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Vaughn AE, Lyttle BD, Louiselle AE, Cooper E, Niemiec SM, Phillips R, Hilton SA, Kinsella JP, Gien J, Derderian SC, Liechty KW. Muscle Flap Technique Safe for On-ECMO Congenital Diaphragmatic Hernia Repair. J Pediatr Surg 2024; 59:962-968. [PMID: 38160185 DOI: 10.1016/j.jpedsurg.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Prosthetic patches (patch) and muscle flaps (flap) are techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extra-corporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared to patch due to the hemostatic advantage of native tissue. METHODS A single-center retrospective comparative study of patients who underwent on-ECMO CDH repair between 2008 and 2022 was performed. RESULTS Fifty-two patients met inclusion criteria: 18 patch (34.6%) and 34 flap (65.4%). There was no difference in CDH severity between groups. On univariate analysis, reoperation for surgical bleeding was lower following flap repair compared to patch (23.5% vs 55.6%, respectively; p = 0.045), 48-h postoperative blood product transfusion was lower after flap repair (132 mL/kg vs 273.5 mL/kg patch; p = 0.006), and two-year survival was increased in the flap repair group compared to patch (53.1% vs 17.7%, respectively; p = 0.036). On multivariate analysis adjusting for CDH side, day on ECMO repaired, and day of life CDH repaired, flap repair was significantly associated with lower five-day postoperative packed red blood cell transfusion amount, improved survival to hospital discharge, and improved two-year survival. CONCLUSIONS Our experience suggests that the muscle flap technique for on-ECMO CDH repair is associated with reduced bleeding complications compared to prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. These results support the flap repair technique as a favored method for on-ECMO CDH repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alyssa E Vaughn
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States.
| | - Bailey D Lyttle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Amanda E Louiselle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Emily Cooper
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Stephen M Niemiec
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Ryan Phillips
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Sarah A Hilton
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - S Christopher Derderian
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Kenneth W Liechty
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Division of Pediatric Surgery, Department of Surgery, University of Arizona Tucson College of Medicine and Banner Children's Hospital at Diamond Children's Medical Center, Tucson, AZ, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
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Wild KT, Rintoul N, Hedrick HL, Heimall L, Soorikian L, Foglia EE, Ades AM, Herrick HM. Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia: Lessons Learned through Video Review. Fetal Diagn Ther 2024:000538536. [PMID: 38531327 DOI: 10.1159/000538536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework. METHODS Single center observational study of video recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation. RESULTS We analyzed 31 video recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The 'Internal Environment' and 'Tasks' components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation. CONCLUSION Video review revealed variation in event timing and order during CDH resuscitations. Standardization of room set-up, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.
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Wild KT, Rintoul NE, Ades AM, Gebb JS, Moldenhauer JS, Mathew L, Flohr S, Bostwick A, Reynolds T, Ruiz RL, Javia LR, Nelson O, Peranteau WH, Partridge EA, Adzick NS, Hedrick HL. The Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia Treated with Fetoscopic Endoluminal Tracheal Occlusion: Beyond the Balloon. Fetal Diagn Ther 2024; 51:184-190. [PMID: 38198774 DOI: 10.1159/000536209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Randomized controlled trials found that fetoscopic endoluminal tracheal occlusion (FETO) resulted in increased fetal lung volume and improved survival for infants with isolated, severe left-sided congenital diaphragmatic hernia (CDH). The delivery room resuscitation of these infants is particularly unique, and the specific delivery room events are largely unknown. The objective of this study was to compare the delivery room resuscitation of infants treated with FETO to standard of care (SOC) and describe lessons learned. METHODS Retrospective single-center cohort study of infants treated with FETO compared to infants who met FETO criteria during the same period but who received SOC. RESULTS FETO infants were more likely to be born prematurely with 8/12 infants born <35 weeks gestational age compared to 3/35 SOC infants. There were 5 infants who required emergent balloon removal (2 ex utero intrapartum treatment and 3 tracheoscopic removal on placental bypass with delayed cord clamping) and 7 with prenatal balloon removal. Surfactant was administered in 6/12 FETO (50%) infants compared to 2/35 (6%) in the SOC group. Extracorporeal membrane oxygenation use was lower at 25% and survival was higher at 92% compared to 60% and 71% in the SOC infants, respectively. CONCLUSION The delivery room resuscitation of infants treated with FETO requires thoughtful preparation with an experienced multidisciplinary team. Given increased survival, FETO should be offered to infants with severe isolated left-sided CDH, but only in high-volume centers with the experience and capability of removing the balloon, emergently if needed. The neonatal clinical team must be skilled in managing the unique postnatal physiology inherent to FETO where effective interdisciplinary teamwork is essential. Empiric and immediate surfactant administration should be considered in all FETO infants to lavage thick airway secretions, particularly those delivered <48 h after balloon removal.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Juliana S Gebb
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sabrina Flohr
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anna Bostwick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryan L Ruiz
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Luv R Javia
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Emily A Partridge
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Ersöz Köse E, Yalçınkaya İ. Congenital diaphragmatic hernia. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S89-S97. [PMID: 38584782 PMCID: PMC10995690 DOI: 10.5606/tgkdc.dergisi.2024.25705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 11/29/2023] [Indexed: 04/09/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by the herniation of abdominal contents into the chest, resulting in varying degrees of pulmonary hypoplasia and pulmonary hypertension. Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. In the postnatal period, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of pulmonary hypertension have led to improved outcomes in infants with CDH. Surgical repair of CDH is not urgent in most circumstances and can be delayed until the pulmonary status of the patient has stabilized. This article provides a comprehensive review of CDH, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
- Elçin Ersöz Köse
- Department of Thoracic Surgery, Health Sciences University Istanbul Hamidiye Medical Faculty, Süreyyapaşa Chest Diseases and Thoracic Surgery Hospital, Istanbul, Türkiye
| | - İrfan Yalçınkaya
- Department of Thoracic Surgery, Health Sciences University Istanbul Hamidiye Medical Faculty, Süreyyapaşa Chest Diseases and Thoracic Surgery Hospital, Istanbul, Türkiye
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Wild KT, Mathew L, Hedrick HL, Rintoul NE, Ades A, Soorikian L, Matthews K, Posencheg MA, Kesler E, Van Hoose KT, Panitch HB, Flibotte J, Foglia EE. Respiratory function after birth in infants with congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2023; 108:535-539. [PMID: 36400455 DOI: 10.1136/archdischild-2022-324415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To characterise the transitional pulmonary physiology of infants with congenital diaphragmatic hernia (CDH) using measures of expiratory tidal volume (TV) and end-tidal carbon dioxide (ETCO2). DESIGN Prospective single-centre observational study. SETTING Quaternary neonatal intensive care unit. PATIENTS Infants with an antenatal diagnosis of CDH born at the Children's Hospital of Philadelphia. INTERVENTIONS TV and ETCO2 were simultaneously recorded using a respiratory function monitor (RFM) during invasive positive pressure ventilation immediately after birth. MAIN OUTCOME MEASURES TV per birth weight and ETCO2 values were summarised for each minute after birth. Subgroups of interest were defined by liver position (thoracic vs abdominal) and extracorporeal membrane oxygenation (ECMO) treatment. RESULTS RFM data were available for 50 infants from intubation until a median (IQR) of 9 (7-14) min after birth. TV and ETCO2 values increased for the first 10 min after birth, but intersubject values were heterogeneous. TVs were overall lower and ETCO2 values higher in infants with an intrathoracic liver and infants who were ultimately treated with ECMO. On hospital discharge, survival was 88% (n=43) and 34% (n=17) of infants were treated with ECMO. CONCLUSION Respiratory function immediately after birth is heterogeneous for infants with CDH. Lung aeration, as evidenced by expired TV and ETCO2, appears to be ongoing throughout the first 10 min after birth during invasive positive pressure ventilation. Close attention to expired TV and ETCO2 levels by 10 min after birth may provide an opportunity to optimise and individualise ventilatory support for this high-risk population.
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Affiliation(s)
- K Taylor Wild
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leane Soorikian
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Kelle Matthews
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Michael A Posencheg
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erin Kesler
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - K Taylor Van Hoose
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard B Panitch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Imanishi Y, Usui N, Furukawa T, Nagata K, Hayakawa M, Amari S, Yokoi A, Masumoto K, Yamoto M, Okazaki T, Inamura N, Toyoshima K, Terui K, Okuyama H. Outcomes of congenital diaphragmatic hernia among preterm infants: inverse probability of treatment weighting analysis. J Perinatol 2023; 43:884-888. [PMID: 37055479 DOI: 10.1038/s41372-023-01647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/19/2023] [Accepted: 03/08/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVES To evaluate the survival and intact-survival rates among preterm infants with congenital diaphragm hernia (CDH). STUDY DESIGN Multicenter retrospective cohort study of 849 infants born between 2006 and 2020 at 15 Japanese CDH study group facilities. Multivariate logistic regression analysis adjusted using inverse probability treatment weighting (IPTW) method was used. We also compare trends of intact-survival rates among term and preterm infants with CDH. RESULTS After adjusting using the IPTW method for CDH severity, sex, APGAR score at 5 min, and cesarean delivery, gestational age and survival rates have a significantly positive correlation [coefficient of determination (COEF) 3.40, 95% confidence interval (CI), 1.58-5.21, p value <0.001] and higher intact-survival rate [COEF 2.39, 95% CI, 1.73-4.06, p value 0.005]. Trends of intact-survival rates for both preterm and term infants had significantly changed, but improvement in preterm infants was much smaller than in term infants. CONCLUSION Prematurity was a significant risk factor for survival and intact-survival among infants with CDH, regardless of adjustment for CDH severity.
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Affiliation(s)
- Yousuke Imanishi
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan.
