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Montgomery A, Peiffer S, Mehl S, Lee TC, Keswani SG, King A. Management and Outcomes of Patients With High-Risk (Congenital Lung Malformation Volume Ratio≥ 1.6) Congenital Lung Malformations. J Surg Res 2024; 295:559-566. [PMID: 38086256 DOI: 10.1016/j.jss.2023.11.048] [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: 03/06/2023] [Revised: 06/23/2023] [Accepted: 11/16/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Congenital lung malformations (CLMs) have a variable natural history. Larger lesions with CLM volume ratio (CVR) ≥ 1.6 are associated with hydrops and fetal mortality. The purpose of this study is to describe the management and outcomes of high-risk (CVR ≥ 1.6) CLM patients. METHODS A retrospective cohort study was performed for all fetuses evaluated between May 2015 and May 2022. Demographics, prenatal imaging factors, prenatal and postnatal treatment, and outcomes were collected. Descriptive statistics were used to compare the cohorts. RESULTS Of 149 fetal CLM patients referred to our fetal center, 21/149 (14%) had CVR ≥ 1.6. One CLM patient had intrauterine fetal demise, and 2 patients were lost to follow-up. Of the remaining 18 patients, 11/18 (67%) received maternal steroids. Seven out of 18 patients (39%) underwent resection at the time of delivery with 1/7 (14%) undergoing exutero intrapartum treatment (EXIT)-to-resection, 5/7 (71%) undergoing EXIT-to-exteriorization-to-resection, and 1/7 (14%) undergoing a coordinated delivery to resection; among those undergoing resection, there were 2 fatalities (28.5%). Seven out of 18 (39%) patients required urgent neonatal open lobectomies, and the remaining 4/18 (22%) patients underwent elective thoracoscopic lobectomies with no mortality. CONCLUSIONS The natural history and outcomes of severe CLM patients remain highly variable. The EXIT-to-exteriorization-to-resection procedure may be a safe and effective approach for a subset of CLM patients with persistent symptoms of mass effect and severe mediastinal shift due to the observed decreased operative time requiring placental support observed in our study.
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Affiliation(s)
- Ashley Montgomery
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven Mehl
- Michael E. DeBakey Department of Surgery, 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, 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, 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, Houston, Texas.
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Peiffer S, Mehl SC, Montgomery A, Ketwaroo P, Donepudi R, Lee TC, Keswani SG, King A. Novel Clinical Algorithm for Prenatal Monitoring of Congenital Lung Malformations. J Surg Res 2024; 293:373-380. [PMID: 37806224 DOI: 10.1016/j.jss.2023.08.002] [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: 03/06/2023] [Revised: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Congenital lung malformations (CLMs) are readily identified early in pregnancy with a variable natural history. Monitoring for lesion size and mediastinal shift (MS) is recommended following diagnosis. The purpose of this study is to propose a risk-stratified clinical algorithm for prenatal monitoring of CLM. METHODS After ethical approval, all fetuses with CLMs evaluated at our fetal center from January 2015 to June 2022 were retrospectively reviewed. Patient demographics, imaging characteristics, and fetal interventions were collected. Lesions were stratified by congenital lung malformation volume ratio (CVR) and the presence of MS. Descriptive statistics and receiver operating characteristic curves were employed in the analysis. RESULTS We analyzed 111 patients with a mean of 23.4 wk gestational age, a median CVR of 0.5 (interquartile range, 0.3-1.2), and MS in 76 of 111(68%) patients on initial evaluation. Among low-risk patients (CVR ≤1.1), 96% remained low-risk on final evaluation. No patients transitioned from low to high risk during the growth period. Patients with CVR >1.1 often had persistent MS (P < 0.001). Hydrops (5/111, 5%) and fetal intervention (4/111, 4%) only occurred in patients with CVR >1.1 (P < 0.001, P = 0.002) and MS (P = 0.144, P = 0.214). On receiver operating characteristic curve analysis, initial CVR >1.1 had 100% sensitivity and negative predictive value for hydrops and fetal intervention. CONCLUSIONS CLMs with initial CVR ≤1.1 are low risk for hydrops and fetal intervention. We propose a risk-stratified algorithm for the monitoring of CLM during the growth period based on CVR. While our experience suggests that patients with CLM and MS are at higher risk, the current subjective assessment of MS is not adequately predictive. Incorporating an MS grading system may further refine risk stratification in the management of CLM.
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Affiliation(s)
- Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Ashley Montgomery
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Pamela Ketwaroo
- Division of Pediatric Radiology, Department of Radiology, Texas Children's Hospital, Houston, Texas
| | - Rooopali Donepudi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, 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, 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, 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, Houston, Texas.
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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [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: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Abstract
The ex-utero intrapartum treatment (EXIT) procedure was originally developed to reverse tracheal occlusion in fetuses with severe congenital diaphragmatic hernia that underwent fetal tracheal occlusion. The EXIT procedure has since been applied to a wide range of indications, but the primary indication remains securing a patent airway and providing respiratory support in fetuses with anticipated difficult airways. The authors review perinatal management of the anticipated difficult airway and their single-institution's experience with the EXIT procedure.
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Affiliation(s)
- M Silena Mosquera
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Sara Yuter
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA.
