 2023. Patients were identified from operating theatre logbooks with a documented preoperative diagnosis of EA/TEF. All patients who were evaluated and treated for EA/TEF were included. Patients who had any operative intervention before arrival at CHUK were excluded. Clinical and demographic data collection Data was collected from paper medical records available from the CHUK Records and Archives department by matching patient medical record numbers from operating theatre logbooks with archive codes for patients that met our inclusion criteria. The patient's full name and date of birth were used as additional identifiers to ensure data was obtained from the correct paper chart. Demographic characteristics collected included age, sex, province, district of primary residence, health insurance status, type of health insurance, and place of birth. Preoperative variables obtained included maternal prenatal care, prenatal diagnosis of an additional congenital anomaly, birth weight, age at arrival to CHUK, weight upon admission, and additional congenital anomalies. Patient-specific perioperative clinical characteristics included the number of days between initial admission and surgical repair, weight at the time of surgical repair, surgical repair approach, EA/TEF Gross classification type, length of stay, and any complications that occurred following surgical repair. Outcomes The primary outcome was 30-day mortality, which was determined from either a filed death certificate, ongoing inpatient status, or recorded outpatient follow-up at CHUK, which was greater than 30 days postop. Secondary outcomes of interest were complications in the postoperative period related to the EA/TEF repair, including anastomotic leaks, fistula recurrence, esophageal strictures, and stenosis. Other complications unrelated to the technical aspects of the repair included sepsis, pneumonia, and respiratory failure. Data Analysis Continuous variables were summarized using the mean with standard deviation (SD) or the median with interquartile range (IQR), and compared between groups using either the t-test or the Wilcoxon Rank Sum test, as appropriate. Categorical variables were presented as counts and proportions, and compared between groups using the Chi-square test or Fisher’s exact test, as applicable. Missing data was documented. Univariable logistic regression models were used to assess associations between patient characteristics and 30-day mortality. Results are reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs) and p-values. Due to the limited sample size, multivariable analysis was not performed. Statistical significance was defined as a two-sided p-value < 0.05. Statistical analyses were performed using R version 4.3.2 (R Statistical Software Vienna, Austria). Results Figure 1 demonstrates the patients included in our study. Eighty-four patients with a diagnosis of EA/TEF treated at CHUK from January 2015 to December 2023 were identified. Twenty-eight patients were excluded from our analysis: 1 had acquired tracheoesophageal fistula as the only diagnosis, 23 had inaccurate/inconsistent, or missing documentation, and four patients who were offered surgical repair at CHUK but were ultimately transferred to another hospital due to critical care bed availability. One patient had received a diverting colostomy prior to transfer to CHUK, but was not excluded as this was unrelated to EA/TEF repair. Our final study population was 56 patients, and all surgeries were performed by fellowship-trained pediatric surgeons. Table 1 summarizes the demographic and clinical characteristics of the 56 patients. Any characteristics with missing information are also indicated. Among patients in our study population, 27 (48%) were male and 29 (52%) were female. Average birth weight was 2520g (638). Median gestational age was 40 weeks (36, 40). 36 (64%) patients were born in a health facility. Eight patients (14.3%) had missing information for place of birth. Fifty-one patients (96%) had health insurance. Fifty (98%) patients were born to mothers who had at least one prenatal visit during their pregnancy, while 32 (67%) had at least one prenatal scan. 43% of patients in our study resided in a region less than 50km from the tertiary facility. 21% lived greater than 50 kilometers but less than 100 kilometers away, and 36% lived more than 100 kilometers away. The mean age upon arrival at CHUK was 7 days (SD 5.2), while the mean weight upon arrival was 2410g (SD 646). Type C EA/TEF was the most common type identified in this patient population, affecting 38 (68%) patients, followed by type A (isolated atresia) in 7 patients (12.5%), and type B in 1 patient (2%). The type of EA/TEF was missing from the medical records for 10 patients (18%). In our study cohort of 56 patients, 30 (54%) infants had an additional congenital anomaly of any type, and of that subset, 23 patients (41%) had a cardiac anomaly. Table 1: Infant Demographic and Clinical Characteristics Birth weight in grams, mean(SD)↷ 2520 (638) Gestational age in weeks, median (IQR) 40 (36, 40) Age upon arrival to tertiary hospital in days, median(IQR) ^ 5 (4,10) Weight upon arrival to tertiary hospital in grams, mean(SD)↹ 2410 (646) Sex, n (%) Male 27 (48) Female 29 (52) Distance from region of primary residence to CHUK, n (%) 100km 20 (36) Prenatal visit (at least 1), n (%) ↬ Yes 50 (98) No 1 (2) Prenatal scan (at least 1), n (%) ↜ Yes 32 (67) No 16 (33) Insured, n (%) ⇭ 51 (96) Birth location, n (%) ↜ Health care facility 36 (64) Other 12 (21) Type of EA/TEF, n (%) ↟ Type A 7 (12) Type B 1 (2) Type C 38 (68) Additional congenital anomaly, n (%) 30 (54) Cardiac congenital anomaly, n (%) 23 (41%) Death within 30 days of initial surgery, n (%) * Yes 24 (52) No 22 (48) *mortality data available for only 46 patients. ↷ 4 missing ^ 2 missing ⇭ 3 missing ↬ 5 missing ↜ 8 missing ↟ 10 missing ↹17 missing During the study period, infants evaluated at CHUK underwent various types of surgical interventions. Of the cohort, 49 patients (87.5%) underwent definitive repair of their EA/TEF. Eight patients (14.3%) had gastrostomy tube placement, either with or without a diverting esophagostomy. One patient (1.79%) underwent only a thoracotomy with repair of a gastric perforation. However, it is unclear whether that patient also had a laparotomy. Mortality data were available for 46/56 (82.1%) patients. 30-day mortality was ascertained through either a filed death certificate, ongoing inpatient status, or recorded outpatient follow-up at CHUK that exceeded 30 days postoperatively. 24 patients (52%) died within 30 days of their initial surgical procedure Table 2 summarizes the frequency of post-operative complications. The anastomotic leak rate was 29.2%. Esophageal stricture or stenosis affected 14.6% of patients. In comparison, recurrent fistula was observed in 4.8% of those who underwent complete repair and in 14.3% of patients who received fistula ligation without end-to-end anastomosis. Other postoperative complications, detailed in Table 2, included sepsis, which was the most common at 66%, and cardiopulmonary arrest, occurring in 30.4%. Among the 56 patients with EA, 3 (5.3%) experienced no complications—2 had EA/TEF repair for type C EA/TEF, and 1 had gastrostomy with esophagostomy for type A EA/TEF. Table 2: Post-operative outcomes by type of surgery offered Primary repair n = 42 (%) Fistula ligation without anastomosis* n = 7 (%) Gastrostomy tube only , n= 7 (%) Repair-related postoperative complications Anastomotic leak 12 (29.2%) Stricture/stenosis 6 (14.3%) Recurrent fistula 2 (4.8%) 1 (14.3%) Other postoperative complications Sepsis 28 (66.7%) 6 (85.7%) 3 (42.9%) Pneumonia 11 (26.2%) 1 (14.3%) 1 (14.3%) Renal injury 4 (16.7%) 1 (14.3%) 0 (0.0%) Respiratory failure 10 (23.8%) 2 (28.6%) 1 (14.3%) Cardiopulmonary arrest 11 (26.2%) 3 (42.9%) 3 (42.9%) *includes children who also had a combined gastrostomy tube or diversion esophagostomy without an anastomosis A summary of the univariate analysis of patient clinical and demographic characteristics’ effect on mortality can be found in Table 3. There was no significant association between mortality outcome and sex at birth, birth weight, distance travelled from the region of primary residence, age at surgery, type of EA/TEF, type of surgery performed, or time from admission to surgery. 