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal‑Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Tsukuba University, Tsukuba, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kinki University, Higashiosaka, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Pugnaloni F, Capolupo I, Patel N, Giliberti P, Dotta A, Bagolan P, Kipfmueller F. Role of microRNAs in Congenital Diaphragmatic Hernia-Associated Pulmonary Hypertension. Int J Mol Sci 2023; 24:ijms24076656. [PMID: 37047629 PMCID: PMC10095389 DOI: 10.3390/ijms24076656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Epigenetic regulators such as microRNAs (miRNAs) have a key role in modulating several gene expression pathways and have a role both in lung development and function. One of the main pathogenetic determinants in patients with congenital diaphragmatic hernia (CDH) is pulmonary hypertension (PH), which is directly related to smaller lung size and pulmonary microarchitecture alterations. The aim of this review is to highlight the importance of miRNAs in CDH-related PH and to summarize the results covering this topic in animal and human CDH studies. The focus on epigenetic modulators of CDH-PH offers the opportunity to develop innovative diagnostic tools and novel treatment modalities, and provides a great potential to increase researchers’ understanding of the pathophysiology of CDH.
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Affiliation(s)
- Flaminia Pugnaloni
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Neil Patel
- Department of Neonatology, The Royal Hospital for Children, Glasgow G51 4TF, UK
| | - Paola Giliberti
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Pietro Bagolan
- Area of Fetal, Neonatal and Cardiological Sciences Children’s Hospital Bambino Gesù-Research Institute, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00165 Rome, Italy
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany
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Olutoye OO, Mehl SC, Moturu A, Pettit RW, Coleman RD, Vogel AM, Lee TC, Keswani SG, King A. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res 2023; 282:168-173. [PMID: 36306587 PMCID: PMC11132729 DOI: 10.1016/j.jss.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. METHODS A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. RESULTS Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. CONCLUSIONS Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Anoosha Moturu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ryan D Coleman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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Horn-Oudshoorn EJJ, Peters NCJ, Franx A, Eggink AJ, Cochius-den Otter SCM, Reiss IKM, DeKoninck PLJ. Termination of pregnancy after a prenatal diagnosis of congenital diaphragmatic hernia: Factors influencing the parental decision process. Prenat Diagn 2023; 43:95-101. [PMID: 36443507 PMCID: PMC10107614 DOI: 10.1002/pd.6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). STUDY DESIGN Single-centre retrospective cohort includes all prenatally detected CDH cases born between January 2009 and December 2021. Parental factors, such as parity, and fetal characteristics, such as disease severity, were collected. Descriptive statistics were used to present the data. Differences between terminated and continued pregnancies were analysed. RESULTS The study population consisted of 278 prenatally detected CDH cases of which 80% detected <24 weeks of gestation. The TOP rate was 28% in cases that were detected <24 weeks of gestation. Twenty continued pregnancies resulted in either intrauterine fetal demise (n = 6), preterm birth <24 weeks (n = 2), or comfort care after birth (n = 12). The survival rate was 70% in the remaining 195 live born cases. Factors associated with the decision for TOP were additional fetal genetic or anatomical abnormalities (p < 0.0001) and expected severity of pulmonary hypoplasia in left-sided CDH (p = 0.0456). CONCLUSION The decision to terminate a pregnancy complicated by fetal CDH depends on the severity of pulmonary hypoplasia and the presence of additional abnormalities. This emphasises the importance of early referral to expertise centres for detailed evaluation and multidisciplinary counselling.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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10
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The efficacy of the postnatal nasogastric tube position as a prognostic marker of left-sided isolated congenital diaphragmatic hernia. Pediatr Surg Int 2022; 38:1873-1880. [PMID: 36138323 DOI: 10.1007/s00383-022-05226-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The prenatal diagnosis of the stomach position in congenital diaphragmatic hernia (CDH) has been a reliable prognostic factor, but few studies have focused on the postnatal position. We therefore evaluated the significance of the nasogastric (NG) tube position just after birth. METHODS The Japanese CDH Study Group database enrolled 1037 CDH neonates over 15 years. In our multicenter retrospective study, 464 cases of left-sided isolated CDH with prenatal diagnoses were divided into two groups: NG tube below the diaphragm (BD; n = 190) or above the diaphragm (AD; n = 274). The primary outcome was the 90-day survival rate, and the secondary outcomes were mechanical ventilation duration, hospitalization duration, and recurrence rate. RESULTS The BD group had a significantly higher 90-day survival rate (98.4 vs. 89.4%, p < 0.001), shorter mechanical ventilation (11 vs. 19 days, p < 0.001), shorter hospitalization (38 vs. 59 days, p < 0.001), and lower recurrence rate (p = 0.002) than the AD group. A multivariate analysis showed that BD (adjusted odds ratio, 3.68; 95% confidence interval 1.02-13.30) was a favorable prognostic factor for the 90-day survival. CONCLUSION The assessment of the NG tube position revealed it to be a reliable prognostic factor of left-sided isolated CDH. Therefore, it should be included as a routine assessment.
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11
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Masahata K, Yamoto M, Umeda S, Nagata K, Terui K, Fujii M, Shiraishi M, Hayakawa M, Amari S, Masumoto K, Okazaki T, Inamura N, Toyoshima K, Koike Y, Furukawa T, Yazaki Y, Yokoi A, Endo M, Tazuke Y, Okuyama H, Usui N. Prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1745-1757. [PMID: 36102982 DOI: 10.1007/s00383-022-05232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to evaluate prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia (CDH). METHODS A systematic literature search was performed to identify relevant observational studies that evaluated the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e-LHR), observed-to-expected total fetal lung volume (o/e-TFLV), lung-to-thorax transverse area ratio (L/T ratio), intrathoracic herniation of the liver and the stomach, and side of diaphragmatic hernia, using a threshold for the prediction of mortality in fetuses with CDH. Study quality was assessed using the QUADAS-2 tool. Hierarchical summary receiver operating characteristic curves were constructed. RESULTS A total of 50 articles were included in this meta-analysis. The QUADAS-2 tool identified a high risk of bias in more than one domain scored in all parameters. Among those parameters, the diagnostic odds ratio of mortality with o/e-LHR < 25%, o/e-TFLV < 25%, and L/T ratio < 0.08 were 11.98 [95% confidence interval (CI) 4.65-30.89], 11.14 (95% CI 5.19-23.89), and 10.28 (95% CI 3.38-31.31), respectively. The predictive values for mortality were similar between the presence of liver herniation and retrocardiac fetal stomach position. CONCLUSIONS This systematic review suggests that o/e-LHR, o/e-TFLV, and L/T ratio are equally good predictors of neonatal mortality in fetuses with isolated CDH.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Fujii
- Department of Health Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Katsuaki Toyoshima
- Departments of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Yokoi
- Departments of Pediatric Surgery, Kobe Children's Medical Center, Kobe, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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12
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The Rearing of Maternal-Fetal Surgery: The Maturation of a Field from Conception to Adulthood. Clin Perinatol 2022; 49:799-810. [PMID: 36328599 DOI: 10.1016/j.clp.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Maternal-fetal surgery is fraught with inherent controversy from within the medical community and general public. Despite these challenges, the field of maternal-fetal surgery evolved into an international enterprise. Carefully nurtured by pioneers with foresight and resilience, the field navigated ethical dilemmas with rigorous scientific methodology, collaboration, transparency, and accordance. These central pillars are consistent throughout the brief but momentous history of maternal-fetal surgery, serving as the catalyst for its success. The maturation of fetal intervention is an exemplar of technological innovation propelling clinical innovation, as well as a celebration of mastering the delicate balance between caution and optimism.
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13
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Dahl MJ, Lavizzari A, Davis JW, Noble PB, Dellacà R, Pillow JJ. Impact of fetal treatments for congenital diaphragmatic hernia on lung development. Anat Rec (Hoboken) 2022. [PMID: 36065499 DOI: 10.1002/ar.25059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022]
Abstract
The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.
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Affiliation(s)
- Mar Janna Dahl
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Anna Lavizzari
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jonathan W Davis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Peter B Noble
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Raffaele Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - J Jane Pillow
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
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14
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Improved survival for infants with severe congenital diaphragmatic hernia. J Perinatol 2022; 42:1189-1194. [PMID: 35461332 DOI: 10.1038/s41372-022-01397-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Survival for severe (observed to expected lung-head ratio (O:E LHR) < 25%) congenital diaphragmatic hernia (CDH) remains a challenge (15-25%). Management strategies have focused on fetal endoscopic tracheal occlusion (FETO) and/or extracorporeal membrane oxygenation therapy (ECMO) utilization. OBJECTIVE(S) Describe single center outcomes for infants with severe CDH. STUDY DESIGN Observational study of 13 severe CDH infants managed with ECMO, a protocolized DR algorithm, and early repair on ECMO with an innovative perioperative anticoagulation strategy. RESULTS 13/140 (9.3%) infants met criteria and were managed with ECMO. 77% survived ECMO and 69% survived to discharge. 22% underwent tracheostomy. Median days on mechanical ventilation was 39 days (IQR 22:107.5) and length of stay 135 days (IQR 62.5:211.5). All infants received a gastrostomy tube (GT) and were discharged home on oxygen and pulmonary hypertension (PH) meds. CONCLUSION Survival for infants with severe CDH can be optimized with early aggressive intervention and protocolized algorithms (149).
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15
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Lung to thorax transverse area ratio as a predictor of neurodevelopmental outcomes in fetuses with congenital diaphragmatic hernia. Early Hum Dev 2022; 170:105598. [PMID: 35679750 DOI: 10.1016/j.earlhumdev.2022.105598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Infants with congenital diaphragmatic hernia (CDH) are at risk of neurodevelopmental disabilities. This study aimed to investigate the association between lung to thorax transverse area ratio (LTR) and neurodevelopmental outcomes at 3 years of age in fetuses with CDH. METHODS We performed a retrospective study of infants with prenatally diagnosed isolated left-sided CDH born in Kyushu University Hospital between 2008 and 2016. We examined the association between prenatal ultrasound findings including LTR and development quotient (DQ) at 36 to 42 months of chronological age. RESULTS We identified 34 live-born fetuses with isolated left-sided CDH, of which 30 survived and four died before discharge. The median LTR in the survivors was higher than in the non-survivors (p < 0.01). Among the survivors, 26 had available data on LTR (median 0.12, range 0.08-0.18) and overall DQ at 3 years of age (93, 61-112). Their median gestational age and birth weight were 37.6 (range 34.4-39.1) weeks and 2716 (2.256-3494) grams, respectively. There was no significant difference in overall DQ scores between the two groups divided according to the median LTR values (p = 0.62). LTR values were not associated with overall DQ scores after adjusting for gestational age (p = 0.39). In addition, no association was observed between LTR values and any subscale DQ scores. CONCLUSION In fetuses with isolated left-sided CDH, prenatal LTR predicts the mortality but not neurodevelopmental outcomes at 3 years of age.
