Impact of Azygos Vein Preservation on Postoperative Outcomes in Esophageal Atresia: A Systematic Review and Meta-Analysis from the Pediatric Surgery Meta-analysis (PESMA) study group

Objective: To evaluate whether preservation of the azygos vein influences postoperative outcomes in infants undergoing repair of esophageal atresia with tracheoesophageal fistula (EA-TEF). Materials and methods: A systematic review and meta-analysis were conducted using six major databases, identifying all relevant studies published up to January 2025. Seven studies met inclusion criteria, including five randomized controlled trials and two retrospective analyses. Outcomes assessed were anastomotic leaks, esophageal strictures, chest infections, and mortality. Results: Across studies, azygos vein preservation was generally associated with fewer postoperative complications compared with ligation. Preservation of the Azygos vein appeared to reduce the risk of anastomotic leak, chest infection, and mortality, while also showing a trend toward fewer strictures. However, the strength of evidence was limited by study heterogeneity, small sample sizes, and variation in surgical techniques. Conclusion: This systematic review and meta-analysis suggest that preserving the azygos vein may be beneficial in reducing major postoperative complications. Nevertheless, because most included studies were small and of mixed quality, these findings should be interpreted with caution. Larger, high-quality randomized trials are needed to confirm whether Azygos vein preservation directly improves clinical outcomes.