75% of patients who died within 30 days of surgery had an additional congenital anomaly compared to 6% among those who were alive within 30 days of surgery (p=0.001). Similarly, there was a significant association between mortality and the presence of any congenital cardiac anomaly; 58% of patients who died within 30 days of surgery had an additional congenital anomaly compared to 18% among those who were alive beyond 30 days of surgery (p=0.01). Furthermore, Table 3.1 summarizes the significant association between mortality and post-operative morbidity specific to EA/TEF repair, including anastomotic leak, recurrent fistula, and esophageal stricture or stenosis (p < 0.05), and other surgical morbidity, including sepsis, pneumonia, cardiopulmonary arrest, respiratory failure, and acute liver injury. Further analysis of predictors of mortality with univariate regression analysis is shown in Table 4. In a similar pattern, the following were all significant predictors of mortality (p<0.05): the presence of an additional congenital anomaly and more specifically the presence of a congenital cardiac anomaly, generally known complications after EA repair, and the presence of other post-operative complications specified in Table 2. Table 3: Univariable analysis of patient characteristics impact on 30-day mortality 30-day mortality Variable Yes (n=24) No (n=22) p-value Sex, n (%) Male 11 (45.8) 13 (59.1) 0.37 Female 13 (54.2) 9 (40.9) Birth weight in grams, , n (%) 0.681 3000 7 (30.4) 7 (36.8) Distance travelled in km, , n (%) 100 6 (25.0) 10 (45.5) Age at initial surgery in days, n (%) 14 4 (16.7) 5 (22.7) Health Insurance, n (%) Yes 23 (100) 18 (90) 0.21 No 0 (0) 2 (10) Type of EA/TEF, n (%) Type C 17 (70.8) 14 (63.6) 0.84 Other (A or B) 3 (12.5) 4 (18.2) Not reported 4 (16.7) 4 (18.2) Type of surgical intervention offered at CHUK, n (%) Primary repair 18 (75.0) 14 (63.6) 0.4 Other surgery 6 (25.0) 8 (36.4) Time from admission to surgical intervention in days, n (%) 0.6 6 4 (16.7) 6 (27.2) Presence of any congenital anomaly, n (%) Yes 18 (75.0) 6 (27.3) 0.001 No 6 (25.0) 16 (72.7) Presence of cardiac congenital anomaly, n (%) 0.014 Yes 14 (58.3) 4 (18.2) No 10 (41.7) 18 (81.8) *All percentages are of those reported. Missing data is denoted in Table 1. Table 3.1 Surgical morbidities associated with 30-day mortality after EA/TEF repair 30-day mortality Variable Yes No p-value Presence of EA/TEF-repair associated morbidity, n (%)↮ Yes 3 (14.3) 13 (72.2) 0.0003 No 18 (85.7) 5 (27.8) Presence of other post-operative morbidity, n (%)↯ Yes 20 (95.2) 10(55.6) 0.0006 No 1(4.8) 8(44.4) ↮includes anastomotic leak, anastomotic stricture or stenosis, and recurrent fistula. ↯ post-operative morbidity includes sepsis, pneumonia, cardiopulmonary arrest, respiratory failure, and renal injury. Table 4: Univariable Logistic regression for predictors of mortality. Variable n = 46 OR (95% CI) p-value Sex, n (%) Female 22 (47.8) 1.71 (0.53, 5.50) 0.37 Male 24 (52.2) 1.00 Birth weight in grams ↷ 0.999 >=3000 14 (33.3) 1.00 Gestational age <37 weeks⇯ 10 (30.3) 2.55 (0.52, 12.37) 0.25 Distance traveled in kilometers =100 16 (34.8) 1.00 Type of EA/TEF Type C 31 (81.6) 1.00 Non-Type C 7 (18.4) 0.61 (0.11, 3.26) 0.57 Weight at surgery (g) 0.999 2000-2999 13 (39.4) 1.17 (0.22, 6.08) >=3000 10 (30.3) 1.00 Additional congenital anomaly 24(52.2) 8.00 (2.14, 29.85) 0.002 Presence of cardiac anomaly 19 (41.3) 4.76 (1.32, 17.22) 0.017 EA/TEF-repair associated morbidity 39 (84.8) 0.06 (0.01, 0.28) 0.0007 Other post-operative morbidity 39 (84.8) 16 (2.45, 318.97) 0.014 ↷4 missing ⇯ 13 missing Discussion The clinical outcomes of patients with EA/TEF are frequently employed as an indicator of a nation's healthcare infrastructure and accessibility. (13) This study provides an analysis of the incidence, current surgical management, and post-operative outcomes of infants with esophageal atresia with /without tracheoesophageal fistula at CHUK, the largest tertiary referral and teaching hospital in Rwanda. The incidence of EA/TEF in Rwanda is not well documented in the literature. An epidemiological review of pediatric surgical care at two tertiary referral centers in Rwanda—CHUK and Butare University Teaching Hospital—over one year from 2013 to 2014 showed that 905 children received surgical care at CHUK and 369 children at Butare, with congenital anomalies accounting for nearly 25% of the surgeries performed (14). These findings demonstrate that congenital anomalies are frequently encountered in specialized hospitals in Rwanda and highlight the importance of pediatric surgeon expertise. Overall, 30-day mortality in this study cohort was 52%. This mortality rate is higher than that observed in HICs, which have reported mortality rates for EA/TEF between 5% and 15%(6)(8)(15)(16). However, this finding reflects more favorable outcomes of EA/TEF in Rwanda compared to other LMICs.(17)(18)(19)(20). A study in Bangladesh reported an EA/TEF mortality rate of 88%. Another study in Senegal found it to be 71%. A study involving 225 neonates in Ethiopia documented a rate of 71%, and a different study reported 74% in Benin(21)(22)(23). Type C EA/TEF was the most common type observed in this population, affecting 68% of patients, which is lower than the expected prevalence of type C reported in the literature at 84 - 86%(2)(24)(25)(26). This finding may be attributable to incomplete information in patients’ medical records, considering that this variable was absent in the records of ten patients. The presence of an additional congenital anomaly, and more specifically the presence of a cardiac congenital anomaly, was the only predictor in this study. Similar results have been reported in other studies demonstrating a similar association between other congenital anomalies and mortality in EA/TEF(3)(27)(28). Historically, corrective surgery for congenital cardiovascular anomalies in Rwanda relied on visiting surgeons who were in the country for short periods of time to perform surgeries. Still, since 2022, a dedicated cardiac surgery program has been established with a full-time pediatric cardiac surgeon, treating a wide range of congenital heart defects since its inception(29). Partnerships with congenital cardiac specialists and further studies on the types of cardiac anomalies with the highest risk are needed to reduce the associated increased risk potentially. Sepsis was a leading cause of morbidity in this cohort, affecting 69.4% of patients (n=34/49) who underwent a definitive repair or trachea-esophageal fistula closure. An increased mortality due to sepsis has been shown in the literature in LMICs, and in a large international study of gastrointestinal congenital anomalies in 74 countries, Wright et al reported a higher proportion of patients presenting with sepsis in LMICs compared to HICs. While sepsis was not associated with mortality in HICs, it was significantly associated with mortality in LMICs(8). Additionally, a retrospective review of infants with gastroschisis and intestinal atresia in Rwanda by Davis et al. reported that sepsis was present in 100% of patients who died within 48 hours of presentation compared to 46% who survived beyond 48 hours(30). The association between sepsis and mortality in this population has been previously shown(28)(31). The potential need for mechanical ventilation, central venous catheters, and the potential need for invasive devices in these postsurgical patients can also be predictive factors for infections and increase the risk of sepsis (32). Further studies are needed to identify the leading causes of sepsis in this population and to develop standards for sepsis management that can improve outcomes for infants with EA/TEF, supporting the development of targeted interventions. This study has several potential limitations. First, it is retrospective in nature and subject to inherent bias, including selection and information bias. We identified over 80 