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16
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Chaturvedi A, Klionsky N, Biyyam D, Chess MA, Sultan N. Acutely presenting congenital chest lesions: a primer for the radiologist. Emerg Radiol 2022; 29:557-570. [PMID: 35253079 DOI: 10.1007/s10140-022-02035-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
Abstract
Congenital chest lesions encompass several important entities. Without prompt intervention, many of these can culminate in serious complications. Timely and accurate radiologic interpretation of these entities is integral to patient management. Imaging can help characterize and prognosticate several of these entities, and may both suggest the need for and guide therapy. We overview the clinical presentation, associated complications, imaging characteristics, and prognostic indicators-both postnatal and antenatal-of the spectrum of emergently presenting congenital chest lesions. We also outline current and evolving management strategies, whether fetal, peripartum, or postnatal. The ultimate goal is to help radiologists formulate timely and effective diagnoses of these entities and boost the relevance of their input towards clinical decision-making.
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Affiliation(s)
- Apeksha Chaturvedi
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA.
| | - Nina Klionsky
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | | | - Mitchell A Chess
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Nadia Sultan
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
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17
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Horn-Oudshoorn EJJ, Knol R, Cochius-den Otter SCM, Te Pas AB, Hooper SB, Roberts CT, Rafat N, Schaible T, de Boode WP, van der Lee R, Debeer A, Kipfmueller F, Roehr CC, Reiss IKM, DeKoninck PLJ. Spontaneous breathing approach in mild congenital diaphragmatic hernia: A resuscitation algorithm. Front Pediatr 2022; 10:945090. [PMID: 35923783 PMCID: PMC9339647 DOI: 10.3389/fped.2022.945090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infants with a congenital diaphragmatic hernia (CDH) and expected mild pulmonary hypoplasia have an estimated survival rate of 90%. Current guidelines for delivery room management do not consider the individual patient's disease severity, but an individualized approach with spontaneous breathing instead of routine mechanical ventilation could be beneficial for the mildest cases. We developed a resuscitation algorithm for this individualized approach serving two purposes: improving the success rate by structuring the approach and providing a guideline for other centers. METHODS An initial algorithm was discussed with all local stakeholders. Afterwards, the resulting algorithm was refined using input from international experts. RESULTS Eligible CDH infants: left-sided defect, observed to expected lung-to-head ratio ≥50%, gestational age at birth ≥37.0 weeks, and no major associated structural or genetic abnormalities. To facilitate fetal-to-neonatal transition, we propose to start stabilization with non-invasive respiratory support and to adjust this individually. CONCLUSIONS Infants with mild CDH might benefit from an individualized approach for neonatal resuscitation. Herein, we present an algorithm that could serve as guidance for centers implementing this.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Robin van der Lee
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Critical Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Charles C Roehr
- National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,Newborn Services Southmead Hospital, North Bristol Trust, Bristol, United Kingdom.,Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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18
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Cruz-Martínez R, Molina-Giraldo S, Etchegaray A, Ventura W, Pavón-Gómez N, Gil-Guevara E, Villalobos-Gómez R, Luna-García J, Gámez-Varela A, Martínez-Rodríguez M, López-Briones H, Chávez-González E. Prediction of neonatal survival according to lung-to-head ratio in fetuses with right congenital diaphragmatic hernia (CDH): A multicentre study from the Latin American CDH Study Group registry. Prenat Diagn 2021; 42:357-363. [PMID: 34861055 DOI: 10.1002/pd.6070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate survival outcomes of fetuses with right sided congenital diaphragmatic hernia (CDH) treated in Latin American centres and to assess the utility of left lung area to predict neonatal survival. METHODS A retrospective cohort including isolated right sided CDH cases managed expectantly during pregnancy in six tertiary centers from five Latin American countries. The utility of the observed/expected lung-to-head ratio (O/E-LHR) in predicting neonatal survival was assessed, and the best cut-off to predict prognosis was automatically selected by decision tree analysis. RESULTS A total of 99 right sided CDH cases were recruited, 58 isolated fetuses were selected at a median gestational age of 26.2 weeks, showing an overall survival rate of 26.2%. A linear trend was observed between survival and the O/E-LHR, showing that at higher O/E-LHR, the greater probability of survival (r = 0.56, p < 0.001). O/E-LHR discriminates two groups with different survival outcomes: fetuses with an O/E-LHR ≥65% showed a significantly higher survival rate than those with an O/E-LHR <65% (81.8% vs. 15.6%, p < 0.01). CONCLUSIONS Overall survival rate in right sided CDH is lower in Latin American countries. The severity category of pulmonary hypoplasia should be classified according to lung area and the survival rate in such population.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Saulo Molina-Giraldo
- Section of Fetal Therapy and Fetal Surgery Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hospital de San José, Fundación Universitaria de Ciencias de la Salud - FUCS, Clínica Colsubsidio 94, FetoNetwork Colombia, Bogotá, Colombia
| | - Adolfo Etchegaray
- Department of Fetal Medicine, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Walter Ventura
- Department of Fetal Medicine, Instituto Nacional Materno Perinatal y Clínica Angloamericana, British Medical Hospital, Lima, Perú
| | - Néstor Pavón-Gómez
- Division of Maternal Fetal Medicine, Hospital Bertha Calderón Roque, Managua, Nicaragua
| | - Enrique Gil-Guevara
- Department of Fetal Diagnosis, Instituto Peruano de Medicina y Cirugía Fetal, Lima, Perú
| | - Rosa Villalobos-Gómez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Jonahtan Luna-García
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Alma Gámez-Varela
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Miguel Martínez-Rodríguez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Hugo López-Briones
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Eréndira Chávez-González
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
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19
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Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Griggio A, Conte L, Macchini F, Condò V, Persico N, Fabietti I, Ghirardello S, Pierro M, Tafuri B, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. A maChine and deep Learning Approach to predict pulmoNary hyperteNsIon in newbornS with congenital diaphragmatic Hernia (CLANNISH): Protocol for a retrospective study. PLoS One 2021; 16:e0259724. [PMID: 34752491 PMCID: PMC8577746 DOI: 10.1371/journal.pone.0259724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/25/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Outcome predictions of patients with congenital diaphragmatic hernia (CDH) still have some limitations in the prenatal estimate of postnatal pulmonary hypertension (PH). We propose applying Machine Learning (ML), and Deep Learning (DL) approaches to fetuses and newborns with CDH to develop forecasting models in prenatal epoch, based on the integrated analysis of clinical data, to provide neonatal PH as the first outcome and, possibly: favorable response to fetal endoscopic tracheal occlusion (FETO), need for Extracorporeal Membrane Oxygenation (ECMO), survival to ECMO, and death. Moreover, we plan to produce a (semi)automatic fetus lung segmentation system in Magnetic Resonance Imaging (MRI), which will be useful during project implementation but will also be an important tool itself to standardize lung volume measures for CDH fetuses. METHODS AND ANALYTICS Patients with isolated CDH from singleton pregnancies will be enrolled, whose prenatal checks were performed at the Fetal Surgery Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (Milan, Italy) from the 30th week of gestation. A retrospective data collection of clinical and radiological variables from newborns' and mothers' clinical records will be performed for eligible patients born between 01/01/2012 and 31/12/2020. The native sequences from fetal magnetic resonance imaging (MRI) will be collected. Data from different sources will be integrated and analyzed using ML and DL, and forecasting algorithms will be developed for each outcome. Methods of data augmentation and dimensionality reduction (feature selection and extraction) will be employed to increase sample size and avoid overfitting. A software system for automatic fetal lung volume segmentation in MRI based on the DL 3D U-NET approach will also be developed. ETHICS AND DISSEMINATION This retrospective study received approval from the local ethics committee (Milan Area 2, Italy). The development of predictive models in CDH outcomes will provide a key contribution in disease prediction, early targeted interventions, and personalized management, with an overall improvement in care quality, resource allocation, healthcare, and family savings. Our findings will be validated in a future prospective multicenter cohort study. REGISTRATION The study was registered at ClinicalTrials.gov with the identifier NCT04609163.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- Monza and Brianza Mother and Child Foundation, San Gerardo Hospital, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Luana Conte
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Pierro
- NICU, Bufalini Hospital, Azienda Unità Sanitaria Locale della Romagna, Cesena, Italy
| | - Benedetta Tafuri
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Giuseppe Como
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università degli Studi di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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20
