Bairdain Sigrid, Smithers Charles Jason, Hamilton Thomas E, Zurakowski David, Rhein Lawrence, Foker John E, Baird Christopher, Jennings Russell W
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
J Pediatr Surg. 2015 Jun;50(6):972-7. doi: 10.1016/j.jpedsurg.2015.03.016. Epub 2015 Mar 14.
Tracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea's anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM.
The records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar's test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient.
Twenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5 months (range, 0.5-38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p=0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p=0.01), lower trachea (p<0.001), and right bronchus (p=0.04).
The use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity.
气管支气管软化症（TBM）与食管闭锁、气管食管瘘和先天性心脏病相关。TBM会导致慢性咳嗽、黏液清除不良和反复肺炎。明显危及生命的事件或反复肺炎可能需要手术治疗。TBM通常采用主动脉固定术治疗，该手术间接抬高气管前壁。然而，气管软骨畸形和气管后壁膜性组织内陷可能会限制其疗效。本研究描述了接受直接气管支气管固定术治疗TBM的患者的预后情况。
回顾性分析2011年1月至2014年4月在本机构接受直接气管支气管固定术的患者记录。主要结局包括TBM复发和主要症状的缓解。采用McNemar配对二元检验和逻辑回归模型分析数据，以考虑每位患者在多个时间点内镜检查时管腔狭窄的情况。
共确定20例患者。术前评估指导气管支气管固定术的类型。30%的患者接受单纯前侧气管支气管固定术，50%接受单纯后侧气管支气管固定术，20%接受前后侧联合固定术。随访时间为5个月（范围0.5 - 38个月）。术后无患者发生明显危及生命的事件，肺炎显著减少（p = 0.0005）。在这些解剖区域，术后内镜检查时气管支气管塌陷的患者减少：气管中段（p = 0.01）、气管下段（p < 0.001）和右主支气管（p = 0.04）。
在我们的患者中，采用直接气管支气管固定术可使明显危及生命的事件得到缓解，并减少反复肺炎的发生。气管中段、下段及右主支气管的TBM情况也有所改善。鉴于我们研究人群的异质性，需要进一步研究以确定长期预后及TBM严重程度的分级标准。
