Musculoskeletal outcomes following thoracoscopic versus conventional open repair of esophageal atresia: A systematic review and meta-analysis from pediatric surgery meta-analysis (PESMA) study group

Abstract

Background and objective: Thoracic musculoskeletal deformities are a recognized long-term complication after esophageal atresia (EA) repair. Although evidence remains limited, thoracoscopic repair (TR) is thought to reduce morbidity compared to conventional open repair (COR), with potential benefits including earlier recovery, reduced pain, improved cosmesis, and fewer musculoskeletal sequelae. This systematic review and meta-analysis aimed to compare the incidence of musculoskeletal deformities following EA repair via TR versus COR, emphasizing their long-term clinical implications. Method: The protocol for this review was registered in PROSPERO(CRD42024576044). A comprehensive literature search was conducted across Ovid Medline, Cochrane, PubMed, Web of Science, EMBASE, SCOPUS, and Google scholar from inception to January 2025. The primary outcomes assessed were scoliosis, rib anomalies (including deformity, fusion, and adhesions), chest wall anomalies, and scapula alata. Statistical analysis was performed using Review Manager (RevMan) version 5.4. Results: Four retrospective studies comprising 283 patients (TR: 96; COR: 187) were included. TR was associated with significantly lower rates of scoliosis (3.1 % vs. 16 %; RR 0.35, 95 % CI 0.14e0.84, p ¼ 0.02) and rib anomalies (0 % vs. 41.5 %; RR 0.05, 95 % CI 0.01e0.25, p ¼ 0.0002). No significant differences were observed for chest wall anomalies (RR 0.65, p ¼ 0.41) or scapula alata (RR 0.37, p ¼ 0.30). However, the small number of studies and variability in diagnostic methods limit the strength and generalizability of these findings. Conclusion: TR of EA may reduce long-term musculoskeletal morbiditydparticularly scoliosis and rib anomaliesdwhen compared to COR. While promising, these results should be interpreted with caution given the limited sample size and methodological heterogeneity. Further multicenter studies with standardized outcome definitions are warranted to confirm these findings and explore the role of muscle-sparing techniques.