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Didier RA, Oliver ER, Rungsiprakarn P, Debari SE, Adams SE, Hedrick HL, Adzick NS, Khalek N, Howell LJ, Coleman BG. Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:744-749. [PMID: 33724570 DOI: 10.1002/uog.23630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/15/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the influence of stomach position on postnatal outcome in cases of left congenital diaphragmatic hernia (CDH) without liver herniation, diagnosed and characterized on prenatal ultrasound (US), by comparing those with ('stomach-up' CDH) to those without ('stomach-down' CDH) intrathoracic stomach herniation. METHODS Infants with left CDH who underwent prenatal US and postnatal repair at our institution between January 2008 and March 2017 were eligible for inclusion in this retrospective study. Detailed prenatal US examinations, fetal magnetic resonance imaging (MRI) studies, operative reports and medical records of infants enrolled in the pulmonary hypoplasia program at our institution were reviewed. Cases with liver herniation and those with an additional anomaly were excluded. Cases in which bowel loops were identified within the fetal chest on US while the stomach was intra-abdominal were categorized as having stomach-down CDH. Cases in which bowel loops and the stomach were visualized within the fetal chest on US were categorized as having stomach-up CDH. Prenatal imaging findings and postnatal outcomes were compared between the two groups. RESULTS In total, 152 patients with left CDH were initially eligible for inclusion. Seventy-eight patients had surgically confirmed liver herniation and were excluded. Of the 74 included CDH cases without liver herniation, 28 (37.8%) had stomach-down CDH and 46 (62.2%) had stomach-up CDH. Of the 28 stomach-down CDH cases, 10 (35.7%) were referred for a suspected lung lesion. Sixty-eight (91.9%) cases had postnatal outcome data available for analysis. There was no significant difference in median observed-to-expected (o/e) lung-area-to-head-circumference ratio (LHR) between cases with stomach-down CDH and those with stomach-up CDH (41.5% vs 38.4%; P = 0.41). Furthermore, there was no difference in median MRI o/e total lung volume (TLV) between the two groups (49.5% vs 44.0%; P = 0.22). Compared with stomach-up CDH patients, stomach-down CDH patients demonstrated lower median duration of intubation (18 days vs 9.5 days; P < 0.01), median duration of extracorporeal membrane oxygenation (495 h vs 223.5 h; P < 0.05), rate of supplemental oxygen requirement at 30 days of age (20/42 (47.6%) vs 3/26 (11.5%); P < 0.01) and rate of pulmonary hypertension at initial postnatal echocardiography (28/42 (66.7%) vs 9/26 (34.6%); P = 0.01). No neonatal death occurred in stomach-down CDH patients and one neonatal death was seen in a patient with intrathoracic stomach herniation. CONCLUSIONS In infants with left CDH without liver herniation, despite similar o/e-LHR and o/e-TLV, those with stomach-down CDH have decreased neonatal morbidity compared to those with stomach herniation. Progressive or variable physiological distension of the stomach over the course of gestation may explain these findings. Stomach-down left CDH is mistaken for a lung mass in a substantial proportion of cases. Accurate prenatal US characterization of CDH is crucial for appropriate prenatal counseling and patient management. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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MESH Headings
- Adult
- Cephalometry
- Female
- Fetus/diagnostic imaging
- Fetus/pathology
- Head/diagnostic imaging
- Head/pathology
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/embryology
- Infant, Newborn, Diseases/pathology
- Lung/diagnostic imaging
- Lung/embryology
- Lung/pathology
- Magnetic Resonance Imaging
- Male
- Morbidity
- Pregnancy
- Retrospective Studies
- Stomach/diagnostic imaging
- Stomach/embryology
- Stomach/pathology
- Ultrasonography, Prenatal
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Affiliation(s)
- R A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E R Oliver
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - P Rungsiprakarn
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Debari
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Adams
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - H L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Khalek
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B G Coleman
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Affiliation(s)
- F Sessions Cole
- From the Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and St. Louis Children's Hospital - both in St. Louis
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Deprest JA, Benachi A, Gratacos E, Nicolaides KH, Berg C, Persico N, Belfort M, Gardener GJ, Ville Y, Johnson A, Morini F, Wielgoś M, Van Calster B, DeKoninck PLJ. Randomized Trial of Fetal Surgery for Moderate Left Diaphragmatic Hernia. N Engl J Med 2021; 385:119-129. [PMID: 34106555 PMCID: PMC7613454 DOI: 10.1056/nejmoa2026983] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetoscopic endoluminal tracheal occlusion (FETO) has been associated with increased postnatal survival among infants with severe pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, but data are lacking to inform its effects in infants with moderate disease. METHODS In this open-label trial conducted at many centers with experience in FETO and other types of prenatal surgery, we randomly assigned, in a 1:1 ratio, women carrying singleton fetuses with a moderate isolated congenital diaphragmatic hernia on the left side to FETO at 30 to 32 weeks of gestation or expectant care. Both treatments were followed by standardized postnatal care. The primary outcomes were infant survival to discharge from a neonatal intensive care unit (NICU) and survival without oxygen supplementation at 6 months of age. RESULTS In an intention-to-treat analysis involving 196 women, 62 of 98 infants in the FETO group (63%) and 49 of 98 infants in the expectant care group (50%) survived to discharge (relative risk , 1.27; 95% confidence interval [CI], 0.99 to 1.63; two-sided P = 0.06). At 6 months of age, 53 of 98 infants (54%) in the FETO group and 43 of 98 infants (44%) in the expectant care group were alive without oxygen supplementation (relative risk, 1.23; 95% CI, 0.93 to 1.65). The incidence of preterm, prelabor rupture of membranes was higher among women in the FETO group than among those in the expectant care group (44% vs. 12%; relative risk, 3.79; 95% CI, 2.13 to 6.91), as was the incidence of preterm birth (64% vs. 22%, respectively; relative risk, 2.86; 95% CI, 1.94 to 4.34), but FETO was not associated with any other serious maternal complications. There were two spontaneous fetal deaths (one in each group) without obvious cause and one neonatal death that was associated with balloon removal. CONCLUSIONS This trial involving fetuses with moderate congenital diaphragmatic hernia on the left side did not show a significant benefit of FETO performed at 30 to 32 weeks of gestation over expectant care with respect to survival to discharge or the need for oxygen supplementation at 6 months. FETO increased the risks of preterm, prelabor rupture of membranes and preterm birth. (Funded by the European Commission and others; TOTAL ClinicalTrials.gov number, NCT00763737.).
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Affiliation(s)
- Jan A Deprest
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Alexandra Benachi
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Eduard Gratacos
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Kypros H Nicolaides
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Christoph Berg
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Nicola Persico
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Michael Belfort
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Glenn J Gardener
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Yves Ville
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Anthony Johnson
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Francesco Morini
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Mirosław Wielgoś
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Ben Van Calster
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Philip L J DeKoninck
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
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23
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Deprest JA, Nicolaides KH, Benachi A, Gratacos E, Ryan G, Persico N, Sago H, Johnson A, Wielgoś M, Berg C, Van Calster B, Russo FM. Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia. N Engl J Med 2021; 385:107-118. [PMID: 34106556 PMCID: PMC7613453 DOI: 10.1056/nejmoa2027030] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational studies have shown that fetoscopic endoluminal tracheal occlusion (FETO) has been associated with increased survival among infants with severe pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, but data from randomized trials are lacking. METHODS In this open-label trial conducted at centers with experience in FETO and other types of prenatal surgery, we randomly assigned, in a 1:1 ratio, women carrying singleton fetuses with severe isolated congenital diaphragmatic hernia on the left side to FETO at 27 to 29 weeks of gestation or expectant care. Both treatments were followed by standardized postnatal care. The primary outcome was infant survival to discharge from the neonatal intensive care unit. We used a group-sequential design with five prespecified interim analyses for superiority, with a maximum sample size of 116 women. RESULTS The trial was stopped early for efficacy after the third interim analysis. In an intention-to-treat analysis that included 80 women, 40% of infants (16 of 40) in the FETO group survived to discharge, as compared with 15% (6 of 40) in the expectant care group (relative risk, 2.67; 95% confidence interval [CI], 1.22 to 6.11; two-sided P = 0.009). Survival to 6 months of age was identical to the survival to discharge (relative risk, 2.67; 95% CI, 1.22 to 6.11). The incidence of preterm, prelabor rupture of membranes was higher among women in the FETO group than among those in the expectant care group (47% vs. 11%; relative risk, 4.51; 95% CI, 1.83 to 11.9), as was the incidence of preterm birth (75% vs. 29%; relative risk, 2.59; 95% CI, 1.59 to 4.52). One neonatal death occurred after emergency delivery for placental laceration from fetoscopic balloon removal, and one neonatal death occurred because of failed balloon removal. In an analysis that included 11 additional participants with data that were available after the trial was stopped, survival to discharge was 36% among infants in the FETO group and 14% among those in the expectant care group (relative risk, 2.65; 95% CI, 1.21 to 6.09). CONCLUSIONS In fetuses with isolated severe congenital diaphragmatic hernia on the left side, FETO performed at 27 to 29 weeks of gestation resulted in a significant benefit over expectant care with respect to survival to discharge, and this benefit was sustained to 6 months of age. FETO increased the risks of preterm, prelabor rupture of membranes and preterm birth. (Funded by the European Commission and others; TOTAL ClinicalTrials.gov number, NCT01240057.).
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Affiliation(s)
- Jan A Deprest
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Kypros H Nicolaides
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Alexandra Benachi
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Eduard Gratacos
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Greg Ryan
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Nicola Persico
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Haruhiko Sago
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Anthony Johnson
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Mirosław Wielgoś
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Christoph Berg
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Ben Van Calster
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Francesca M Russo
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
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van der Veeken L, Inversetti A, Galgano A, Bleeser T, Papastefanou I, van de Merwe J, Rex S, Deprest J. Fetally-injected drugs for immobilization and analgesia do not modify fetal brain development in a rabbit model. Prenat Diagn 2021; 41:1164-1170. [PMID: 33892522 DOI: 10.1002/pd.5954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE During fetal surgery, fetuses receive medication (atropine-fentanyl-curare) to prevent fetal pain, movement and bradycardia. Although essential there has been no detailed review of potential side effects. Herein we aimed to assess the effects of this medication cocktail on fetal brain development in a rabbit model. METHODS Pregnant does underwent laparotomy at 28 days of gestation. Two pups of each horn were randomized to an ultrasound guided injection with medication (atropine-cisatracurium-fentanyl, as clinically used) or saline (sham). The third pup was used as control. At term, does were delivered by cesarean. Outcome measures were neonatal biometry, neuromotoric functioning and neuro-histology (neuron density, synaptic density and proliferation). RESULTS Maternal vital parameters remained stable during surgery. Fetal heart rates did not differ before and after injection, and were comparable for the three groups. At birth, neonatal body weights and brain-to-body weight ratios were also comparable. Both motor and sensory neurobehavioral scores were comparable. There were no differences in neuron density or proliferation. Sham pups, had a lower synaptic density in the hippocampus as compared to the medication group, however there was no difference in the other brain areas. CONCLUSION In the rabbit model, fetal medication does not appear to lead to short-term neurocognitive effects.
