Learning Curve and Early Outcomes of Thoracoscopic Esophageal Atresia Repair in an Emerging Pediatric Minimally Invasive Surgery (MIS) Program: A Cumulative Sum Analysis

Background: Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains technically challenging due to the rarity of these procedures and the demanding intracorporeal suturing within the confined neonatal thorax. The aim of this study is to report the learning curve and early outcomes during the transition from open to thoracoscopic EA/TEF repair at a single center, evaluated using the cumulative sum (CUSUM) method. Methods: We retrospectively reviewed data of 79 consecutive EA/TEF patients operated on between January 2015 and June 2026. Twenty-eight underwent thoracoscopic repair and 51 open repairs. The open cohort served as a historical institutional comparator, reflecting the standard of care prior to the adoption of thoracoscopic technique. The thoracoscopic group was stratified into three learning curve phases: Early (n = 9), Intermediate (n = 9), and Proficient (n = 10). Anastomotic leak was defined by contrast extravasation on postoperative esophagogram. Complications were graded using the Clavien–Dindo classification. Results: The mean operative time was 2.9 ± 1.2 h (thoracoscopic) vs. 2.3 ± 1.2 h (open; p = 0.036). CUSUM analysis demonstrated a learning curve of approximately 15 cases, with operative time decreasing from 3.4 h (Phase 1) to 2.5 h (Phase 3; p = 0.034). Anastomotic leak occurred in 9/28 (32.1%) vs. 7/51 (13.7%; p = 0.137; underpowered comparison). Within the thoracoscopic group, long-gap patients (n = 8) had significantly higher stricture rates (37.5% vs. 0%; p = 0.017) and longer hospital stays (66 vs. 30 days; p = 0.005). The three long-gap patients with stricture required 11 total endoscopic dilation sessions. No statistically significant difference in mortality was observed (7.1% vs. 5.9%; p = 1.000). Conclusions: Thoracoscopic EA/TEF repair is feasible in an emerging MIS program with acceptable complication rates. The CUSUM-based learning curve was 15 cases. Long-gap thoracoscopic repair carries significantly higher stricture risk.