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Engwall-Gill AJ, Weller JH, Salvi PS, Penikis AB, Sferra SR, Rhee DS, Solomon DG, Kunisaki SM. Morbidity and Mortality in Neonates with Symptomatic Congenital Lung Malformation. J Am Coll Surg 2023; 236:1139-1146. [PMID: 36786474 DOI: 10.1097/xcs.0000000000000653] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Neonatal resection is the mainstay treatment of children presenting with symptomatic congenital lung malformation (CLM) at birth. The objective of this study was to evaluate risk factors for increased morbidity and mortality after neonatal CLM resection using a large multicenter database. STUDY DESIGN Retrospective review of the Pediatric Health Information System database was performed. Children with a symptomatic CLM managed by lung resection before 30 days of age were included (2016 to 2021). Primary outcomes measures were postoperative respiratory complication and any complication, including death. RESULTS Of 1,791 CLM patients identified, 256 (14%) underwent neonatal resection for symptomatic disease. Pathology included 123 (48%) congenital pulmonary airway malformation, 24 (10%) bronchopulmonary sequestration, 5 (2%) congenital lobar emphysema, 16 (6%) hybrid, and 88 (34%) unclassified lesion. Preoperative mechanical ventilation and extracorporeal membrane oxygenation (ECMO) were employed in 149 (58.2%) and 17 (6.7%) of cases, respectively. The median age at resection was 6.5 days (interquartile range 2 to 23). Postoperatively, 25 (10%) required mechanical ventilation for 48 hours or more, 3 (1%) continued ECMO, and 3 (1%) required ECMO rescue. The overall respiratory complication rate was 34% (87), rate of any complication was 51% (130), median postoperative length of stay was 20 days (interquartile range 9 to 52), and mortality rate was 14.5% (37). Birthweight was inversely correlated with complication risk (incidence rate ratio 0.55, 95% CI 0.36 to 0.83, p = 0.006). Cardiac structural anomaly was associated with a 21-day longer postoperative length of stay (95% CI 6 to 35, p = 0.006) and 2.2 times increased risk of any complication (95% CI 1.18 to 4.02, p = 0.014). CONCLUSIONS In this large multicenter study, ECMO use and mortality are relatively uncommon among neonates undergoing lung resection for a symptomatic CLM. However, postoperative morbidity remains high, particularly in those with cardiac structural disease.
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Affiliation(s)
- Abigail J Engwall-Gill
- From the Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Engwall-Gill, Weller, Penikis, Sferra, Rhee)
| | - Jennine H Weller
- From the Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Engwall-Gill, Weller, Penikis, Sferra, Rhee)
| | - Pooja S Salvi
- the Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT (Salvi, Solomon, Kunisaki)
| | - Annalise B Penikis
- From the Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Engwall-Gill, Weller, Penikis, Sferra, Rhee)
| | - Shelby R Sferra
- From the Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Engwall-Gill, Weller, Penikis, Sferra, Rhee)
| | - Daniel S Rhee
- From the Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Engwall-Gill, Weller, Penikis, Sferra, Rhee)
| | - Daniel G Solomon
- the Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT (Salvi, Solomon, Kunisaki)
| | - Shaun M Kunisaki
- the Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT (Salvi, Solomon, Kunisaki)
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6
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Abstract
Congenital lung malformations represent a spectrum of lesions, each with a distinct cause and tailored clinical approach. This article will focus on the following malformations: congenital pulmonary airway malformations, formally known as congenital cystic adenomatoid malformations, bronchopulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst. Each of these malformations will be defined and examined from an embryologic, pathophysiologic, and clinical management perspective unique to that specific lesion. A review of current recommendations in both medical and surgical management of these lesions will be discussed as well as widely accepted treatment algorithms.
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Affiliation(s)
- Brittany N Hegde
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA
| | - Shinjiro Hirose
- Division of Pediatric, Thoracic, and Fetal Surgery, University of California-Davis Medical Center, 2335 Stockton Boulevard, Sacramento, CA 95817, USA.
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Karlsson M, Conner P, Ehren H, Bitkover C, Burgos CM. The natural history of prenatally diagnosed congenital pulmonary airway malformations and bronchopulmonary sequestrations. J Pediatr Surg 2022; 57:282-287. [PMID: 35431039 DOI: 10.1016/j.jpedsurg.2022.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The natural history of congenital pulmonary airway malformations (CPAM) and bronchopulmonary sequestrations (BPS) is not fully understood, and the management of the newborn with an asymptomatic lesion is a controversial issue. We aimed to study the natural history and outcome of CPAM/BPS at our institution with a policy of watchful waiting, and to investigate if any prognostic factors in the pre- and/or postnatal- period may predict the need for surgery. MATERIAL AND METHODS A retrospective review study was conducted of children prenatally diagnosed with CPAM and/or BPS during the 18-year period, from 2002 to 2020. Data from the pre and postnatal period was collected and analysed. RESULTS Sixty- six patients with prenatally observed lung lesions were entered in the study, with an overall survival rate of 94%. Fifty-six percent of the lesions decreased in size during gestation. Thirty-one percent had surgery and 69% could be managed conservatively with a median follow-up of 4 years. Nineteen percent developed symptoms after the neonatal period. Children with a presence of mediastinal shift on postnatal imaging (p = 0.003), with a high CVR (p = 0.005) and a large lesion size during gestation (p = 0.014) were significantly more likely to require surgery. CONCLUSION Prenatal regression is common among prenatally diagnosed CPAM/BPS and the majority of children that are asymptomatic beyond the neonatal period will remain asymptomatic throughout their childhood. Future analysis with a longer follow-up might give new insights in order to identify children at risk of developing symptoms. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matilda Karlsson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Peter Conner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Center for Fetal Medicine Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Ehren
