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

Abstract

Objective

This study aimed 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 the 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.

Keywords

esophageal atresia - tracheoesophageal fistula - azygos vein - azygos vein preservation - thoracoscopic repair

Contributors' Statement

C.G.H.: Conceptualization, writing–original draft, writing–review and editing. M.A.: Conceptualization, data curation, formal analysis, writing–review and editing. M.G.: Conceptualization, investigation, methodology. T.O.K.: Formal analysis, supervision, validation. M.E.: Conceptualization, project administration. S.K.: Investigation, supervision. E.K.: Methodology, supervision. T.R.: Data curation, formal analysis. S.P-B.: Conceptualization, data curation, investigation. M.F.M.G.: Resources, supervision. F.P.: Methodology, supervision, writing–review and editing. F.C.: Supervision, validation, visualization. A.M.: Project administration, validation, visualization. C.E.: Project administration, supervision, visualization, writing–review and editing.

Data Availability Statement

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Publication History

Received: 11 June 2025

Accepted: 13 January 2026

Accepted Manuscript online:
20 January 2026

Article published online:
28 January 2026

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