patients; however, a significant number were excluded due to missing or incomplete information. This study was also conducted in a single center, resulting in a small sample size. Thus, it is more challenging to observe true relationships between the outcome of interest and predictive variables. Additionally, data was collected from paper medical records, which were all handwritten. Legibility was sometimes challenging, and there were frequent occurrences of missing or incomplete documentation and differences in documentation style among providers. Conclusion This study highlights the improved mortality outcomes, driven mainly by sepsis and ventilator-associated complications, in EA/TEF management due to significant changes that occurred in the health system capacity, such as the availability of a fellowship-trained pediatric surgeon, a dedicated pediatric operating room, and expansion of neonatal and pediatric intensive care units in a low-income country. This represents an improvement based on what has been reported in LMICs. Targeted strategies for infants with EA/TEF and other associated congenital anomalies, especially cardiac anomalies, could further improve outcomes. Additional strategies to improve outcomes include developing standardized bundles for sepsis management within the limitations of available resources. Declarations This study was approved by the IRB board at the University of Virginia, and the University of Rwanda Ethics Committee approved the study, waiving the requirement for written informed consent. Funding : C.M. was supported by NIH/NHLBI T32 training grant (#T32HL007849). This research was supported by the CGHE University Scholar Award from the Center for Global Health Equity at the University of Virginia. Conflict of Interest: All authors declare they have no conflicts of interest to disclose. Data Availability Statement: De-identified datasets used and analyzed in this study are available from the corresponding author upon reasonable request. Author contributions: All authors contributed to the study’s conceptualization, methodology, design, and writing. Material preparation and data collection were performed by KD, ST, OS, and CM. Data analysis was performed by RJ and KD. Supervision was provided by CM, SK, and EN. All authors wrote, read, and approved the final manuscript. References Cassina M, Ruol M, Pertile R, Midrio P, Piffer S, Vicenzi V, et al. Prevalence, characteristics, and survival of children with esophageal atresia: A 32-year population-based study including 1,417,724 consecutive newborns. Birth Defects Res A Clin Mol Teratol. 2016 Jul;106(7):542–8. Pinheiro PFM, Simões e Silva AC, Pereira RM. Current knowledge on esophageal atresia. World J Gastroenterol. 2012 Jul 28;18(28):3662–72. Wang B, Tashiro J, Allan BJ, Sola JE, Parikh PP, Hogan AR, et al. A nationwide analysis of clinical outcomes among newborns with esophageal atresia and tracheoesophageal fistulas in the United States. Journal of Surgical Research. 2014 Aug;190(2):604–12. 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Moneme","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYBAC/mYGxgcMDDZAJg8QFzAkENQicZiB2YCBIQ2qxcCAsBYDBwY2CQaGw6RoYedONuZtO5+44fjZgw9+GPzJY2DvffwCrxZm3o2PedtuJ244k5ds2GNgUMzAc9zMgoCWzca8224nzmzIMZPgMTBIbJBIYzMgoGWbNO+2c4kz+9+Y//xDlBZnsJYDif0SOWbMUFuYH+DTInGYd7Ph3H/Jxv0Sb4ylZQyME9t4jrHh08HA339244M3Z+xk2/hzDD++qZBL7GdvY/6AVw8GAFoBiikSAam2jIJRMApGwTAHAEK0RtLElb4mAAAAAElFTkSuQmCC","orcid":"","institution":"University of Virginia","correspondingAuthor":true,"prefix":"","firstName":"Chioma","middleName":"","lastName":"Moneme","suffix":""},{"id":521848560,"identity":"7d4dcc09-2571-49ed-903e-975d8a52ea8e","order_by":1,"name":"Kimberley Duru","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Kimberley","middleName":"","lastName":"Duru","suffix":""},{"id":521848561,"identity":"965e1500-c9e9-4966-9caf-f952e9705ea2","order_by":2,"name":"Owen Selden","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Owen","middleName":"","lastName":"Selden","suffix":""},{"id":521848562,"identity":"db927c59-0e53-42b3-9e07-9d3a4eb7e0e9","order_by":3,"name":"Shaina Twardus","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Shaina","middleName":"","lastName":"Twardus","suffix":""},{"id":521848563,"identity":"cdb8db87-ebe7-498a-b923-2b55fc9461a6","order_by":4,"name":"Jordan Gooding","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Jordan","middleName":"","lastName":"Gooding","suffix":""},{"id":521848564,"identity":"be75c45e-eca7-4a28-9443-450932416c30","order_by":5,"name":"Jean Pierre Habumufasha","email":"","orcid":"","institution":"University of Rwanda, University Teaching Hospital of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Pierre","lastName":"Habumufasha","suffix":""},{"id":521848565,"identity":"5b4c74d3-ee9b-4409-ba7c-f0e80f61ef52","order_by":6,"name":"Aimable Kanyamuhunga","email":"","orcid":"","institution":"University of Rwanda, University Teaching Hospital of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Aimable","middleName":"","lastName":"Kanyamuhunga","suffix":""},{"id":521848566,"identity":"0ac2731b-9553-4ec7-8f94-4ab32aa85ac9","order_by":7,"name":"Ruyun Jin","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Ruyun","middleName":"","lastName":"Jin","suffix":""},{"id":521848567,"identity":"f000dd27-f541-4db6-9256-aeb02571e77d","order_by":8,"name":"Tracy Kelly","email":"","orcid":"","institution":"University of Virginia","correspondingAuthor":false,"prefix":"","firstName":"Tracy","middleName":"","lastName":"Kelly","suffix":""},{"id":521848568,"identity":"f5fb0810-dab1-4775-bbed-4aba8b8888a3","order_by":9,"name":"Sandra Kabagambe","email":"","orcid":"","institution":"University of Illinois Urbana-Champaign","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Kabagambe","suffix":""},{"id":521848569,"identity":"771c7a66-4586-4ddc-9545-c2bd9f97d935","order_by":10,"name":"Edmond Ntaganda","email":"","orcid":"","institution":"University of Rwanda, University Teaching Hospital of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Edmond","middleName":"","lastName":"Ntaganda","suffix":""}],"badges":[],"createdAt":"2025-09-22 14:38:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7678868/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7678868/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92574305,"identity":"653fa79a-e5f3-4ee0-87c8-b5e532e5dc14","added_by":"auto","created_at":"2025-10-01 08:11:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":153420,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart demonstrating the definition of the study population and reasons for exclusion from our analysis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7678868/v1/afc8c939526a3b4b093fb8d5.png"},{"id":92576310,"identity":"9397c758-6cb9-47e0-81a4-adc0e51e9014","added_by":"auto","created_at":"2025-10-01 08:27:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":866575,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7678868/v1/aa1ff4c3-1e25-4527-b717-2ec4739c00d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of Esophageal Atresia at University Tertiary Hospital of Kigali, Rwanda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEsophageal atresia with or without tracheoesophageal fistula (EA/TEF) is the most common congenital anomaly of the esophagus, estimated to affect 1 of every 2,500 to 4,000 live births, and results from the failure of separation of the foregut. \u0026nbsp;(1\u0026ndash;4). EA/TEF is known to occur in isolation but often occurs in association with other congenital and chromosomal anomalies including VACTERL association (vertebral, anal, cardiac, tracheoesophageal, renal and limb anomalies), CHARGE association (coloboma, heart anomalies, choanal atresia, retarded growth, genital anomalies, and ear anomalies), cardiac defects, trisomy 18 and trisomy 21 with additional anomalies seen in up to 55% of congenital EA/TEF cases. (2,3,5). It confers an elevated risk of mortality and morbidity during the early neonatal period due to aspiration, respiratory failure, and failure to thrive (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCongenital disorders