Tracheobronchial Replacement: A Systematic Review

Abstract

Importance: Tracheobronchial replacement remains a surgical and biological challenge despite several decades of experimental and clinical research.

Objective: To compile a comprehensive state-of-the-science review examining the current indications, techniques, and outcomes of tracheobronchial replacement in human patients.

Evidence review: A systematic review of the literature was conducted on July 1, 2024, to identify studies examining tracheobronchial replacement. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines and the PRISMA 2020 statement. We selected the following 3 databases: (1) PubMed via the US National Library of Medicine's PubMed.gov; (2) Embase via Elsevier's Embase.com; and (3) the Cochrane Central Register of Controlled Trials (CENTER) via Wiley's Cochrane Library. An additional search was performed using the following clinical trials registers: the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov, provided by the US National Library of Medicine.

Findings: The initial search produced 6043 results, with a total of 126 publications included in the final review. Only 1 prospective cohort study and 1 registry, both concerning the use of cryopreserved aortic allografts, were identified. Most publications were case reports and series. From July 1, 2002, to July 1, 2024, a total of 137 cases of tracheobronchial replacement were published. Tracheobronchial replacement was indicated for extensive neoplastic tumors (108 cases [78.8%]) or benign stenoses (29 cases [21.2%]). The most common malignancies were thyroid cancers and adenoid cystic carcinomas. The most frequent resections involved the upper half of the trachea, with reconstructions using muscle flaps, or, most notably, cryopreserved aortic allografts, which have shown promising outcomes and have become the most widely used method since 2022. In the only available registry, the 30-day postoperative mortality and morbidity rates were 2.9% and 22.9%, respectively. Long-term follow-up showed that mortality was related to local recurrences and metastases in patients with cancer.

Conclusions and relevance: This systematic review indicates that extensive malignant lesions are the primary indication for tracheobronchial replacement, with cryopreserved aortic allografts being the only scientifically evaluated surgical technique. Postoperative outcomes were comparable to other major thoracic surgical procedures, while long-term results depended on the underlying disease, especially in cancer cases.