image: Postoperative outcomes in patients who underwent R-TBP at Lenox Hill Northwell Health, New York, N.Y. view more
Credit: Richard Lazzaro, MD
SAN DIEGO - April 30, 2018 - Robot-assisted tracheobronchoplasty (R-TBP) can be safely performed, and expands the treatment options for patients with tracheobronchomalacia, a complex, high-risk population, according to a study presented at the American Association for Thoracic Surgery's 98th Annual Meeting. This procedure is minimally invasive compared to the accepted treatment, and resulted in low morbidity, no mortality, and significant improvement of patients' symptoms.
Tracheobronchomalacia (TBM) is a debilitating disease of the central airways with limited treatment options. When severe symptoms develop, the accepted surgical option is open tracheobronchoplasty, but it is only performed in highly selected patients due to its significant risks for complications and death. TBM is caused by softening or damage to the cartilaginous structures of the airway walls in the trachea and bronchi. Patients experience breathing difficulties, persistent cough, and are often predisposed to pneumonia and other respiratory infections. Severe TBM leads to complete or near complete collapse of the trachea.
"TBM is a vastly underdiagnosed condition that has remained virtually untreated for decades," explains Richard Lazzaro, MD, Chief, Division General Thoracic Surgery, Lenox Hill Hospital, New York, N.Y. "Its prevalence has been estimated to be as high as 10 percent in the general population, but data indicate that only 262 tracheoplasties were performed in the US between 2002 and 2017. A minimally invasive approach may expand the possibilities."
The first robot-assisted, minimally invasive R-TBP in the US to treat a patient with severe TBM was performed by Dr. Lazzaro at Lenox Hill Hospital, New York, N.Y. in 2013. Since then, more than 40 patients have been treated at the hospital using this technique. Data presented at the AATS 98th Annual Meeting evaluate the patient demographics, complications, surgical outcomes, and patient satisfaction.
Records of 435 patients with clinical suspicion of TBM who underwent dynamic CT scans between May 2016 and December 2017 were examined. TBM was defined as greater than 50% collapse of the airway by CT scan. Of these, 145 were further evaluated by thoracic surgery and 42 patients with severe symptomatic TBM underwent R-TBP.
Pulmonary function tests at around four months after surgery showed significant improvement in the majority of patients. There was a substantial increase in the mean percent forced vital capacity (FVC) from 70.6 percent to 85.6 percent after R-TBP. Correspondingly, the mean preoperative percent predicted peak expiratory flow rate (PEFR) was 61.75 percent and rose to 80.85 percent after surgery. No patients required immediate postoperative bronchoscopies, nor were any patients reintubated. Postoperative complications were minimal: one patient developed pneumonia and two patients developed pneumothorax. All patients were discharged home and there were no deaths at 90 days after surgery.
Although long-term patient follow-up is still ongoing, 35 patients completed a five-point (Likert scale) postoperative survey assessing satisfaction with the R-TBP procedure. Over 80 percent of patients reported satisfaction with the overall results of the procedure, and the majority reported subjective improvement of cough, shortness of breath, and ability to manage respiratory infections.
"These results show that R-TBP can be performed with low morbidity and mortality," says Dr Lazzaro. "Early follow-up reveals that most patients clearly see a dramatic relief in symptoms with a corresponding rise in pulmonary function tests. However, there are still many challenges to overcome. First and foremost is patient selection. A minority of patients do not have significant benefit, but reasons are often unclear."
Further investigation is needed into the role of stents, optimal mesh size, and customized repair for unique malacic airway geometry. More advanced imaging may assist with operative planning and better non-invasive diagnosis.
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