are one of the leading causes of death in children under the age of 5 worldwide. (7) \u0026nbsp;Over 90% of deaths associated with congenital anomalies occur in low -and middle-income countries (LMICs). (8) Evolution in management of EA/TEF has been well described, and early surgical intervention remains the mainstay of management. (9) With advances in pediatric surgery expertise and operative techniques, mortality rates in high-resource settings are as low as 5%. (6)(10) Conversely, management of infants with EA/TEF in low-resource settings continues to present a significant challenge, with mortality rates up to 80%. (11)\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhereas mortality in high-resource settings in infants with EA/TEF is highly associated with additional congenital anomalies, delays in care delivery, sub-optimal health infrastructure, and lack of skilled health care providers significantly affect mortality rates in LMICs(10)(12). Nonetheless, healthcare delivery is not static in low-resource settings, and recruitment of skilled providers, relevant training, and infrastructure improvement may alter outcomes. Few studies exist in the literature that describe outcomes in infants with EA/TEF in LMICs where fellowship-trained pediatric surgeons are available. This study aimed to evaluate the surgical management, anatomic classification distribution, and outcomes of infants with EA/TEF at Centre Hospitalier Universitaire de Kigali (CHUK), a high-volume tertiary center and teaching hospital in Rwanda, with fellowship-trained pediatric surgeons.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003e\u003cem\u003eIRB ethical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study received Institutional Review Board approval from the CHUK Office of Clinical Education and Research and the University of Virginia (UVA) Health Sciences Research Institutional Review Board (#HSR230210). Patient identifiers were not collected and were only used to identify patient medical files. \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient selection\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is a single-center, retrospective cohort study of neonates who presented to CHUK with esophageal atresia, with or without a tracheoesophageal fistula, from 2015 to 2023. Patients were identified from operating theatre logbooks with a documented preoperative diagnosis of EA/TEF. All patients who were evaluated and treated for EA/TEF were included. Patients who had any operative intervention before arrival at CHUK were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical and demographic data\u003c/em\u003e \u003cem\u003ecollection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData was collected from paper medical records available from the CHUK Records and Archives department by matching patient medical record numbers from operating theatre logbooks with archive codes for patients that met our inclusion criteria. The patient\u0026apos;s full name and date of birth were used as additional identifiers to ensure data was obtained from the correct paper chart. Demographic characteristics collected included age, sex, province, district of primary residence, health insurance status, type of health insurance, and place of birth. Preoperative variables obtained included maternal prenatal care, prenatal diagnosis of an additional congenital anomaly, birth weight, age at arrival to CHUK, weight upon admission, and additional congenital anomalies. Patient-specific perioperative clinical characteristics included the number of days between initial admission and surgical repair, weight at the time of surgical repair, surgical repair approach, EA/TEF Gross classification type, length of stay, and any complications that occurred following surgical repair. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcomes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was 30-day mortality, which was determined from either a filed death certificate, ongoing inpatient status, or recorded outpatient follow-up at CHUK, which was greater than 30 days postop. \u0026nbsp;Secondary outcomes of interest were complications in the postoperative period related to the EA/TEF repair, including anastomotic leaks, fistula recurrence, esophageal strictures, and stenosis. Other complications unrelated to the technical aspects of the repair included sepsis, pneumonia, and respiratory failure. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were summarized using the mean with standard deviation (SD) or the median with interquartile range (IQR), and compared between groups using either the t-test or the Wilcoxon Rank Sum test, as appropriate. Categorical variables were presented as counts and proportions, and compared between groups using the Chi-square test or Fisher\u0026rsquo;s exact test, as applicable. Missing data was documented. Univariable logistic regression models were used to assess associations between patient characteristics and 30-day mortality. Results are reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs) and p-values. Due to the limited sample size, multivariable analysis was not performed. Statistical significance was defined as a two-sided p-value \u0026lt; 0.05. Statistical analyses were performed using R version 4.3.2 (R Statistical Software Vienna, Austria).\u0026nbsp;\u003c/p\u003e"},{"header":"Results ","content":"\u003cp\u003eFigure 1 demonstrates the patients included in our study. Eighty-four patients with a diagnosis of EA/TEF treated at CHUK from January 2015 to December 2023 were identified. Twenty-eight patients were excluded from our analysis: 1 had acquired tracheoesophageal fistula as the only diagnosis, 23 had inaccurate/inconsistent, or missing documentation, and four patients who were offered surgical repair at CHUK but were ultimately transferred to another hospital due to critical care bed availability. One patient had received a diverting colostomy prior to transfer to CHUK, but was not excluded as this was unrelated to EA/TEF repair. Our final study population was 56 patients, and all surgeries were performed by fellowship-trained pediatric surgeons.\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the demographic and clinical characteristics of the 56 patients. Any characteristics with missing information are also indicated. Among patients in our study population, 27 (48%) were male and 29 (52%) were female. Average birth weight was 2520g (638). Median gestational age was 40 weeks (36, 40). \u0026nbsp; 36 (64%) patients were born in a health facility. Eight patients (14.3%) had missing information for place of birth. Fifty-one patients (96%) had health insurance.\u003cem\u003e\u0026nbsp;\u003c/em\u003eFifty (98%) patients were born to mothers who had at least one prenatal visit during their pregnancy, while 32 (67%) had at least one prenatal scan. 43% of patients in our study resided in a region less than 50km from the tertiary facility. 21% lived greater than 50 kilometers but less than 100 kilometers away, and 36% lived more than 100 kilometers away.