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Affiliation(s)
- Lennart van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Annalisa Inversetti
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
| | - Angela Galgano
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
| | - Tom Bleeser
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Belgium
| | | | - Johannes van de Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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25
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Evans LL, Harrison MR. Modern fetal surgery-a historical review of the happenings that shaped modern fetal surgery and its practices. Transl Pediatr 2021; 10:1401-1417. [PMID: 34189101 PMCID: PMC8192985 DOI: 10.21037/tp-20-114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The history of fetal surgery is one of constant evolution. Over the last 50 years, fetal surgery has progressed from a mere idea to an internationally respected innovative field of surgery. This article aims to provide a historical review of how the enterprise of maternal-fetal surgery came to be its modern version. This review is less focused on the history of specific therapies for a relatively small number of conditions, and more on how the whole field of maternal-fetal surgery evolved. The various internal and external influences that steered the field's evolution are discussed in chronologic order. Since the start of modern fetal surgery in the 1980s, large paradigm shifts have characterized the growth of the field as a whole. Innovative interventions are now based on physiologic manipulation as opposed to simple anatomic repair, fetoscopy has become the more frequently preferred surgical approach, and rigorous scientific evaluation with randomized controlled trials is now the standard expected by the community. In a very similar fashion to when the field first began in the early 1980s, recently community's leaders have risen to protect the integrity of maternal-fetal surgery by publishing ethical guidelines for innovation and clinical practice. This incredible history of innovation, rigorous science and ethical contemplation is the foundation on which modern maternal-fetal surgery rests.
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
| | - Michael R Harrison
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
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26
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Bergholz R, Fromm F, Meinzer A, Muehlfeld C, Boettcher M, Wenke K, Tiemann B, Reinshagen K, Krebs T. Stereological Lung Parameters After Fetoscopic Abdominal Decompression of Congenital Diaphragmatic Hernia in an Ovine Model: A Pilot Study. J Laparoendosc Adv Surg Tech A 2021; 31:712-718. [PMID: 33913757 DOI: 10.1089/lap.2020.0954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Fetoscopic endoluminal tracheal occlusion (FETO) improves lung maturation in severe cases of congenital diaphragmatic hernia (CDH) but it does not ameliorate lung compression by herniated abdominal organs. Surgically opening the fetal abdomen (abdominal decompression [AD]) reduces the intrathoracic pressure by diverting the abdominal organs into the amniotic cavity-a probable causal therapy for lung hypoplasia and pulmonary hypertension in CDH. Open surgical abdominal decompression has been reported: we describe a minimally invasive approach in an ovine model of CDH as a probable fetoscopic intervention. Materials and Methods: Eight fetuses were included, 2 were kept as HEALTHY controls. A CDH (left side, liver down) was created by open fetal surgery at midgestation in 6 fetuses, 2 were taken as CDH controls. Fetoscopic abdominal decompression (fAD) was performed 21 days later in 4 animals. The fetuses were retrieved at the end of gestation and evaluated by lung stereology. Results: fAD led to a near total evacuation of the thoracic cavity in 2 of the 4 animals. Fetuses with CDH had a lower total volume and fraction of alveolar air space, a lower volume fraction of the parenchyma, and an increase of the volume fraction of the alveolar septa and atelectasis, as well as an increased mean thickness of alveolar septa compared with HEALTHY fetuses. Fetuses treated with abdominal decompression showed an improvement of stereological parameters. Conclusions: In spite of relevant limitations (pilot study, small groups, spontaneous closure of the abdominal incision) we were able to demonstrate that abdominal decompression for CDH can be performed by fetoscopy. Our results support the hypothesis of causally improving lung development by abdominal decompression, thus implying increased survival in extreme cases of CDH. A refinement of the fetoscopic techniques and direct comparison to FETO appears warranted.
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Affiliation(s)
- Robert Bergholz
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, UKSH University Hospital of Schleswig-Holstein Kiel Campus, Kiel, Germany
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Felipe Fromm
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Andreas Meinzer
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, UKSH University Hospital of Schleswig-Holstein Kiel Campus, Kiel, Germany
| | - Christian Muehlfeld
- Institute of Functional and Applied Anatomy, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Katharina Wenke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bastian Tiemann
- Department of Experimental Animal Research, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Thomas Krebs
- Department of Pediatric Surgery, Ostschweizer Children's Hospital, St.Gallen, Switzerland
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27
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Verweij EJ, de Vries MC, Oldekamp EJ, Eggink AJ, Oepkes D, Slaghekke F, Spoor JKH, Deprest JA, Miller JL, Baschat AA, DeKoninck PLJ. Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery? Prenat Diagn 2021; 41:949-956. [PMID: 33778976 PMCID: PMC8360048 DOI: 10.1002/pd.5940] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Since the completion of the Management of Myelomeningocoele Study, maternal-fetal surgery for spina bifida has become a valid option for expecting parents. More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach. Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence.
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Affiliation(s)
- E Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Oldekamp
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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28
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Sampat K, Losty PD. Fetal surgery. Br J Surg 2021; 108:632-637. [PMID: 33720314 DOI: 10.1093/bjs/znaa153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 11/13/2022]
Abstract
Fetal medicine is a super-specialty enterprise and a technology-driven field. The growth and interest in fetal surgery can be largely attributed to advances in fetal imaging and bespoke instruments for in utero intervention. Previously fatal fetal conditions are now being treated using open surgery, minimally invasive procedures, and percutaneous fetal technologies. Several fetal conditions, including myelomeningocele and twin-to-twin transfusion syndrome, have been tested rigorously in RCTs. However, as the specialty of fetal surgery grows, a robust evidence base with long-term follow-up is obligatory for every procedure. This article offers an overview of fetal surgery and antenatal intervention. As more cutting edge therapies come into clinical practice, growing public opinion and medical ethics will play a significant role in the future of this multidisciplinary specialty.
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Affiliation(s)
- K Sampat
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - P D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.,Institute of Child Health, Alder Hey Children's Hospital, Liverpool, UK
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29
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Corroenne R, Zhu KH, Johnson R, Mehollin-Ray AR, Shamshirsaz AA, Nassr AA, Belfort MA, Cortes MS, Shetty A, Lee W, Espinoza J. Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia. Eur J Obstet Gynecol Reprod Biol 2021; 260:22-28. [PMID: 33713885 DOI: 10.1016/j.ejogrb.2021.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES (1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO). METHODS Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension. RESULTS The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04). CONCLUSION Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.
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Affiliation(s)
- Romain Corroenne
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Katherine H Zhu
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Rebecca Johnson
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Amy R Mehollin-Ray
- E. B. Singleton Department of Radiology, Texas Children's Hospital & Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Anil Shetty
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA.
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Russo FM, Cordier AG, Basurto D, Salazar L, Litwinska E, Gomez O, Debeer A, Nevoux J, Patel S, Lewi L, Pertierra A, Aertsen M, Gratacos E, Nicolaides KH, Benachi A, Deprest J. Fetal endoscopic tracheal occlusion reverses the natural history of right-sided congenital diaphragmatic hernia: European multicenter experience. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:378-385. [PMID: 32924187 DOI: 10.1002/uog.23115] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the neonatal outcome of fetuses with isolated right-sided congenital diaphragmatic hernia (iRCDH) based on prenatal severity indicators and antenatal management. METHODS This was a retrospective review of prospectively collected data on consecutive cases diagnosed with iRCDH before 30 weeks' gestation in four fetal therapy centers, between January 2008 and December 2018. Data on prenatal severity assessment, antenatal management and perinatal outcome were retrieved. Univariate and multivariate logistic regression analysis were used to identify predictors of survival at discharge and early neonatal morbidity. RESULTS Of 265 patients assessed during the study period, we excluded 40 (15%) who underwent termination of pregnancy, two cases of unexplained fetal death, two that were lost to follow-up, one for which antenatal assessment of lung hypoplasia was not available and six cases which were found to have major associated anomalies or syndromes after birth. Of the 214 fetuses with iRCDH included in the neonatal outcome analysis, 86 were managed expectantly during pregnancy and 128 underwent fetal endoscopic tracheal occlusion (FETO) with a balloon. In the expectant-management group, lung size measured by ultrasound or by magnetic resonance imaging was the only independent predictor of survival (observed-to-expected lung-to-head ratio (o/e-LHR) odds ratio (OR), 1.06 (95% CI, 1.02-1.11); P = 0.003). Until now, stratification for severe lung hypoplasia has been based on an o/e-LHR cut-off of 45%. In cases managed expectantly, the survival rate was 15% (4/27) in those with o/e-LHR ≤ 45% and 61% (36/59) for o/e-LHR > 45% (P = 0.001). However, the best o/e-LHR cut-off for the prediction of survival at discharge was 50%, with a sensitivity of 78% and specificity of 72%. In the expectantly managed group, survivors with severe pulmonary hypoplasia stayed longer in the neonatal intensive care unit than did those with mildly hypoplastic lungs. In fetuses with an o/e-LHR ≤ 45% treated with FETO, survival rate was higher than in those with similar lung size managed expectantly (49/120 (41%) vs 4/27 (15%); P = 0.014), despite higher prematurity rates (gestational age at birth: 34.4 ± 2.7 weeks vs 36.8 ± 3.0 weeks; P < 0.0001). In fetuses treated with FETO, gestational age at birth was the only predictor of survival (OR, 1.25 (95% CI, 1.04-1.50); P = 0.02). CONCLUSIONS Antenatal measurement of lung size can predict survival in iRCDH. In fetuses with severe lung hypoplasia, FETO was associated with a significant increase in survival without an associated increase in neonatal morbidity. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F M Russo
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - A-G Cordier
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
- Centre for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - D Basurto
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Salazar
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - E Litwinska
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - O Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - A Debeer
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - J Nevoux
- ENT Department, AP-HP, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - S Patel
- Department of Paediatric Surgery, Kings' College Hospital, London, UK
| | - L Lewi
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - A Pertierra
- Clinical Department of Neonatology, Sant Joan de Déu University Hospital, Barcelona, Spain
| | - M Aertsen
- Clinical Department of Radiology, Unit Pediatric Radiology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Imaging and Pathology, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Gratacos
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Benachi
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
- Centre for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - J Deprest
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
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de Haro Jorge I, Prat Ortells J, Martín-Solé O, Muñoz Fernandez E, Pertierra A, Martin-Lluis A, Tarrado X. Porcine dermal patches as a risk factor for recurrence after congenital diaphragmatic hernia repair. Pediatr Surg Int 2021; 37:59-65. [PMID: 33245446 DOI: 10.1007/s00383-020-04787-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Recurrence of congenital diaphragmatic hernia (CDH) is a treatment-related morbidity which can be preventable. There is no consensus about the ideal material for diaphragmatic substitution. The aim of our study is to identify if the use of porcine dermis patches increases the risk of CDH recurrence. METHODS Retrospective review of medical records of CDH patients treated between 2013 and 2017 in our center was carried out. Demographic, clinical and surgical variables were collected. Regression analysis was performed to identify which factors increase the risk of recurrence. RESULTS 50 patients entered the study. 94% of the patients had a left CDH, mean observed/expected lung-to-head ratio was 46%. 17 patients underwent a primary closure, the rest a patch closure: 25 Gore-Tex® and 8 porcine dermis patches were used. Seven patients presented recurrence (14%). Median follow-up time was 3.5 years (1.2-6.2). Univariate analysis revealed that the use of a porcine dermis patch (75%) increased the risk of recurrence compared with Gore-Tex® patch (4%) and primary closure (0%) p < 0.001 (HR 58.7; IC 95%: 6.9-501.2; p < 0.001). CONCLUSION The main risk factor for CDH recurrence is the use of a porcine dermis patch. We do not recommend the use of these patches for CDH repair.
