Efficacy and safety of internal traction in long-gap esophageal atresia: a systematic review and meta-analysis

Background Long-gap esophageal atresia (LGEA) presents a significant surgical challenge due to the extensive gap precluding tension-free primary repair. Internal traction offers a potentially safer, esophagus-preserving alternative to external traction (Foker) techniques by avoiding prolonged sedation and ventilation. However, evidence is limited to small case series.Methods We searched several databases, such as PubMed, Embase, and Scopus, through October 4, 2025. Eight single-arm studies (122 patients) met inclusion criteria. Pooled proportions were calculated using random-effects models with Freeman-Tukey double arcsine transformation; heterogeneity was assessed via I² statistics.Results Internal traction achieved delayed primary anastomosis in 92% of patients (95% confidence interval (CI=80%–99%; I²=21.1%), with 90% achieving full oral feeding (95% CI=58%–100%). Esophageal replacement was rare (5%) and mortality low (5%). However, morbidity was substantial: gastroesophageal reflux occurred in 73% of patients, stricture requiring dilation in 46%, postoperative stenosis in 52%, and anastomotic leak in 28%. Complication rates directly attributable to internal traction were 28%, with fundoplication required in 22% of patients. Heterogeneity was moderate to substantial for several secondary outcomes.Conclusion Internal traction is a promising organ-preserving approach for LGEA, with high anastomotic success but substantial reflux- and stricture-related morbidity. Prospective, multicenter studies with standardized outcome definitions and comparator groups are needed to define its optimal role in LGEA management.PROSPERO registration number CRD420251161975.