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean age upon arrival at CHUK was 7 days (SD 5.2), while the mean weight upon arrival was 2410g (SD 646). Type C EA/TEF was the most common type identified in this patient population, affecting 38 (68%) patients, followed by type A (isolated atresia) in 7 patients (12.5%), and type B in 1 patient (2%). The type of EA/TEF was missing from the medical records for 10 patients (18%). \u0026nbsp;In our study cohort of 56 patients, 30 (54%) infants had an additional congenital anomaly of any type, and of that subset, 23 patients (41%) had a cardiac anomaly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Infant Demographic and Clinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eBirth weight in grams, mean(SD)↷\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e2520 (638)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eGestational age in weeks, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e40 (36, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eAge upon arrival to tertiary hospital in days, median(IQR) ^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e5\u0026nbsp;(4,10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eWeight upon arrival to tertiary hospital in grams, mean(SD)↹\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e2410 (646)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e27 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eFemale \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e29 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eDistance from region of primary residence to CHUK, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003e\u0026lt; 50km \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e24 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003e50km - 100km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e12 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003e\u0026gt;100km\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e20 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003ePrenatal visit (at least 1), n (%)\u0026nbsp;↬\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e50 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003ePrenatal scan (at least 1), n (%) ↜\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e32 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e16 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eInsured, n (%) ⇭\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e51 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eBirth location, n (%) ↜\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eHealth care facility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e36 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e12 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eType of EA/TEF, n (%)\u0026nbsp;↟\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eType A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e7 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eType B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003e\u0026nbsp; Type C\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e38 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eAdditional congenital anomaly, n (%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e30 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eCardiac congenital anomaly, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e23 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eDeath within 30 days of initial surgery, n (%) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e24 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.298%;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.702%;\"\u003e\n \u003cp\u003e22 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*mortality data available for only 46 patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e↷ 4 missing\u003c/p\u003e\n\u003cp\u003e^ 2 missing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e⇭ 3 missing\u003c/p\u003e\n\u003cp\u003e↬ 5 missing\u003c/p\u003e\n\u003cp\u003e↜ 8 missing\u003c/p\u003e\n\u003cp\u003e↟ 10 missing\u003c/p\u003e\n\u003cp\u003e↹17 missing\u003c/p\u003e\n\u003cp\u003eDuring the study period, infants evaluated at CHUK underwent various types of surgical interventions. Of the cohort, 49 patients (87.5%) underwent definitive repair of their EA/TEF. Eight patients (14.3%) had gastrostomy tube placement, either with or without a diverting esophagostomy. One patient (1.79%) underwent only a thoracotomy with repair of a gastric perforation. However, it is unclear whether that patient also had a laparotomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMortality data were available for 46/56 (82.1%) patients. 30-day mortality was ascertained through either a filed death certificate, ongoing inpatient status, or recorded outpatient follow-up at CHUK that exceeded 30 days postoperatively. 24 patients (52%) died within 30 days of their initial surgical procedure\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes the frequency of post-operative complications. The anastomotic leak rate was 29.2%. Esophageal stricture or stenosis affected 14.6% of patients. In comparison, recurrent fistula was observed in 4.8% of those who underwent complete repair and in 14.3% of patients who received fistula ligation without end-to-end anastomosis. Other postoperative complications, detailed in Table 2, included sepsis, which was the most common at 66%, and cardiopulmonary arrest, occurring in 30.4%. Among the 56 patients with EA, 3 (5.3%) experienced no complications\u0026mdash;2 had EA/TEF repair for type C EA/TEF, and 1 had gastrostomy with esophagostomy for type A EA/TEF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Post-operative outcomes by type of surgery offered\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003ePrimary repair\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en = 42\u003c/p\u003e\n \u003cp\u003e(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003eFistula ligation without anastomosis*\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en = 7\u003c/p\u003e\n \u003cp\u003e(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003eGastrostomy tube only , n= 7\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eRepair-related postoperative complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eAnastomotic leak\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e12 (29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eStricture/stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e6 \u0026nbsp;(14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eRecurrent fistula\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e2 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eOther postoperative complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eSepsis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e28 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e6 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e3 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003ePneumonia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e11 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eRenal injury\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e4 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eRespiratory failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e10 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e2 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.6042%;\"\u003e\n \u003cp\u003eCardiopulmonary arrest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1736%;\"\u003e\n \u003cp\u003e11 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.9583%;\"\u003e\n \u003cp\u003e3 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2639%;\"\u003e\n \u003cp\u003e3 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*includes children who also had a combined gastrostomy tube or diversion esophagostomy without an anastomosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA summary of the univariate analysis of patient clinical and demographic characteristics\u0026rsquo; effect on mortality can be found in Table 3. There was no significant association between mortality outcome and sex at birth, birth weight, distance travelled from the region of primary residence, age at surgery, type of EA/TEF, type of surgery performed, or time from admission to surgery. \u0026nbsp;75% of patients who died within 30 days of surgery had an additional congenital anomaly compared to 6% among those who were alive within 30 days of surgery (p=0.001). Similarly, there was a significant association between mortality and the presence of any congenital cardiac anomaly; 58% of patients who died within 30 days of surgery had an additional congenital anomaly compared to 18% among those who were alive beyond 30 days of surgery (p=0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, Table 3.1 summarizes the significant association between mortality and post-operative morbidity specific to EA/TEF repair, including anastomotic leak, recurrent fistula, and esophageal stricture or stenosis (p \u0026lt; 0.05), and other surgical morbidity, including sepsis, pneumonia, cardiopulmonary arrest, respiratory failure, and acute liver injury. Further analysis of predictors of mortality with univariate regression analysis is shown in Table 4. In a similar pattern, the following were all significant predictors of mortality (p\u0026lt;0.05): the presence of an additional congenital anomaly and more specifically the presence of a congenital cardiac anomaly, generally known complications after EA repair, and the presence of other post-operative complications specified in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Univariable analysis of patient characteristics impact on 30-day mortality\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"591\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 591px;\"\u003e\n \u003cp\u003e30-day mortality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;Variable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003eYes (n=24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNo (n=22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e13 (54.