Surgical Strategies for Native Esophagus Preservation in Long-Gap Esophageal Atresia: A 20-Year Population-Based Study

Background/Objectives: Long-gap esophageal atresia (LGEA) is most commonly associated with Gross types A and B, which are usually diagnosed preoperatively, but may also be encountered in Gross type C, where the long gap is recognized intraoperatively, during fistula ligation. This study aimed to describe and explore outcomes associated with two native esophagus-preserving procedures, delayed primary anastomosis (DPA) and the Foker procedure (FP), and to assess their respective roles in the management of LGEA. Methods: We analyzed a population-representative cohort of 38 patients with LGEA treated at two tertiary centers in Belgrade between 2003 and 2023. Patients treated with DPA (n = 20) or FP (n = 18) were evaluated regarding Gross type, gap length, gastrostomy, treatment duration, complications, major adverse outcomes (including esophageal replacement, redo surgery, or death), and hospital stay. Results: Gross types A and B were analyzed together and were more frequently treated with DPA, whereas FP predominated in type C (p = 0.001). Sex, gestational age, birth weight, and gap length did not differ between treatment groups. Gastrostomy was performed in all DPA cases and in 50% of FP cases. No statistically significant differences in complication rates or major adverse outcomes were observed between the DPA and FP groups. Hospital stay was significantly longer in the DPA group (p < 0.001), although this may be partially influenced by temporal bias related to the later introduction of FP. Conclusions: FP may offer practical advantages in type C LGEA, where thoracic access is already required for fistula ligation, whereas DPA may be a suitable approach in types A/B, avoiding an additional thoracic procedure. These findings suggest that anatomical subtype may be an important consideration in treatment selection in LGEA, although validation in larger multicenter prospective studies is warranted.