Efficacy and safety of internal traction in long-gap esophageal atresia: a systematic review and meta-analysis
8 affiliations
- 1Rawalpindi Medical University, Rawalpindi, Pakistan
- 2Foundation University Medical College, Islamabad, Pakistan
- 3Services Institute of Medical Sciences, Lahore, Pakistan
- 4Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
- 5Tbilisi State Medical University, Tbilisi, Georgia
- 6Federal Medical and Dental College, Islamabad, Pakistan
- 7Khyber Medical University, Peshawar, Pakistan
- 8Fatima Jinnah Medical University, Lahore, Pakistan
Abstract
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.
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BibTeX
@article{bibi2026efficacy,
title = {{Efficacy and safety of internal traction in long-gap esophageal atresia: a systematic review and meta-analysis}},
author = {Arooj Bibi and Muhammad Aatir Aslam and Ali Amjad and Jannat Yusuf and Hareema Tabassum and Isra Laeeq and Laiba Saleem and Rayyan Mohammad Makki Bakhsh and Faiza Hayat Qadri and Afnan Javed and Ayesha Khuram and Samar Tariq and Ayesha Akbar and Aiman Farheen and Haider Imran and Haseeb Sadaqat and Tuba Shakoor},
journal = {World Journal of Pediatric Surgery},
year = {2026},
month = nov,
doi = {10.1136/wjps-2026-001219},
url = {https://doi.org/10.1136/wjps-2026-001219},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Efficacy and safety of internal traction in long-gap esophageal atresia: a systematic review and meta-analysis
AU - Arooj Bibi
AU - Muhammad Aatir Aslam
AU - Ali Amjad
AU - Jannat Yusuf
AU - Hareema Tabassum
AU - Isra Laeeq
AU - Laiba Saleem
AU - Rayyan Mohammad Makki Bakhsh
AU - Faiza Hayat Qadri
AU - Afnan Javed
AU - Ayesha Khuram
AU - Samar Tariq
AU - Ayesha Akbar
AU - Aiman Farheen
AU - Haider Imran
AU - Haseeb Sadaqat
AU - Tuba Shakoor
PY - 2026
DA - 2026/11/04
JO - World Journal of Pediatric Surgery
DO - 10.1136/wjps-2026-001219
UR - https://doi.org/10.1136/wjps-2026-001219
AB - 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.
SN - 2096-6938
SN - 2516-5410
ER -