Recurrent Tracheoesophageal Fistula A Systematic Review and Meta-Analysis on Surgical and Endotracheal Treatment

Background: Recurrent tracheoesophageal fistula (rTEF) is a complication of Esophageal Atresia (EA), with treatment posing a significant challenge. Surgical treatment (ST) can be performed through thoracotomy, thoracoscopy, or via endotracheal treatment (ET) with de-epithelialization and/or sealants. The optimal treatment option for rTEF, however, remains unclear. Aim: This study systematically reviewed the outcomes of ST and ET for rTEF to determine which treatment approach yields the best outcome. Methods: The study was conducted following PRISMA guidelines. PubMed, Embase, and the Cochrane Library were comprehensively searched for studies published from 2000 to December 2024. Two reviewers independently screened and analyzed the relevant studies. Success and complication rates were pooled using a random effects model for the meta-analysis. For additional outcomes, descriptive statistics were used. Results: Twenty-seven studies (15 case series, 12 cohort studies) including 540 patients with rTEF were eligible for inclusion for the systematic review. Meta-analysis showed a pooled success rate after the first procedure of 92.4% [95% CI: 87.8% - 95.4%] for ST and 27.7% [95% CI: 18.3% - 39.6%] for ET. After revisional procedures, the success rates increased to 97.7% [95% CI: 92.7% - 99.3%] for ST and 72.6% [95% CI: 59.5% - 82.6%] for ET. The mean number of procedures ranged from 1.0 to 1.2 for ST and from 1.3 to 3.8 for ET. The pooled complication rate for ST was 31.0% [95% CI: 5.7% - 77.1%]. The pooled complication rate for ET was 2.1% [95% CI: 0.01% - 24.1%]. The most reported complications for ST included anastomotic strictures and leakage, while postoperative respiratory tract infections were the primary complications for ET. Conclusion: These findings demonstrate that although ST is highly effective and efficient, it is also associated with a high risk of severe complications. In contrast, ET demonstrates a lower success rate, but complications occur less frequently and are less severe. Despite the lower success rate, the minimally invasive techniques and reduced complication risk of endotracheal repair may support its consideration as a first-line treatment option. Type of study: systematic review and meta-analysis