Whether prophylactic intraoperative chest drain insertion in esophageal atresia-tracheoesophageal fistula is an evidence-based practice or just a prejudice: A systematic review and meta-analysis

Background: Various controversial practices in the management of Esophageal atresia-tracheoesophageal fistula (EA-TEF) can be noticed among pediatric surgeons. Routine intraoperative chest drain (IOCD) insertion is often debated and lacks any concrete evidence. This meta-analysis aims to compare the postoperative outcomes among newborns with and without IOCD insertion.

Methods: The authors searched EMBASE, PubMed, Scopus, and Web of Science on 30^th April 2021. The requirement for chest drain in the postoperative period (POCD), anastomotic leak (and/or pneumothorax), mortality rate, and revisit(s) to the operation room (RVOR) were compared among two groups of newborns, i.e. groups A and B with and without IOCD insertion respectively. The statistical analysis was performed using a fixed-effects model. The pooled risk ratio (RR) and heterogeneity (I²) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

Results: A total of 498 newborns were included in the present analysis. As compared to group B, newborns within group A showed no significant difference in the requirement for POCD (RR 2.47; 95% CI 0.88-6.98, p = 0.09), the occurrence of anastomotic leak and/or pneumothorax (RR 1.35; 95% CI 0.89-2.06, p = 0.16), and mortality rate (RR 2.24; 95% CI 0.81-6.26, p = 0.12). However, RVOR was significantly higher in group A (RR 1.75; 95% CI 1.07-2.87, p = 0.03). All included studies had a moderate risk of bias.

Conclusions: The present meta-analysis revealed no additional benefit of prophylactic IOCD insertion. However, due to moderate risk of bias, further studies need to be conducted for an optimal comparison between the two groups.