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Affiliation(s)
- Irene de Haro Jorge
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Jordi Prat Ortells
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Oriol Martín-Solé
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Elena Muñoz Fernandez
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Africa Pertierra
- Department of Neonatology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Alba Martin-Lluis
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
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32
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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33
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Russo FM, Debeer A, De Coppi P, Devriendt K, Crombag N, Hubble T, Power B, Benachi A, Deprest J. What should we tell parents? Congenital diaphragmatic hernia. Prenat Diagn 2020; 42:398-407. [PMID: 33599313 DOI: 10.1002/pd.5880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/13/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.
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Affiliation(s)
- Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Anne Debeer
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK.,Stem Cells & Regenerative Medicine Section, NIHR Biomedical Research Center, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Neeltje Crombag
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Talia Hubble
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Saclay, Clamart, France.,Centre Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Clamart, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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Abstract
Congenital diaphragmatic hernia (CDH) is a potentially severe anomaly that should be referred to a fetal care center with expertise in multidisciplinary evaluation and management. The pediatric radiologist plays an important role in the evaluation of CDH, both in terms of anatomical description of the anomaly and in providing detailed prognostic information for use in caring for the fetus and pregnant mother as well as planning for delivery and postnatal care. This article reviews the types of hernias, including distinguishing features and imaging clues. The most common methods of predicting severity are covered, and current fetal and postnatal therapies are explained. The author of this paper provides a handy reference for pediatric radiologists presented with a case of CDH as part of their daily practice.
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35
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Vergote S, Pizzolato D, Russo F, Dierickx K, Deprest J, Crombag N. The TOTAL trial dilemma: A survey among professionals on equipoise regarding fetal therapy for severe congenital diaphragmatic hernia. Prenat Diagn 2020; 41:179-189. [PMID: 33074552 DOI: 10.1002/pd.5849] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Running randomized clinical trials (RCT) in fetal therapy is challenging. This is no different for fetoscopic endoluminal tracheal occlusion (FETO) for severe left-sided Congenital Diaphragmatic Hernia (CDH). We assessed the knowledge, attitude and practice (KAP) of maternal-fetal medicine specialists toward the antenatal management of CDH, and the randomized controlled clinical (RCT) "Tracheal Occlusion To Accelerate Lung growth-trial." METHODS A cross-sectional KAP-survey was conducted among 311 registrants of the 18th World Congress in Fetal Medicine. RESULTS The overall knowledge of CDH and FETO was high. Remarkably only 45% considers prenatal prediction of neonatal outcome reliable. Despite, in their clinical practice they perform severity assessment (80%) and refer families for FETO either within the context of an RCT (43%) or on patient request (32%). Seventy percent perceives not offering FETO on patient demand seems as if no treatment is provided to a fetus with predicted poor outcome. Only 20% of respondents considers denying access to FETO on patient demand not as a psychological burden. CONCLUSION Often the views of individual respondents contradicted with their clinical practice. It seems that, for severe CDH, clinicians face personal and practical dilemmas that undermine equipoise. To us, this indicates the tension between the clinical and scientific obligations physicians experience.
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Affiliation(s)
- Simen Vergote
- Department of Development and Regeneration cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Daniel Pizzolato
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Francesca Russo
- Department of Development and Regeneration cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Kris Dierickx
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Institute of Women's Health, University College of London, London, UK
| | - Neeltje Crombag
- Department of Development and Regeneration cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
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36
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Wada S, Ozawa K, Sugibayashi R, Suyama F, Amari S, Ito Y, Kanamori Y, Okuyama H, Usui N, Sasahara J, Kotani T, Hayakawa M, Kato K, Taguchi T, Endo M, Sago H. Feasibility and outcomes of fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: A Japanese experience. J Obstet Gynaecol Res 2020; 46:2598-2604. [PMID: 32989906 PMCID: PMC7756773 DOI: 10.1111/jog.14504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/03/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
AIM To present the feasibility, safety and outcomes of fetoscopic endoluminal tracheal occlusion (FETO) for the treatment of severe congenital diaphragmatic hernia (CDH). METHODS This was a single-arm clinical trial of FETO for isolated left-sided CDH with liver herniation and Kitano Grade 3 stomach position (>50% stomach herniation into the right chest). FETO was performed at 27-29 weeks of gestation for cases with observed/expected lung to head ratio (o/e LHR) <25% and at 30-31 weeks for cases with o/e LHR ≥25%. RESULTS Eleven cases were enrolled between March 2014 and March 2016, and balloon insertion was successful in all cases. The median o/e LHR at entry was 27% (range, 20-33%). The median gestational age at FETO was 30.9 (range, 27.1-31.7) weeks. There were no severe maternal adverse events. One fetus died unexpectedly at 33 weeks of gestation due to cord strangulation by the detached amniotic membrane. There were 3 cases (27%) of preterm premature rupture of membranes. In all 10 cases, balloon removal at 34-35 weeks of gestation was successful. The median gestational age at delivery was 36.5 (range, 34.2-38.3) weeks. The median duration of occlusion and the median interval between balloon insertion and delivery were 26 days (range: 17-49 days) and 43 days (range, 21-66 days), respectively. Both the survival rate at 90 days of age and the rate of survival to discharge were 45% (5/11). CONCLUSION The FETO is feasible without maternal morbidity in Japan and could be offered to women whose fetuses show severe isolated left-sided CDH to accelerate fetal lung growth.
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Affiliation(s)
- Seiji Wada
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Katsusuke Ozawa
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Rika Sugibayashi
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Fumio Suyama
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Shoichiro Amari
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yushi Ito
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yutaka Kanamori
- Division of Surgery, Department of Surgical SpecialtiesNational Center for Child Health and DevelopmentTokyoJapan
| | - Hiroomi Okuyama
- Department of Pediatric SurgeryOsaka University Graduate School of MedicineSuitaJapan
| | - Noriaki Usui
- Department of Pediatric SurgeryOsaka Women's and Children's HospitalIzumiJapan
| | - Jun Sasahara
- Department of Maternal Fetal MedicineOsaka Women's and Children's HospitalIzumiJapan
| | - Tomomi Kotani
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal‐Neonatal CareNagoya University HospitalNagoyaJapan
| | - Kiyoko Kato
- Department of Obstetrics and GynecologyKyushu University School of MedicineFukuokaJapan
| | - Tomoaki Taguchi
- Department of Pediatric SurgeryKyushu University School of MedicineFukuokaJapan
| | - Masayuki Endo
- Department of Obstetrics and GynecologyOsaka University Graduate School of MedicineSuitaJapan
| | - Haruhiko Sago
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
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Hmadouch SA, Barkat A. [Congenital diaphragmatic hernia: a condition which is not always easy to diagnose]. Pan Afr Med J 2020; 36:353. [PMID: 33224419 PMCID: PMC7664133 DOI: 10.11604/pamj.2020.36.353.13525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/25/2017] [Indexed: 11/16/2022] Open
Abstract
Congenital hernia of the diaphragmatic dome (CDC) is a congenital embryopathy where all or part of the diaphragmatic dome fails to form. Its rate is 1/3500 live births with a male predominance. This study reports a case of Bochdalek hernia as well as data in the literature and highlights the diagnostic and therapeutic challenges in this disease. Diagnosis and antenatal management are essential to reduce patient's mortality and morbidity. Prognosis is poor and depends on the presence and degree of pulmonary hypoplasia and on the association with congenital malformations.
