Is surgical resection superior to bronchoscopic resection in patients with symptomatic endobronchial hamartoma?

A best evidence topic was written according to a structured protocol. The question addressed was: in surgically fit patients with biopsy proven symptomatic endobronchial hamartoma (EH), is surgical resection superior to bronchoscopic resection in terms of outcome. A total of 756 articles were identified using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Three studies included patients who had either bronchoscopic or surgical treatment of EH in the same study. Modalities of surgery included performing a lobectomy, segmentectomy, bronchotomy and a pneumonectomy. Complete resection was 100% in the surgical group and ranged from 8% to 100% in the group treated bronchoscopically. Morbidity was present in 1 patient in a single study (6.6%) in the form of a pneumothorax after a bronchoscopic resection. No mortality was recorded in any study. A follow-up period of 16.2, 26 and up to 60 months showed recurrence of 26.7%, 12% and 0% respectively in the groups treated by bronchoscopy and no recurrence in the surgical group. Four studies looked at bronchoscopic treatment only for EH. Modalities of treatment included mechanical resection, laser, cryotherapy and Argon plasma coagulation. Complete resection ranged from 50-100% with patients achieving only partial resection requiring repeated endoscopic sessions. Morbidity was present in 3 out of the 4 studies; 1 case of pneumothorax in each of 2 studies (4.4% and 2%) and 25% morbidity rate in the third study (pneumothorax/airway stenosis). No mortality was present in any study. One study reported no recurrence after a median follow-up of 12.2 months, while another reported 50% recurrence, although the follow-up period was not stated. The final study included patients with EH treated only by surgical resection due to end stage lung damage caused by prolonged endobronchial obstruction. The majority of resections (71.4%) were in the form of lobectomies. Two major morbidities were recorded (28.5%) with no mortality. After a mean follow-up period of 7 years, no recurrences were recorded. To conclude, in biopsy proven symptomatic EHs, bronchoscopic treatment should be the first choice except in patients with end stage lung damage requiring surgical resection. Morbidity is low with pneumothorax the most common complication. Patients may require multiple sessions for complete removal as a significant recurrence rate is present, but is usually managed effectively by repeated bronchoscopic management.