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Bitkover
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Carmen Mesas Burgos
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Mehl SC, Short WD, Kinley A, Olutoye OO, Lee TC, Keswani SG, King A. Maternal Steroids in High-Risk Congenital Lung Malformations. J Surg Res 2022; 280:312-319. [PMID: 36030607 DOI: 10.1016/j.jss.2022.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The purpose of the present study is to evaluate our institutional management of high-risk congenital lung malformations (CLM) with particular consideration of the use of multiple maternal steroid courses and maternal steroids in CLMs with pathologies other than congenital pulmonary airway malformation (CPAM). METHODS A single-center retrospective review was performed for all fetuses evaluated for CLM who received maternal steroids and/or had a CLM volume ratio (CVR) ≥ 1.6 (2015-2020). Fetuses were categorized as receiving no steroids, single steroid, or multiple steroid courses. Outcomes evaluated included CVR growth rate, resolution of early hydrops, and resolution of hydrops. Results are reported with a descriptive analysis. RESULTS Nineteen patients were identified who had CVR ≥ 1.6 (single steroid course 9/19, multiple steroid courses 6/19, and no steroids 4/19). A majority (n = 13, 68%) of all lesions had a reduction or no change in CVR between initial and final measurements (single steroid course 7/9, 78%; multiple steroid courses 4/6, 67%). When evaluating by pathology, ≥ 50% of each classification had reduction or no growth of CVR (CPAM 7/11, bronchial atresia 2/4, sequestration 3/3, congenital lobar emphysema 1/1). Seventy five percent (3/4) of lesions with early hydrops had resolution following steroid treatment (single steroid course 1, multiple steroid courses 2). Of the four lesions that had hydrops, only one had resolution after receiving multiple steroid courses. CONCLUSIONS Our institutional experience reports the majority of CLM (including pathologies other than CPAM) who received steroids had reduction or no change in CVR. Given the low risk-benefit ratio of maternal steroids, physicians could consider use of multiple steroid courses for CLM refractory to a single course.
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Affiliation(s)
- Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas.
| | - Walker D Short
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Austin Kinley
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Oluyinka O Olutoye
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Timothy C Lee
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Sundeep G Keswani
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Alice King
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
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9
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Mehl SC, Short WD, Kinley A, Lee TC, Sun RC, Belfort MA, Shamshirsaz AA, Espinoza J, Donepudi R, Sanz-Cortes M, Nassr AA, Mehollin-Ray AR, Keswani SG, King A. Delivery planning for congenital lung malformations: A CVR based perinatal care algorithm. J Pediatr Surg 2022; 57:833-839. [PMID: 35065806 DOI: 10.1016/j.jpedsurg.2021.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/29/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Congenital lung malformation (CLM) volume ratio (CVR) of ≥1.1 has been shown to be highly predictive of the need for urgent, perinatal surgical intervention. The purpose of this study was to utilize this information to propose a delivery planning and clinical management algorithm based on this threshold. METHODS A retrospective cohort study was performed for all fetuses evaluated at our fetal center between 5/2015 and 11/2020. Demographics, ultrasound findings, late gestation CVR (≥27 weeks gestational age), prenatal and postnatal treatment, and outcomes were analyzed with nonparametric univariate analysis based on late gestation CVR of 1.1. Receiver operating characteristic curve analysis was performed to evaluate association between late gestation CVR, hydrops, need for fetal intervention, and need for urgent perinatal surgery. RESULTS Of the 90 CLMs referred to our fetal center, 65 had late gestation CVR with a majority <1.1 (47/65, 72%). All patients with late gestation CVR ≥ 1.1 were managed with resection (18/18) with most resections requiring fetal intervention or urgent neonatal resection (13/18). Late gestation CVR < 1.1 were managed with elective resection (36/47, 77%) or non-operative observation (11/47, 23%). Late gestation CVR ≥ 1.1 had 100% sensitivity and NPV for hydrops, need for fetal intervention, and need for urgent perinatal surgery. CONCLUSION CLM with CVR ≥ 1.1 were associated with urgent perinatal surgical intervention and expectant mothers should plan for delivery at centers equipped to manage neonatal resuscitation and potential urgent neonatal resection. Conversely, CLM with CVR < 1.1 may be safe to deliver at patient hospital of choice.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.