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Affiliation(s)
- Soukaina Ait Hmadouch
- Service de Néonatologie P5, Hôpital d’Enfant, CHU Ibn Sina, Rabat, Maroc
- Equipe de Recherche en Santé et en Nutrition du Couple Mère-enfant, Faculté de Médecine et de Pharmacie de Rabat, Université Mohamed V, Rabat, Maroc
| | - Amina Barkat
- Service de Néonatologie P5, Hôpital d’Enfant, CHU Ibn Sina, Rabat, Maroc
- Equipe de Recherche en Santé et en Nutrition du Couple Mère-enfant, Faculté de Médecine et de Pharmacie de Rabat, Université Mohamed V, Rabat, Maroc
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Masahata K, Usui N, Shimizu Y, Takeuchi M, Sasahara J, Mochizuki N, Tachibana K, Abe T, Yamamichi T, Soh H. Clinical outcomes and protocol for the management of isolated congenital diaphragmatic hernia based on our prenatal risk stratification system. J Pediatr Surg 2020; 55:1528-1534. [PMID: 31864663 DOI: 10.1016/j.jpedsurg.2019.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/24/2019] [Accepted: 10/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to evaluate our prenatal risk stratification system for risk-adjusted management in fetuses with isolated congenital diaphragmatic hernia (CDH). METHODS Ninety-four infants prenatally diagnosed with isolated CDH treated between 1998 and 2017 at our institution were included in this retrospective single-center cohort study. RESULTS The patients were prenatally classified into four risk groups: Group A (n = 54), which consisted of infants with neither liver-up nor a contralateral lung-to-thorax transverse area (L/T) ratio <0.08. The infants in group A were divided into two subgroups: Group A-1 (n = 24) consisted of mild conditions; and Group A-2 (n = 30) consisted of severe conditions; Group B (n = 23), which consisted of infants with either liver-up or L/T ratio <0.08; and Group C (n = 17), which consisted of infants with both liver-up and L/T ratio <0.08. The rates of survival to discharge in Groups A-1, A-2, B, and C were 100.0%, 100.0%, 87.0%, and 58.8%, respectively. The rates of intact discharge were 91.7%, 90.0%, 52.1%, and 23.5%, respectively. CONCLUSIONS Our prenatal risk stratification system demonstrated a significant difference in the severity of postnatal status and clinical outcomes between the groups. STUDY TYPE Case Series, Retrospective Review. LEVELS OF EVIDENCE LEVEL IV.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan.
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Jun Sasahara
- Department of Obstetrics, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Narutaka Mochizuki
- Department of Neonatology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Takatoshi Abe
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Taku Yamamichi
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Hideki Soh
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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Bouchghoul H, Saada J, Etienne M, Cordier AG, Benachi A. [How I do… an ultrasound scan of a fetus with a congenital diaphragmatic hernia?]. ACTA ACUST UNITED AC 2020; 49:143-146. [PMID: 32622010 DOI: 10.1016/j.gofs.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Indexed: 10/23/2022]
Affiliation(s)
- H Bouchghoul
- Service de gynécologie obstétrique, AP-HP, hôpital Bicêtre, Le Kremlin-Bicêtre, France; Centre de référence maladies rares hernie de coupole diaphragmatique, hopital Antoine-Béclère, Clamart, France.
| | - J Saada
- Centre de référence maladies rares hernie de coupole diaphragmatique, hopital Antoine-Béclère, Clamart, France; Service de gynécologie obstétrique, AP-HP, hôpital Antoine-Béclère, Clamart, France
| | - M Etienne
- Service de gynécologie obstétrique, AP-HP, hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - A-G Cordier
- Service de gynécologie obstétrique, AP-HP, hôpital Bicêtre, Le Kremlin-Bicêtre, France; Centre de référence maladies rares hernie de coupole diaphragmatique, hopital Antoine-Béclère, Clamart, France
| | - A Benachi
- Centre de référence maladies rares hernie de coupole diaphragmatique, hopital Antoine-Béclère, Clamart, France; Service de gynécologie obstétrique, AP-HP, hôpital Antoine-Béclère, Clamart, France
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Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia. Ann Surg 2020; 275:e586-e595. [PMID: 33055583 DOI: 10.1097/sla.0000000000003943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effect of combining antenatal sildenafil with fetal tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). BACKGROUND Although antenatal sildenafil administration rescues vascular abnormalities in lungs of fetal rabbits with CDH, it only partially improves airway morphometry. We hypothesized that we could additionally stimulate lung growth by combining this medical treatment with fetal TO. METHODS CDH was created on gestational day (GD)23 (n=54). Does were randomized to receive either sildenafil 10 mg/kg/d or placebo by subcutaneous injection from GD24 to GD30. On GD28, fetuses were randomly assigned to TO or sham neck dissection. At term (GD30) fetuses were delivered, ventilated, and finally harvested for histological and molecular analyses. Unoperated littermates served as controls. RESULTS The lung-to-body-weight ratio was significantly reduced in sham-CDH fetuses either (1.2 ± 0.3% vs 2.3 ± 0.3% in controls, P=0.0003). Sildenafil had no effect on this parameter, while CDH fetuses undergoing TO had a lung-to-body-weight ratio comparable to that of controls (2.5 ± 0.8%, P<0.0001). Sildenafil alone induced an improvement in the mean terminal bronchiolar density (2.5 ± 0.8 br/mm vs 3.5 ± 0.9 br/mm, P=0.043) and lung mechanics (static elastance 61 ± 36 cmH2O /mL vs 113 ± 40 cmH2O/mL, P=0.008), but both effects were more pronounced in fetuses undergoing additional TO (2.1 ± 0.8 br/mm, P=0.001 and 31 ± 9 cmH2O/mL, P<0.0001 respectively). Both CDH-sham and CDH-TO fetuses treated with placebo had an increased medial wall thickness of peripheral pulmonary vessels (41.9 ± 2.9% and 41.8 ± 3.2%, vs 24.0 ± 2.9% in controls, P<0.0001). CDH fetuses treated with sildenafil, either with or without TO, had a medial thickness in the normal range (29.4% ± 2.6%). Finally, TO reduced gene expression of vascular endothelial growth factor and surfactant protein A and B, but this effect was counteracted by sildenafil. CONCLUSION In the rabbit model for CDH, the combination of maternal sildenafil and TO has a complementary effect on vascular and parenchymal lung development.
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Standardizing congenital diaphragmatic hernia care in Canada: Implementing national clinical practice guidelines. J Pediatr Surg 2020; 55:835-843. [PMID: 32085916 DOI: 10.1016/j.jpedsurg.2020.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/25/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE We sought to identify implementation barriers and opportunities to increase utilization of the Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative's clinical practice guideline. METHODS A validated readiness assessment was sent via SurveyMonkey™ to CAPSNet site coordinators and local CDH stakeholders. The survey was open from 11/2018 to 02/2019. Data and responses were analyzed using descriptive statistics (REB 2019-4753). RESULTS Eighty-six responses were received, of which 65% (n = 56/86) were fully completed. The greatest number of responses came from neonatology (n = 27), pediatric surgery (n = 25), and respiratory therapy (n = 10). Seventy-eight percent (n = 67/86) of respondents were aware of the CDH guideline, and 63% (n = 54/86) used the entire guideline, while 23% (n = 20/86) used only certain sections. Besides recommendations pertaining to fetal intervention and ECLS, interdisciplinary long-term surveillance and prenatal diagnosis were considered most difficult to implement owing to funding limitations. Most respondents (n = 49/56; 87.5%) felt they could implement >75% of the recommendations. Establishing common team goals [i.e., minimize care variations] (n = 33/58;57%), provider buy-in [commitment of all health professionals to the guideline] (n = 28/58;48%), and regular compliance assessment (n = 23/58;40%) would increase uptake. CONCLUSION There is national awareness of the CDH guideline. Implementation strategies ensuring common team goals, provider buy-in, and regular compliance assessment should increase guideline uptake/utilization. Consolidating funding for interdisciplinary long-term surveillance and prenatal diagnosis is necessary for any site-specific implementation strategy. LEVEL OF EVIDENCE Level 4 qualitative, survey.
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Kirby E, Keijzer R. Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up. Pediatr Surg Int 2020; 36:415-429. [PMID: 32072236 DOI: 10.1007/s00383-020-04625-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.
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Affiliation(s)
- Eimear Kirby
- Trinity College Dublin School of Medicine, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - Richard Keijzer
- Thorlakson Chair in Surgical Research, Division of Pediatric Surgery, Department of Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada. .,Department of Pediatrics and Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada. .,Department of Physiology and Pathophysiology and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada.
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43
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Russo FM, De Bie F, Hodges R, Flake A, Deprest J. Sildenafil for Antenatal Treatment of Congenital Diaphragmatic Hernia: From Bench to Bedside. Curr Pharm Des 2020; 25:601-608. [PMID: 30894101 DOI: 10.2174/1381612825666190320151856] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Persistent pulmonary hypertension (PPH) is one of the main causes of mortality and morbidity in infants affected by congenital diaphragmatic hernia (CDH). Since the structural changes that lead to PPH take place already in utero, a treatment starting in the prenatal phase may prevent the occurrence of this complication. OBJECTIVE To summarize the development process of antenatal sildenafil for CDH. METHODS The pharmacokinetics and efficacy of sildenafil have been assessed in the rat and the rabbit model. The transfer of the drug through the human placenta has been measured with the ex-vivo placenta perfusion model. Results from this experiment are being incorporated in a pregnancy-physiologically based pharmacokinetic (p- PBPK) model. A phase I-IIb placental transfer and safety study is ongoing. RESULTS Sildenafil administration to pregnant rats and rabbits led to therapeutic foetal drug levels without maternal and foetal toxicity, although it was associated with impaired vascular development in foetuses with nonhypoplastic lungs. Peak concentrations and 24-hour exposure were higher in pregnant rabbits compared to nonpregnant ones. In rat and rabbit foetuses with CDH, sildenafil rescued the lung vascular anomalies and partially improved parenchymal development. Sildenafil crossed the human placenta at a high rate ex-vivo, independently from the initial maternal concentration. CONCLUSION There is preclinical evidence that maternally administered sildenafil prevents the vascular changes that lead to PPH in CDH newborns. The phase I/IIb clinical study together with the p-PBPK model will define the maternal dose needed for a therapeutic effect in the foetus. Foetal safety will be investigated both in the clinical study and in the sheep. The final step will be a multicentre, randomized, placebo-controlled trial.
