Posterior tracheopexy for pediatric tracheomalacia: A global evidence synthesis and meta-analysis

Severe pediatric tracheomalacia (TM) causes dynamic expiratory airway collapse resulting in recurrent infections, cyanotic spells, respiratory support dependence, and significant morbidity. Posterior tracheopexy (PT) has emerged as a physiologically targeted reconstructive strategy; however, pooled outcome data are limited. Thus, we performed a systematic review and meta-analysis to evaluate the efficacy and safety of PT in children with TM.

PubMed, Embase, Scopus, Cochrane Library, and Google Scholar were searched for studies reporting postoperative outcomes of PT in patients <18 years. Primary outcomes were respiratory symptom improvement and overall symptom resolution. Secondary outcomes included recurrent infections, supplemental oxygen requirement, reintervention, acquired/recurrent tracheoesophageal fistula (TEF), complications, blue spells/brief resolved unexplained events (BRUEs), and mortality. Random-effects generalized linear mixed models generated pooled proportions. Heterogeneity was assessed using I² statistics. Prespecified subgroup analyses evaluated reintervention by operative approach and by the presence of esophageal atresia (EA)/TEF.

Fourteen observational studies (n = 318) met the inclusion criteria. Respiratory symptom improvement occurred in 91.03% (95% CI: 86.63-94.08; I² = 0%) and overall symptom resolution in 95.7% (95% CI: 76.3-99.4; I² = 0%). Blue spells/BRUEs declined to 0.6% (95% CI: 0.04-8.3; I² = 0%). Recurrent infections decreased to 10.60% (95% CI: 5.08-20.78; I² = 33.3%), and supplemental oxygen requirement to 15.0% (95% CI: 3.0-50.6; I² = 66.6%). Reintervention occurred in 9.1% (95% CI: 4.9-16.4; I² = 0%). Acquired/recurrent TEF occurred in 5.7% (95% CI: 1.8-16.1; I² = 0%), and overall complications in 19.6% (95% CI: 13.0-28.5; I² = 0%), with no perioperative mortality. Subgroup analyses demonstrated no statistically significant differences in reintervention by operative approach (p = 0.26) or EA/TEF status (p = 0.67).

PT is associated with high rates of symptom improvement, near-elimination of cyanotic episodes, low reintervention rates, and negligible mortality. Prospective multicenter comparative studies are required to define long-term durability and comparative effectiveness.