| | - Walker D Short
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Austin Kinley
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Tim C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Raphael C Sun
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Magdalena Sanz-Cortes
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Amy R Mehollin-Ray
- Department of Radiology, Division of Pediatric Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
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Abstract
This article reviews the contemporary diagnosis and management of antenatally diagnosed congenital lung lesions. These anomalies, which include congenital pulmonary airway malformation (CPAM) (formerly congenital cystic adenomatoid malformation), bronchopulmonary sequestration (BPS), bronchogenic cyst, and congenital lobar emphysema (CLE), are relatively rare but are increasingly encountered by clinicians because of the improved resolution and enhanced sensitivity of fetal ultrasound. Serial assessment of these lesions throughout pregnancy remains the norm rather than the exception. Perinatal management strategies may differ based on initial size and growth patterns of these masses until delivery. Fetal magnetic resonance imaging and other diagnostic testing can sometimes be helpful in providing additional prognostic information. Over the last decade, maternal steroids have become standard of care in the management of larger lesions at risk for nonimmune hydrops. As a result, fetal surgical procedures, including open resection, thoracoamniotic shunting, and ex utero intrapartum treatment (EXIT), are less uncommonly performed. Decisions regarding whether delivery of these fetuses should occur in a tertiary care center with pediatric surgery coverage versus delivery at a local community hospital are now highly relevant in most prenatal counseling discussions with families. Large lung malformations may require urgent surgical removal in the early postnatal period because of respiratory distress. Other complications, such as recurrent pneumonia, pneumothorax, and cancer, are indications for postnatal lung resection on an elective basis. Many children are good candidates for minimally invasive (thoracoscopic) surgical approaches as an alternative to resection by thoracotomy. In the vast majority of cases, the overall prognosis remains excellent.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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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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12
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Shamshirsaz AA, Aalipour S, Stewart KA, Nassr AA, Furtun BY, Erfani H, Sundgren NC, Cortes MS, Donepudi RV, Lee TC, Mehta DK, Kravitz ES, Asl NM, Espinoza J, Belfort MA. Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis. Prenat Diagn 2021; 41:497-504. [PMID: 33386645 DOI: 10.1002/pd.5894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/09/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas. METHODS Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%). RESULTS We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy. CONCLUSION EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Soroush Aalipour
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Kelsey A Stewart
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ahmed A Nassr
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Egypt
| | - Betul Y Furtun
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Hadi Erfani
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Nathan C Sundgren
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Magdalena S Cortes
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Roopali V Donepudi
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Deepak K Mehta
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Elizabeth S Kravitz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Nazli M Asl
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Jimmy Espinoza
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Belfort
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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13
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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14
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Kunisaki SM, Leys CM. Surgical Pulmonary and Pleural Diseases in Children: Lung Malformations, Empyema, and Spontaneous Pneumothorax. Adv Pediatr 2020; 67:145-169. [PMID: 32591058 DOI: 10.1016/j.yapd.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 7353, Baltimore, MD 21287, USA.
| | - Charles M Leys
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, 600 Highland Avenue, H4/740 CSC, Madison, WI 53792-7375, USA
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15
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Abstract
Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.
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Affiliation(s)
- Kha M Tran
- University of Pennsylvania Perelman School of Medicine, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Debnath Chatterjee
- Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
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16
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Kunisaki SM, Saito JM, Fallat ME, St Peter SD, Lal DR, Johnson KN, Mon RA, Adams C, Aladegbami B, Bence C, Burns RC, Corkum KS, Deans KJ, Downard CD, Fraser JD, Gadepalli SK, Helmrath MA, Kabre R, Landman MP, Leys CM, Linden AF, Lopez JJ, Mak GZ, Minneci PC, Rademacher BL, Shaaban A, Walker SK, Wright TN, Hirschl RB. Development of a multi-institutional registry for children with operative congenital lung malformations. J Pediatr Surg 2020; 55:1313-1318. [PMID: 30879756 DOI: 10.1016/j.jpedsurg.2019.01.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/27/2018] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection. METHODS After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative. RESULTS Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%). CONCLUSION This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Shaun M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA.
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | - Shawn D St Peter
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA
| | - Rodrigo A Mon
- Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA
| | - Cheryl Adams
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bola Aladegbami
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Christina Bence
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - R Cartland Burns
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristine S Corkum
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, the Research Institute and Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | - Jason D Fraser
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA
| | - Michael A Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Allison F Linden
- Section of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Joseph J Lopez
- Center for Surgical Outcomes Research, the Research Institute and Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, the Research Institute and Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Brooks L Rademacher
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Aimen Shaaban
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarah K Walker
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA
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17
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King A, Lee TC, Steen E, Olutoye OO, Belfort MA, Cassady CI, Mehollin-Ray AR, Keswani SG. Prenatal Imaging to Predict Need for Urgent Perinatal Surgery in Congenital Lung Lesions. J Surg Res 2020; 255:463-468. [PMID: 32622160 DOI: 10.1016/j.jss.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Congenital lung malformations (CLMs) have a variable natural history: some patients require urgent perinatal surgical intervention (UPSI) and others remain asymptomatic. These lesions have potential growth until 26-28 wk gestation. CLM volume ratio (CVR) has been shown to predict the risk of hydrops in CLMs. However, no criteria exist to delineate lesions requiring urgent surgical intervention in the perinatal period. Our goal was to determine prenatal diagnostic features that predict the need for UPSI in patients diagnosed with CLM. METHODS Records and imaging features of all fetuses evaluated by our fetal center between May 2015 and December 2018 were retrospectively reviewed. Data included demographics, fetal ultrasound and magnetic resonance imaging, CVR, surgical treatment, and outcome. Features were analyzed for their ability to predict the need for UPSI. RESULTS Sixty-four patients were referred for CLM, with 48 patients serially followed. Nine (18.8%) patients were followed nonoperatively, 35 (72.9%) underwent resection, and four (8.3%) were lost to follow-up. Of the patients who underwent resection, 24 (68.5%) were electively resected and 11 were urgently resected. Five (14.3%) patients underwent ex utero intrapartum treatment resection, and six (17.1%) were urgently resected for symptomatic CLM. There were no cases of UPSI with final CVR <1.1. Of the patients with final CVR 1.1-1.7, 43% required urgent resection. CVR ≥1.1 has 100% sensitivity and 87.8% specificity to predict patients requiring UPSI (area under the curve of 0.98). CONCLUSIONS A final CVR ≥1.1 is highly predictive for UPSI. Patients with a final CVR ≥1.1 should be referred for delivery at centers with pediatric surgeons equipped for potential UPSI for CLM.