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eBirth weight in grams, , n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2000 - 2999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eDistance travelled in km, , n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e50-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e7 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e6 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eAge at initial surgery in days, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e9 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e4 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eHealth Insurance, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e23 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (10)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eType of EA/TEF, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eType C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17 (70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOther (A or B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e3 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e4 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eType of surgical intervention offered at CHUK, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePrimary repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOther surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;6 \u0026nbsp;(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cs\u003e\u0026nbsp;\u003c/s\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eTime from admission to surgical intervention in days, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e12 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e8 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e4 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003ePresence of any congenital anomaly, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e6 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e16 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003ePresence of cardiac congenital anomaly, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e14 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e10 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*All percentages are of those reported. Missing data is denoted in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3.1 Surgical morbidities associated with 30-day mortality after EA/TEF repair\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"591\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003e30-day mortality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003ePresence of EA/TEF-repair associated morbidity, n (%)↮\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003ePresence of other post-operative morbidity, n (%)↯\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e20 (95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e1(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e↮includes anastomotic leak, anastomotic stricture or stenosis, and recurrent fistula.\u003c/p\u003e\n\u003cp\u003e↯ post-operative morbidity includes sepsis, pneumonia, cardiopulmonary arrest, respiratory failure, and renal injury.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Univariable Logistic regression for predictors of mortality.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"625\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003en = 46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e22 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.71 (0.53, 5.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e24 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eBirth weight in grams ↷\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026lt;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e12 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2.00 (0.41, 9.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e2000-2999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e16 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00 (0.24, 4.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026gt;=3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e14 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eGestational age \u0026lt;37 weeks⇯\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e10 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2.55 (0.52, 12.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eDistance traveled in kilometers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026lt;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e19 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2.92 (0.59, 8.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e50 - 99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e11 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2.92 (0.59, 14.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026gt;=100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e16 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eType of EA/TEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eType C\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e31 (81.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eNon-Type C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.61 (0.11, 3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eWeight at surgery (g)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026lt;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e10 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.50 (0.26, 8.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e2000-2999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e13 (39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.17 (0.22, 6.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026gt;=3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e10 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eAdditional congenital anomaly\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e24(52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e8.00 (2.14, 29.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003ePresence of cardiac anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e19 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4.76 (1.32, 17.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eEA/TEF-repair associated morbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e39 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.06 (0.01, 0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eOther post-operative morbidity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e39 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e16 (2.45, 318.