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Background/Purpose: The current study enrolled 113 patients with esophageal atresia (EA) accompanying tracheoesophageal fistula (TEF) (Vogt type IIIb) who were treated at the Central Hospital St. Jurgen Strasse, Department of Pediatric Surgery in Bremen, Germany between 1978 and 1997. Methods: These EA patients were classified into patients preoperatively complicated by respiratory distress syndrome (RDS) or pneumonia and those without complications. In each group, risk factors were classified according to the risk classification described by Spitz et al, and the prognoses and therapeutic problems were evaluated. Based on these results, a new preoperative risk classification consisting of risk factors described by Spitz et al supplemented with RDS and pneumonia was evaluated. Results: When the prognoses of EA were evaluated, the survival rate was markedly decreased when RDS or pneumonia alone or more than 2 of 3 factors including major cardiac anomalies and low birth weight were present as preoperative risk factors. Concerning therapeutic problems, the necessity of treatment with delayed primary repair tended to increase when RDS or pneumonia was present as risk factors. However, it was suggested that secure and safe blockage of TEF was still difficult during the initial surgery. Conclusions: During selection of therapeutic strategies for EA, RDS and pneumonia are still considered to be essential as preoperative risk factors for EA. Our new preoperative risk classification consisting of risk factors described by Spitz et al supplemented with RDS and pneumonia appears to clearly reflect the prognoses and therapeutic problems of EA. J Pediatr Surg 35:584-587. Copyright © 2000 by W.B. Saunders Company.