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Affiliation(s)
- Alice King
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas.
| | - Timothy C Lee
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Emily Steen
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Oluyinka O Olutoye
- General Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael A Belfort
- Division of Obstetrics and Gynecology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Christopher I Cassady
- Division of Obstetrics and Gynecology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas; Division of Radiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Amy R Mehollin-Ray
- Division of Obstetrics and Gynecology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas; Division of Radiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
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18
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Shamshirsaz AA, Stewart KA, Erfani H, Nassr AA, Sundgren NC, Mehollin-Ray AR, Morris SA, Espinoza J, Sanz Cortes M, Cassady C, Lee TC, Castro EC, Olutoye OA, Mehta DK, Cass D, Olutoye OO, Belfort MA. Cervical lymphatic malformations: Prenatal characteristics and ex utero intrapartum treatment. Prenat Diagn 2020; 39:287-292. [PMID: 30707444 DOI: 10.1002/pd.5428] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND The ex utero intrapartum treatment (EXIT) is utilized to transition fetuses with prenatally diagnosed airway obstruction to postnatal life. We describe the unique clinical course, diagnosis, treatment, and outcomes of patients with cervical lymphatic malformation (CLM) managed with EXIT. METHODS Review of fetuses with diagnosed CLM was delivered by EXIT (2001-2018) in a tertiary referral fetal center. Outcomes included survival, tracheostomy at discharge, neonatal course after delivery, and pulmonary hypoplasia. Data are reported as median [range] and rate (%). RESULTS Out of 45 patients delivered by EXIT, 10 were delivered for CLM: seven had polyhydramnios, one had nonimmune hydrops, five delivered preterm, and three were emergency EXITs. The EXIT time and estimated blood loss were 125 minutes (95, 158) and 900 mL (500, 1500), respectively. Airway was secured in all. There was one neonatal death (day 8) with prematurity, sepsis, and pulmonary hypoplasia. Three out of nine were discharged with a tracheostomy. CONCLUSION In CLM, close monitoring for structural neck involvement and development of polyhydramnios are important and may be an indication for EXIT as the optimal delivery mode. An experienced multidisciplinary team is a key factor for an effective approach to the obstructed airway in CLM.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Kelsey A Stewart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Hadi Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Ahmed A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Nathan C Sundgren
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Amy R Mehollin-Ray
- Department of Radiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jimmy Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Christopher Cassady
- Department of Radiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Eumenia C Castro
- Department of Pathology & Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Deepak K Mehta
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Darrell Cass
- Division of Pediatric Surgery, Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Michael A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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19
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Johnson KN, Mon RA, Gadepalli SK, Kunisaki SM. Short-term respiratory outcomes of neonates with symptomatic congenital lung malformations. J Pediatr Surg 2019; 54:1766-1770. [PMID: 30851956 DOI: 10.1016/j.jpedsurg.2019.01.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/17/2018] [Accepted: 01/19/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate short-term respiratory outcomes in neonates with symptomatic congenital lung malformations (CLM). METHODS Consecutive newborns who underwent surgical resection of a CLM were retrospectively reviewed. Demographic, prenatal, and outcomes data were analyzed as appropriate (p < 0.05). RESULTS Twenty-one neonates were managed at a median gestational age of 36.2 weeks [interquartile range (IQR), 33.8-39.0]. Endotracheal intubation was required in 14 (66.7%) for a median of 7.5 days [interquartile range (IQR), 3.0-25.8]. Three (14.3%) children underwent ex utero intrapartum treatment-to-resection, and another 14 (66.7%) had neonatal lung resections performed at a median age of 2.0 days (IQR, 0.08-19.5 days). Excluding one patient who received comfort care at birth, all neonates survived to hospital discharge with a median length of hospitalization of 36.5 days (IQR, 23.8-56.5). More than one-quarter were discharged on supplemental oxygen by nasal cannula. Based on a median follow up of 35.5 months (IQR, 19.0-80.8), CLM-related morbidity was still evident in 55.0%. CONCLUSION Our study suggests a high incidence of complications and chronic respiratory morbidity after neonatal lung resection for symptomatic CLMs. These data highlight the need to provide realistic expectations in perinatal counseling discussions with families and the importance of coordinating appropriate multidisciplinary follow up for these children. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109; Pediatric Surgical Critical Care, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109
| | - Rodrigo A Mon
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109; Pediatric Surgical Critical Care, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109; Pediatric Surgical Critical Care, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109
| | - Shaun M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott, Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109.
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20
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Abstract
Diagnosis and management of congenital lung malformations has evolved dramatically over the past several decades. Advancement in imaging technology has enabled earlier, more definitive diagnoses and, consequently, more timely intervention in utero or after birth, when indicated. These advancements have increased overall survival rates to around 95% from historical rates of 60%. However, further refinement of diagnostic technique and standardization of treatment is needed, particularly as the increased sensitivity of diagnostic imaging results in more frequent diagnoses. In this article, we provide an updated review of the diagnostic strategies, management, and prognosis of congenital lung malformations.
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Affiliation(s)
- Michael Zobel
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Rebecca Gologorsky
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Hanmin Lee
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Lan Vu
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco.
