Primary Posterior Tracheopexy in Esophageal Atresia with Tracheomalacia: From Innovation to Multicenter RCT

BACKGROUND: Tracheomalacia (TM) is a common comorbidity in children with esophageal atresia (EA), reported in up to 87% of patients. Around 30% of EA patients develop severe TM associated with recurrent respiratory morbidity. In such cases, surgical intervention may be required. Traditionally, treatment involved secondary procedures such as aortopexy or posterior tracheopexy. More recently, primary posterior tracheopexy (PPT) has been adopted in an increasing number of centers. The evolution of the surgical treatment of TM from secondary to primary intervention is described. A single-center cohort is evaluated, including 38 EA patients, 14 of whom underwent PPT. Compared with historical controls, PPT reduced brief resolved unexplained events (39% vs. 19%, p=0.09) and significantly decreased respiratory infections (61% vs. 25%, p=0.004). Cost analysis showed lower respiratory-related admissions after excluding outliers. These findings established the TEACHER project, an international framework for training and dissemination, which in turn laid the foundation for the PORTRAIT trial, a multicenter randomized controlled study designed to randomize 78 neonates with TM to PPT versus standard repair.

CONCLUSION: Early data suggest PPT reduces respiratory morbidity and may lower healthcare costs. The PORTRAIT trial aims to provide high-level evidence to determine whether PPT should be adopted as standard treatment during EA repair or avoided to prevent overtreatment.