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e↷4 missing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e⇯ 13 missing\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThe clinical outcomes of patients with EA/TEF are frequently employed as an indicator of a nation\u0026apos;s healthcare infrastructure and accessibility. (13) This study provides an analysis of the incidence, current surgical management, and post-operative outcomes of infants with esophageal atresia with /without tracheoesophageal fistula at CHUK, the largest tertiary referral and teaching hospital in Rwanda. The incidence of EA/TEF in Rwanda is not well documented in the literature. An epidemiological review of pediatric surgical care at two tertiary referral centers in Rwanda\u0026mdash;CHUK and Butare University Teaching Hospital\u0026mdash;over one year from 2013 to 2014 showed that 905 children received surgical care at CHUK and 369 children at Butare, with congenital anomalies accounting for nearly 25% of the surgeries performed (14). \u003csup\u003e\u0026nbsp;\u003c/sup\u003eThese findings demonstrate that congenital anomalies are frequently encountered in specialized hospitals in Rwanda and highlight the importance of pediatric surgeon expertise.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, 30-day mortality in this study cohort was 52%. This mortality rate is higher than that observed in HICs, which have reported mortality rates for EA/TEF between 5% and 15%(6)(8)(15)(16). However, this finding reflects more favorable outcomes of EA/TEF in Rwanda compared to other LMICs.(17)(18)(19)(20). A study in Bangladesh reported an EA/TEF mortality rate of 88%. Another study in Senegal found it to be 71%. A study involving 225 neonates in Ethiopia documented a rate of 71%, and a different study reported 74% in Benin(21)(22)(23). Type C EA/TEF was the most common type observed in this population, affecting 68% of patients, which is lower than the expected prevalence of type C reported in the literature at 84 - 86%(2)(24)(25)(26). This finding may be attributable to incomplete information in patients\u0026rsquo; medical records, considering that this variable was absent in the records of ten patients. The presence of an additional congenital anomaly, and more specifically the presence of a cardiac congenital anomaly, was the only predictor in this study. Similar results have been reported in other studies demonstrating a similar association between other congenital anomalies and mortality in EA/TEF(3)(27)(28). \u003csup\u003e\u0026nbsp;\u003c/sup\u003eHistorically, corrective surgery for congenital cardiovascular anomalies in Rwanda relied on visiting surgeons who were in the country for short periods of time to perform surgeries. Still, since 2022, a dedicated cardiac surgery program has been established with a full-time pediatric cardiac surgeon, treating a wide range of congenital heart defects since its inception(29).\u003csup\u003e\u0026nbsp;\u003c/sup\u003e Partnerships with congenital cardiac specialists and further studies on the types of cardiac anomalies with the highest risk are needed to reduce the associated increased risk potentially.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSepsis was a leading cause of morbidity in this cohort, affecting 69.4% of patients (n=34/49) who underwent a definitive repair or trachea-esophageal fistula closure. An increased mortality due to sepsis has been shown in the literature in LMICs, and in a large international study of gastrointestinal congenital anomalies in 74 countries, Wright et al reported a higher proportion of patients presenting with sepsis in LMICs compared to HICs. While sepsis was not associated with mortality in HICs, it was significantly associated with mortality in LMICs(8). Additionally, a retrospective review of infants with gastroschisis and intestinal atresia in Rwanda by Davis et al. reported that sepsis was present in 100% of patients who died within 48 hours of presentation compared to 46% who survived beyond 48 hours(30). The association between sepsis and mortality in this population has been previously shown(28)(31). The potential need for mechanical ventilation, central venous catheters, and the potential need for invasive devices in these postsurgical patients can also be predictive factors for infections and increase the risk of sepsis (32). Further studies are needed to identify the leading causes of sepsis in this population and to develop standards for sepsis management that can improve outcomes for infants with EA/TEF, supporting the development of targeted interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several potential limitations. First, it is retrospective in nature and subject to inherent bias, including selection and information bias. We identified over 80 patients; however, a significant number were excluded due to missing or incomplete information. This study was also conducted in a single center, resulting in a small sample size. Thus, it is more challenging to observe true relationships between the outcome of interest and predictive variables. Additionally, data was collected from paper medical records, which were all handwritten. Legibility was sometimes challenging, and there were frequent occurrences of missing or incomplete documentation and differences in documentation style among providers.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the improved mortality outcomes, driven mainly by sepsis and ventilator-associated complications, \u0026nbsp;in EA/TEF management due to significant changes that occurred in the health system capacity, such as the availability of a fellowship-trained pediatric surgeon, a dedicated pediatric operating room, and expansion of neonatal and pediatric intensive care units in a low-income country. This represents an improvement based on what has been reported in LMICs. Targeted strategies for infants with EA/TEF and other associated congenital anomalies, especially cardiac anomalies, could further improve outcomes. Additional strategies to improve outcomes include developing standardized bundles for sepsis management within the limitations of available resources.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThis study was approved by the IRB board at the University of Virginia, and the University of Rwanda Ethics Committee approved the study, waiving the requirement for written informed consent.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: C.M. was supported by NIH/NHLBI T32 training grant (#T32HL007849). This research was supported by the CGHE University Scholar Award from the Center for Global Health Equity at the University of Virginia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eAll authors declare they have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eDe-identified datasets used and analyzed in this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u0026nbsp;\u003c/strong\u003eAll authors contributed to the study\u0026rsquo;s conceptualization, methodology, design, and writing. Material preparation and data collection were performed by KD, ST, OS, and CM. Data analysis was performed by RJ and KD. Supervision was provided by CM, SK, and EN. All authors wrote, read, and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCassina M, Ruol M, Pertile R, Midrio P, Piffer S, Vicenzi V, et al. Prevalence, characteristics, and survival of children with esophageal atresia: A 32-year population-based study including 1,417,724 consecutive newborns. Birth Defects Res A Clin Mol Teratol. 2016 Jul;106(7):542\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePinheiro PFM, Sim\u0026otilde;es e Silva AC, Pereira RM. Current knowledge on esophageal atresia. World J Gastroenterol. 2012 Jul 28;18(28):3662\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eWang B, Tashiro J, Allan BJ, Sola JE, Parikh PP, Hogan AR, et al. A nationwide analysis of clinical outcomes among newborns with esophageal atresia and tracheoesophageal fistulas in the United States. Journal of Surgical Research. 2014 Aug;190(2):604\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eRikke Neess Pedersen, Elisa Calzolari, Steffen Husby, Ester Garne, EUROCAT Working group*. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions. Arch Dis Child. 2012 Mar 1;97(3):227. \u003c/li\u003e\n\u003cli\u003eDurkin N, De Coppi P. Management of neonates with oesophageal atresia and tracheoesophageal fistula. Early Human Development. 2022 Nov;174:105681. \u003c/li\u003e\n\u003cli\u003eKeefe G, Culbreath K, Edwards EM, Morrow KA, Soll RF, Modi BP, et al. Current outcomes of infants with esophageal atresia and tracheoesophageal fistula: A multicenter analysis. Journal of Pediatric Surgery. 