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Shamshirsaz AA, Aalipour S, Erfani H, Nassr AA, Stewart KA, Kravitz ES, Rezaei A, Sanz Cortes M, Espinoza J, Belfort MA. Obstetric outcomes of ex-utero intrapartum treatment (EXIT). Prenat Diagn 2019; 39:643-646. [PMID: 31093996 DOI: 10.1002/pd.5477] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/PURPOSE The ex-utero intrapartum treatment (EXIT) procedure is used to secure effective gas exchange prior to postnatal life. We describe the obstetrical course and maternal outcomes of a series of patients who underwent EXIT. METHODS This is a review of all pregnancies in which fetuses were delivered by EXIT from January 2001 to April 2018. Outcome variables included estimated gestational age (EGA) at delivery, need for emergency EXIT, maternal estimated blood loss (EBL), need for maternal blood transfusion, and maternal postoperative length of hospital stay. Data were tested for normality and reported as median [range] and n (%). RESULTS A total of 45 patients were delivered by EXIT procedure. Sixteen (35.6%) of the EXIT procedures were performed emergently. Median maternal EBL was 800 (500-2000) mL; 6 (13.3%) patients received blood transfusion. Median maternal postoperative length of hospital stay was four [3-7] days. CONCLUSION Our data highlight the complexity of the obstetrical management in the EXIT procedure as evidenced by an approximately 36% chance of emergency delivery. Despite having an experienced multidisciplinary team, 13.3% of our subjects underwent maternal blood transfusion. This information can be used in counseling EXIT candidates regarding the risks and benefits of this procedure.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Soroush Aalipour
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Hadi Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.,Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Kelsey A Stewart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Elizabeth S Kravitz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Atefeh Rezaei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Magdalena Sanz Cortes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jimmy Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Erfani H, Nassr AA, Espinoza J, Lee TC, Shamshirsaz AA. A novel approach to ex-utero intrapartum treatment (EXIT) in a case with complete anterior placenta. Eur J Obstet Gynecol Reprod Biol 2018; 228:335-336. [PMID: 29921481 DOI: 10.1016/j.ejogrb.2018.06.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Hadi Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ahmed A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Jimmy Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
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Danzer E, Hoffman C, D'Agostino JA, Boelig MM, Gerdes M, Bernbaum JC, Rosenthal H, Waqar LN, Rintoul NE, Herkert LM, Kallan MJ, Peranteau WH, Flake AW, Adzick NS, Hedrick HL. Short-Term Neurodevelopmental Outcome in Children Born With High-Risk Congenital Lung Lesions. Ann Thorac Surg 2018; 105:1827-1834. [PMID: 29438655 DOI: 10.1016/j.athoracsur.2018.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study sought to evaluate neurodevelopmental outcome in survivors of high-risk congenital lung lesions (CLLs) who underwent prenatal intervention or postnatal surgery within the first month of life. METHODS Forty-five high-risk CLL survivors underwent assessment using the Bayley Scales of Infant Development, 3rd Edition between July 2004 and December 2016. Scores were grouped as average, at-risk, and delayed based on SD intervals. Correlations between outcome and risk factors were analyzed by Fisher's exact test or two-sided t test as appropriate, with significant p values <0.05. RESULTS Open prenatal intervention was required in 13 (28.9%) children (fetal surgical resection, n = 4 , ex utero intrapartum treatment, n = 9), whereas 32 (71.1%) children had respiratory distress postnatally and required resection within the first month of life. Mean age at follow-up was 19.3 ± 10.3 months. Mean composite scores were within the expected average range. A total of 62.2% scored within the average range for all domains. At-risk scores were found in 26.7% of children in at least one domain, and 11.1% had delays in at least one domain. Neurodevelopmental outcome was similar between treatment groups. Prolonged ventilator support and neonatal intensive care unit stay, need for supplemental oxygen at day of life 30, gastroesophageal reflux disease, and delayed enteral feeding were associated with neurologic delays (all p < 0.05). CONCLUSIONS Neurodevelopmental scores for high-risk CLL survivors in infancy and toddlerhood are age appropriate. Neither fetal intervention nor the need for postnatal resection within the first month of life increases the risk of delays. Surrogate markers of a complicated neonatal course are predictive of adverse outcome.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Casey Hoffman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jo Ann D'Agostino
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew M Boelig
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marsha Gerdes
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Judy C Bernbaum
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Rosenthal
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lindsay N Waqar
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Asai H, Tachibana T, Shingu Y, Matsui Y. Ex utero intrapartum treatment-to-extracorporeal membrane oxygenation followed by cardiac operation for truncus arteriosus communis. Interact Cardiovasc Thorac Surg 2017; 26:353-354. [DOI: 10.1093/icvts/ivx303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/21/2017] [Indexed: 11/13/2022] Open
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Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int 2017; 33:939-953. [PMID: 28589256 DOI: 10.1007/s00383-017-4098-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE Variation in management characterizes treatment of infants with a congenital pulmonary airway malformation (CPAM). This review addresses six clinically applicable questions using available evidence to provide recommendations for the treatment of these patients. METHODS Questions regarding the management of a pediatric patient with a CPAM were generated. English language articles published between 1960 and 2014 were compiled after searching Medline and OvidSP. The articles were divided by subject area and by the question asked, then reviewed and included if they specifically addressed the proposed question. RESULTS 1040 articles were identified on initial search. After screening abstracts per eligibility criteria, 130 articles were used to answer the proposed questions. Based on the available literature, resection of an asymptomatic CPAM is controversial, and when performed is usually completed within the first six months of life. Lobectomy remains the standard resection method for CPAM, and can be performed thoracoscopically or via thoracotomy. There is no consensus regarding a monitoring protocol for observing asymptomatic lesions, although at least one chest computerized tomogram (CT) should be performed postnatally for lesion characterization. An antenatally identified CPAM can be evaluated with MRI if fetal intervention is being considered, but is not required for the fetus with a lesion not at risk for hydrops. Prenatal consultation should be offered for infants with CPAM and encouraged for those infants in whom characteristics indicate risk of hydrops. CONCLUSIONS Very few articles provided definitive recommendations for care of the patient with a CPAM and none reported Level I or II evidence. Based on available information, CPAMs are usually resected early in life if at all. A prenatally diagnosed congenital lung lesion should be evaluated postnatally with CT, and prenatal counseling should be undertaken in patients at risk for hydrops.