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Affiliation(s)
- Francesca M Russo
- Cluster Woman and Child, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Felix De Bie
- Cluster Woman and Child, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Ryan Hodges
- The Ritchie Centre, Hudson Institute for Medical Research, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Alan Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jan Deprest
- Cluster Woman and Child, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, Institute of Women's Health, University College London, London, United Kingdom
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Abstract
Congenital diaphragmatic hernia (CDH) remains one of the most elusive birth defects to treat. Despite greater knowledge of disease and advances in technology, approximately one-third of CDH children born today still die. Consequently, clinicians and researchers have struggled to find the optimal treatment strategies for CDH. Without further innovations in postnatal treatment, many have focused an antenatal approach to improve pulmonary function. Fetoscopic Endoluminal Tracheal Occlusion (FETO) for CDH has evolved to the bedside after decades of research. While still under clinical investigation, FETO remains a promising adjunct to the treatment of CDH.
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Affiliation(s)
- KuoJen Tsao
- Departments of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
| | - Anthony Johnson
- Departments Obstetrics, Gynecology & Reproductive Sciences and Pediatric Surgery, Division of Maternal-Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
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Cordier AG, Russo FM, Deprest J, Benachi A. Prenatal diagnosis, imaging, and prognosis in Congenital Diaphragmatic Hernia. Semin Perinatol 2020; 44:51163. [PMID: 31439324 DOI: 10.1053/j.semperi.2019.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antenatal ultrasound screening identifies more than 60% of Congenital Diaphragmatic Hernia (CDH) cases and provides the opportunity for in utero referral to a tertiary care center for expert assessment and perinatal management. Prenatal assessment of fetuses with CDH has tremendously improved over the past ten years. The outcome may be predicted prenatally by medical imaging and advanced genetic testing. The combination of lung size and liver position determination by ultrasound measurements and MRI are widely accepted methods to stratify fetuses into groups that correlate not only with neonatal mortality but also with morbidity. Notwithstanding this, prediction of persistent pulmonary hypertension of the newborn still needs to be improved.
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Affiliation(s)
- Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, 157 rue de la porte de Trivaux, 92140 CLAMART, APHP, Clamart, France; Centre Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France.
| | - Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, 157 rue de la porte de Trivaux, 92140 CLAMART, APHP, Clamart, France; Centre Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
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46
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Abstract
Survivorship of patients with congenital diaphragmatic hernia (CDH) has created a unique cohort of children, adolescents and adults with complex medical and surgical needs. Morbidities specific to this disease benefit from multi-specialty care, and the long term follow up of these patients offers a tremendous opportunity for research and collaboration. Herein we aim to offer an overview of the challenges that modern CDH survivors face, and include a risk-stratified algorithm as a general guideline for a multi-specialty follow up program.
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Affiliation(s)
- Laura E Hollinger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 613/CSB 417, Charleston SC 29425, USA.
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Yu PT, Jen HC, Rice-Townsend S, Guner YS. The role of ECMO in the management of congenital diaphragmatic hernia. Semin Perinatol 2020; 44:151166. [PMID: 31472951 DOI: 10.1053/j.semperi.2019.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.
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Affiliation(s)
- Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States
| | - Howard C Jen
- David Geffen School of Medicine at UCLA, Mattel Children's Hospital at UCLA, Los Angeles, CA, United States
| | - Samuel Rice-Townsend
- Department of Pediatric Surgery, Children's Hospital Boston-Harvard Medical School, Boston, MA, United States
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States.
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Heterogeneous Response in Rabbit Fetal Diaphragmatic Hernia Lungs After Tracheal Occlusion. J Surg Res 2020; 250:23-38. [PMID: 32014698 DOI: 10.1016/j.jss.2019.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/10/2019] [Accepted: 12/11/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fetal tracheal occlusion (TO) is an experimental therapeutic approach to stimulate lung growth in the most severe congenital diaphragmatic hernia (CDH) cases. We have previously demonstrated a heterogeneous response of normal fetal rabbit lungs after TO with the appearance of at least two distinct zones. The aim of this study was to examine the fetal lung response after TO in a left CDH fetal rabbit model. METHODS Fetal rabbits at 25 d gestation underwent surgical creation of CDH followed by TO at 27 d and harvest on day 30. Morphometric analysis, global metabolomics, and fluorescence lifetime imaging microscopy (FLIM) were performed to evaluate structural and metabolic changes in control, CDH, and CDH + TO lungs. RESULTS Right and left lungs were different at the baseline and had a heterogeneous pulmonary growth response in CDH and after TO. The relative percent growth of the right lungs in CDH + TO was higher than the left lungs. Morphometric analyses revealed heterogeneous tissue-to-airspace ratios, in addition to size and number of airspaces within and between the lungs in the different groups. Global metabolomics demonstrated a slower rate of metabolism in the CDH group with the left lungs being less metabolically active. TO stimulated metabolic activity in both lungs to different degrees. FLIM analysis demonstrated local heterogeneity in glycolysis, oxidative phosphorylation (OXPHOS), and FLIM "lipid-surfactant" signal within and between the right and left lungs in all groups. CONCLUSIONS We demonstrate that TO leads to a heterogeneous morphologic and metabolic response within and between the right and left lungs in a left CDH rabbit model.
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Romiti A, Viggiano M, Savelli S, Salvi S, Vicario R, Vassallo C, Valfrè L, Tomà P, Bonito M, Lanzone A, Bagolan P, Caforio L. Comparison of mediastinal shift angles obtained with ultrasound and magnetic resonance imaging in fetuses with isolated left sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2020; 35:269-274. [PMID: 31973612 DOI: 10.1080/14767058.2020.1716714] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: To compare ultrasound (US) and magnetic resonance imaging (MRI) in the assessment of mediastinal shift angles (MSAs) in fetuses affected by isolated left congenital diaphragmatic hernia (CDH). The use of MRI-MSA and US-MSA as prognostic factor for postnatal survival in fetal left CDH was also explored.Methods: This was an observational study of 29 fetuses with prenatally diagnosed isolated left CDH, assessed with both US and MRI examinations between January 2015 and December 2018. The US-MSA measurements performed within 2 weeks from the MRI assessment were considered for the analysis. The primary outcome was the postnatal survival rate.Results: No significant difference between US and MRI MSAs was detected (p = .419). Among the 29 cases, there were 21 alive infants, for an overall postnatal survival rate of 72.41%. After stratifying for postnatal survival, the best cutoffs with the highest discriminatory power in terms of sensibility and specificity were 42.1° for the US-MSA and 39.1° for the MRI-MSA. The performance of MRI-MSA in predicting postnatal survival was close to that of US-MSA in terms of sensitivity (62.5 versus 50.0%), specificity (80.9 versus 90.5%), positive predictive value (55.6 versus 66.7%), negative predictive value (85.0 versus 82.6%) and accuracy (75.9 versus 79.3%). There was no statistically significant difference between the two modalities (p > .05 for all).Conclusions: MRI and US can be interchangeably used for the assessment of MSA in prenatally diagnosed isolated left CDH. Moreover, MSA measured by both US and MRI was confirmed to be correlated with perinatal outcome in terms of survival.
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Affiliation(s)
- Anita Romiti
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Milena Viggiano
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sara Savelli
- Department of Diagnostic Imaging, Pediatric Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Silvia Salvi
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC di Patologia Ostetrica, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Rome, Italy
| | - Roberta Vicario
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Chiara Vassallo
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC di Patologia Ostetrica, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Rome, Italy
| | - Laura Valfrè
- Department of Medical and Surgical Neonatology, Neonatal Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paolo Tomà
- Department of Diagnostic Imaging, Pediatric Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Bonito
- Department of Obstetrics and Gynecology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Antonio Lanzone
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC di Patologia Ostetrica, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Department of Medical and Surgical Neonatology, Neonatal Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Leonardo Caforio
- Department of Medical and Surgical Neonatology, Fetal Medicine and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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50
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Macchini F, Morandi A, Mazzoleni S, Ichino M, Cavallaro G, Raffaeli G, Ferrari C, Gangi S, Mosca F, Fabietti I, Persico N, Leva E. Is Fetal Endoscopic Tracheal Occlusion (FETO) a Predisposing Factor for Acid Gastro-Esophageal Reflux in Infants With Congenital Diaphragmatic Hernia? Front Pediatr 2020; 8:467. [PMID: 32984201 PMCID: PMC7477307 DOI: 10.3389/fped.2020.00467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/03/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction: Various anatomical defects predispose patients with congenital diaphragmatic hernia (CDH) to develop gastroesophageal reflux disease (GERD). The fetal endoscopic tracheal occlusion (FETO) has increased the survival of patients with severe CDHs. The aim of this study was to study GERD in patients who underwent FETO. Materials and Methods: We included patients with CDH treated with or without FETO ("FETO" and "no-FETO" group, respectively) from 2013 to 2016. Data on gestational age (GA), birth weight (BW), initial observed/expected lung to head ratio (O/E LHR), final O/E LHR, duration of ventilation and hospitalization, maximal tracheal diameter, and pulmonary volume were collected. All patients underwent pH-metry after 1 year of life, and the results were compared between groups and correlated to risk factors. Results: Thirty-two patients were included in the study: 10 FETO and 22 no-FETO. No significant differences were observed in the pH-metric results of the two groups. No correlation was found between GA, BW, initial O/E LHR, maximal tracheal diameter, pulmonary volume, and pH-metric results. pH-metric results were correlated with the total duration of ventilation (R = 0.5, p = 0.003) and of hospitalization (R = 0.54, p = 0.001). Gastric herniation is associated with the worse pH-metric result. Conclusions: The FETO procedure does not seem to represent an independent risk factor for GERD. However, patients with the most severe CDH have the worst GERD.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Mazzoleni
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Ichino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Carlo Ferrari
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Gangi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Isabella Fabietti
- Unit of Obstetrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Unit of Obstetrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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