2022 Jun;57(6):970\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eCongenital Disorders [Internet]. Geneva, World Health Organization; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/birth-defects\u003c/li\u003e\n\u003cli\u003eWright NJ, Leather AJM, Ade-Ajayi N, Sevdalis N, Davies J, Poenaru D, et al. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study. The Lancet. 2021 Jul;398(10297):325\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eLal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium. Journal of Pediatric Surgery. 2018 Jul;53(7):1267\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eLal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. Journal of Pediatric Surgery. 2017 Aug;52(8):1245\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eAlslaim HS, Banooni AB, Shaltaf A, Novotny NM. Tracheoesophageal fistula in the developing world: are we ready for thoracoscopic repair? Pediatr Surg Int. 2020 May;36(5):649\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eRosati SF, Maarouf R, Oiticica C, Lange P, Haynes J, Lanning D. A treatment program for babies with esophageal atresia in Belize. Journal of Surgical Research. 2015 Nov;199(1):72\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eTaguchi T. Current progress in neonatal surgery. Surg Today. 2008;38(5):379\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eAbahuje E, Uyisabye I, Ssebuufu R. Epidemiology of pediatric surgery in Rwanda: A one year review. Rwanda Medical Journal. 2016 Mar;73:11\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eOddsberg J, Lu Y, Lagergren J. Aspects of esophageal atresia in a population-based setting: incidence, mortality, and cancer risk. Pediatr Surg Int. 2012 Mar;28(3):249\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eAllin B, Knight M, Johnson P, Burge D, BAPS-CASS. Outcomes at one-year post anastomosis from a national cohort of infants with oesophageal atresia. PLoS One. 2014;9(8):e106149. \u003c/li\u003e\n\u003cli\u003eAl-Salem AH, Tayeb M, Khogair S, Roy A, Al-Jishi N, Alsenan K, et al. Esophageal atresia with or without tracheoesophageal fistula: success and failure in 94 cases. Ann Saudi Med. 2006;26(2):116\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eAmeh EA, Dogo PM, Nmadu PT. Emergency neonatal surgery in a developing country. Pediatr Surg Int. 2001 Jul;17(5\u0026ndash;6):448\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eKarakus SC, Ozokutan BH, Bakal U, Ceylan H, Sarac M, Kul S, et al. Delayed diagnosis: An important prognostic factor for oesophageal atresia in developing countries. J Paediatrics Child Health. 2016 Dec;52(12):1090\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eGupta DK, Sharma S. Esophageal atresia: the total care in a high-risk population. Semin Pediatr Surg. 2008 Nov;17(4):236\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eHasan MS, Islam N, Mitul AR. Neonatal Surgical Morbidity and Mortality at a Single Tertiary Center in a Low- and Middle-Income Country: A Retrospective Study of Clinical Outcomes. Front Surg. 2022;9:817528. \u003c/li\u003e\n\u003cli\u003eFall M, Mbaye PA, Horace HJ, Well\u0026eacute; IB, Lo FB, Traore MM, et al. Oesophageal atresia: Diagnosis and prognosis in Dakar, Senegal. Afr J Paediatr Surg. 2015;12(3):187\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eSamuel Boris Gogan MVL, Romeo Houegban ASC, Metchihoungbe CS, Khen-Dunlop N, Sergine Dossou MGI, Covi AP, et al. Ten Years of Management of Esophageal Atresia in Benin: State of the Art, Experiences and Needs for Families of Children with Stoma. Int J Pediatr Child Health. 2023 Mar 1;11:1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eClark DC. Esophageal atresia and tracheoesophageal fistula. Am Fam Physician. 1999 Feb 15;59(4):910\u0026ndash;6, 919\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eSpitz L. Oesophageal atresia. Orphanet J Rare Dis. 2007 May 11;2:24. \u003c/li\u003e\n\u003cli\u003eKhlevner J, Jodorkovsky D, Bailey DD, Middlesworth W, Sethi A, Abrams J, et al. Management of Adults With Esophageal Atresia. Clin Gastroenterol Hepatol. 2023 Jan;21(1):15\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eNwosu JN, Onyekwulu FA. Oesophageal atresia and tracheooesophageal fistula: a 12 years experience in a developing nation. Niger J Med. 2013;22(4):295\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eOdera A, Peer N, Balakrishna Y, Sheik Gafoor MH. Management and Outcomes of Esophageal Atresia With or Without Tracheo-Esophageal Fistula Over 15 Years in South Africa. Journal of Surgical Research. 2023 Nov;291:442\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eEjigu Y, Mlambo VC, Neil KL, Sime H, Wong R, Gatera MR, et al. Short term outcomes of the first pediatric cardiac surgery program in Rwanda. J Cardiothorac Surg [Internet]. 2024 Dec 31 [cited 2025 Jul 27];19(1). Available from: https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-024-03295-5\u003c/li\u003e\n\u003cli\u003eDavis JR, Nsengiyumva A, Igiraneza D, Hong P, Umutoni R, Neal D, et al. Predictors of Survival: A Retrospective Review of Gastroschisis and Intestinal Atresia in Rwanda. Journal of Surgical Research. 2022 May;273:138\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eZouari M, Ameur HB, Krichen E, Saad NB, Dhaou MB, Mhiri R. Risk factors for adverse outcomes following surgical repair of esophageal atresia. A retrospective cohort study. Dis Esophagus. 2023 Mar 30;36(4):doac070. \u003c/li\u003e\n\u003cli\u003eErshad M, Mostafa A, Dela Cruz M, Vearrier D. Neonatal Sepsis. Curr Emerg Hosp Med Rep. 2019;7(3):83\u0026ndash;90. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rwanda, tracheoesophageal fistula, esophageal atresia, low- and middle-income countries, access to care, pediatric surgical care","lastPublishedDoi":"10.21203/rs.3.rs-7678868/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7678868/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Mortality associated with EA/TEF has declined in HICs with advances in multidisciplinary care. However, it remains as high as 80% in LMICs. This study examines the current clinical outcomes of neonates with EA/TEF at a tertiary-level hospital in Rwanda following the implementation of care by fellowship-trained pediatric surgeons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective cohort study of neonates with EA/TEF from January 2015 to December 2023. Patient data were collected from medical logbooks for all patients who received surgical treatment at Centre Hospitalier Universitaire de Kigali, Rwanda. Univariable logistic regression was used to identify factors associated with higher 30-day mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 56 patients were included. All infants were born at term and, on average, arrived 7 days after birth (6.98 ±5.18). Type C was the most common anomaly (68%). Mortality data were only available for 82.1% of patients. Of this subset, the 30-day mortality was 52.2%. Increased odds of mortality were associated with the presence of any congenital anomaly (p \u0026lt;0.05) and specifically a cardiac congenital anomaly (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This study provides insights into infants with EA/TEF after implementing specialized surgical care, which has helped reduce mortality compared to other LMICs. Targeted quality improvement initiatives for infants with additional associated congenital anomalies could further improve outcomes.\u003c/p\u003e","manuscriptTitle":"Outcomes of Esophageal Atresia at University Tertiary Hospital of Kigali, Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 08:11:50","doi":"10.21203/rs.3.rs-7678868/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f7bba485-64d1-44d8-8ed3-d29fd88a053a","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-01T08:11:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-01 08:11:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7678868","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7678868","identity":"rs-7678868","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}