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Abstract
Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.
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Affiliation(s)
- H Kitagawa
- Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - K C Pringle
- Paediatric Surgery, Department of Obstetrics and Gynaecology, University of Otago, Wellington, P.O. Box 7343, Wellington South, 6242, Wellington, New Zealand
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Fan D, Wu S, Wang R, Huang Y, Fu Y, Ai W, Zeng M, Guo X, Liu Z. Successfully treated congenital cystic adenomatoid malformation by open fetal surgery: A care-compliant case report of a 5-year follow-up and review of the literature. Medicine (Baltimore) 2017; 96:e5865. [PMID: 28079822 PMCID: PMC5266184 DOI: 10.1097/md.0000000000005865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Congenital cystic adenomatoid malformation (CCAM) is a rare hamartomatous cystic lesion. Open fetal surgery currently provides a potential therapeutic option for management of a fetus with CCAM diagnosis. CASE SUMMARY A 22-year-old G2P0 woman presented at (Equation is included in full-text article.)weeks' gestation for evaluation of a fetus with a left lung lesion and diagnosed as CCAM at (Equation is included in full-text article.)weeks' gestation. Open fetal surgery was performed to resection the lesion at (Equation is included in full-text article.)weeks' gestation under deep maternal general anesthesia. The mother presented at (Equation is included in full-text article.)weeks after open fetal surgery with preterm premature rupture of membranes (PPROM) and underwent cesarean delivery at (Equation is included in full-text article.)weeks' gestation. A vigorous woman infant of 1955 g, with good Apgar score, was delivered. At 1 month, 4 years, and present, 5 years after birth, she has continued to do well without any obvious deficit and both respiration and circulation were well maintained. CONCLUSION We present one case of CCAM which was cured by open fetal surgery and continued to do well at follow-up of 5 years. The success of treatment provided preliminary experience for further carrying out such interventions in China.
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Affiliation(s)
- Dazhi Fan
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Shuzhen Wu
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Rui Wang
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Yi Huang
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Yao Fu
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Wen Ai
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Meng Zeng
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Xiaoling Guo
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Zhengping Liu
- Foshan Fetal Treatment Center
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
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Rychik J, Khalek N, Gaynor JW, Johnson MP, Adzick NS, Flake AW, Hedrick HL. Fetal intrapericardial teratoma: natural history and management including successful in utero surgery. Am J Obstet Gynecol 2016; 215:780.e1-780.e7. [PMID: 27530489 DOI: 10.1016/j.ajog.2016.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/21/2016] [Accepted: 08/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intrapericardial teratoma is a rare, lethal tumor often detected in fetal life. Tumor mass and pericardial effusion cause cardiac tamponade that, if relieved, could be life-saving. Optimal timing of intervention and methods for effective fetal treatment are unknown. OBJECTIVE We describe our single-center experience with fetal intrapericardial teratoma including the first report of successful in utero surgical resection with survival to term. STUDY DESIGN We reviewed our database for suspected fetal intrapericardial teratoma. On fetal ultrasound and echocardiography tumor size was estimated by calculation of an ellipse and analyzed in relation to Doppler-derived fetal cardiac output, venous flow patterns, hydrops, and outcome. RESULTS Eight fetuses with suspected intrapericardial teratoma were seen from 2009 through 2015. Gestational age at initial presentation ranged from 21-34 (median 26) weeks. Two cases mimicked the appearance of intrapericardial teratoma, but had no serial change in cardiac output over time and were ultimately determined to be other types of tumor. In 6 cases of true intrapericardial teratoma, tumor growth was extremely rapid and associated with progressive decline in cardiac output (to <400 mL/kg/min) manifesting in hydrops and death if left untreated. One case was treated successfully at 31 weeks through ex utero intrapartum delivery with tumor resection while on placental support. Another case underwent open fetal surgery and resection at 24 weeks, with resumption of gestation until delivery at 37 weeks with excellent outcome. CONCLUSION Fetal intrapericardial teratoma can be successfully managed utilizing serial surveillance and by treatment in a timely manner prior to the predictable onset of hydrops, determined through increasing tumor size and a declining cardiac output. Surgical resection in utero is possible, with good results.
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Affiliation(s)
- Jack Rychik
- Fetal Heart Program, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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30
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Angeborene Lungenfehlbildungen. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0154-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Moreira de Sá RA, Nassar de Carvalho PR, Kurjak A, Adra A, Dayyabu AL, Ebrashy A, Pooh R, Sen C, Wataganara T, Stanojevic M. Is intrauterine surgery justified? Report from the working group on ultrasound in obstetrics of the World Association of Perinatal Medicine (WAPM). J Perinat Med 2016; 44:737-743. [PMID: 26124046 DOI: 10.1515/jpm-2015-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fetal surgery involves a large number of heterogeneous interventions that vary from simple and settled procedures to very sophisticated or still-in-development approaches. The overarching goal of fetal interventions is clear: to improve the health of children by intervening before birth to correct or treat prenatally diagnosed abnormalities. This article provides an overview of fetal interventions, ethical approaches in fetal surgery, and benefits obtained from antenatal surgeries.
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Lin EE, Moldenhauer JS, Tran KM, Cohen DE, Adzick NS. Anesthetic Management of 65 Cases of Ex Utero Intrapartum Therapy. Anesth Analg 2016; 123:411-7. [DOI: 10.1213/ane.0000000000001385] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Laje P, Tharakan SJ, Hedrick HL. Immediate operative management of the fetus with airway anomalies resulting from congenital malformations. Semin Fetal Neonatal Med 2016; 21:240-5. [PMID: 27132111 DOI: 10.1016/j.siny.2016.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prenatal diagnosis has transformed the outcome of fetuses with airway obstruction. The thorough evaluation of prenatal imaging allows for categorizing fetuses with airway compromise into those who will require a special mode of delivery and those who can be delivered without any special resources. The ex-utero intrapartum treatment (EXIT) approach allows accessing the airway while the fetus is under placental support, converting a potentially catastrophic situation into a controlled one. An expert multidisciplinary team is the key to success.
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Affiliation(s)
- Pablo Laje
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sasha J Tharakan
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Holly L Hedrick
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Macardle CA, Ehrenberg-Buchner S, Smith EA, Dillman JR, Mychaliska GB, Treadwell MC, Kunisaki SM. Surveillance of fetal lung lesions using the congenital pulmonary airway malformation volume ratio: natural history and outcomes. Prenat Diagn 2016; 36:282-9. [DOI: 10.1002/pd.4761] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/30/2015] [Accepted: 12/16/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Catriona A. Macardle
- Department of Obstetrics and Gynecology; St. Joseph Mercy Health System; Ann Arbor MI USA
| | - Stacey Ehrenberg-Buchner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Ethan A. Smith
- Department of Radiology, Section of Pediatric Radiology; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Jonathan R. Dillman
- Department of Radiology, Section of Pediatric Radiology; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - George B. Mychaliska
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
- Department of Surgery, Section of Pediatric Surgery; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Marjorie C. Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Shaun M. Kunisaki
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
- Department of Surgery, Section of Pediatric Surgery; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
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David M, Lamas-Pinheiro R, Henriques-Coelho T. Prenatal and Postnatal Management of Congenital Pulmonary Airway Malformation. Neonatology 2016; 110:101-15. [PMID: 27070354 DOI: 10.1159/000440894] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/06/2015] [Indexed: 11/19/2022]
Abstract
Congenital pulmonary airway malformation (CPAM) is one of the most common lung lesions detected prenatally. Despite the research efforts made in the past few years, controversy and lack of clarity in the literature still exist regarding nomenclature, classification, pathogenesis and the management of CPAM. Therefore, it is of greatest importance to delineate the natural history of CPAMs and to create a consensus to guide the management and follow-up of these lesions. This review will focus on classification systems, highlighting the most recent advancements in pathogenesis, and current practice in the prenatal diagnosis of CPAM. Strategies of prenatal management and postnatal management will be reviewed. Long-term follow-up, including lung cancer risk, is discussed and an outcome perspective is presented.
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Affiliation(s)
- Mafalda David
- Pediatric Surgery Department, Centro Hospitalar Sx00E3;o Jox00E3;o, Porto, Portugal
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Abstract
Antenatal diagnosis of lung lesion has become more accurate resulting in dilemma and controversies of its antenatal and postnatal management. Majority of antenatally diagnosed congenital lung lesions are asymptomatic in the neonatal age group. Large lung lesions cause respiratory compromise and inevitably require urgent investigations and surgery. The congenital lung lesion presenting with hydrops requires careful postnatal management of lung hypoplasia and persistent pulmonary hypertension. Preoperative stabilization with gentle ventilation with permissive hypercapnia and delayed surgery similar to congenital diaphragmatic hernia management has been shown to result in good outcome. The diagnostic investigations and surgical management of the asymptomatic lung lesions remain controversial. Postnatal management and outcome of congenital cystic lung lesions are discussed.
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Affiliation(s)
- Dakshesh H Parikh
- Department of Paediatric Surgery, Birmingham Children׳s Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK.
| | - Shree Vishna Rasiah
- Southern West Midlands Newborn Network and Birmingham Women's Health Care NHS Trust, Mindelsohn Way, Edgbaston Birmingham, B15 2TG UK
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Vanishing fetal lung malformations: Prenatal sonographic characteristics and postnatal outcomes. J Pediatr Surg 2015; 50:978-82. [PMID: 25805010 DOI: 10.1016/j.jpedsurg.2015.03.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/10/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to examine the natural history and outcomes of prenatally diagnosed lung masses that appear to undergo complete regression before birth. METHODS An IRB-approved retrospective review was performed on 100 consecutive fetuses with a congenital lung malformation at a single fetal center. Prenatal and postnatal imaging as well as outcomes of vanishing fetal masses was analyzed and compared to those with persistent fetal masses. RESULTS Seventeen lesions (17%) became sonographically undetectable at 35.3 ± 2.3 weeks gestation. Vanishing fetal masses were associated with microcystic disease (100% vs. 69%, p=0.005) and a low initial congenital pulmonary airway malformation volume ratio (CVR; 0.31 ± 0.35 vs. 0.70 ± 0.66, p=0.002) when compared to those with persistent fetal lesions. Based on postnatal CT imaging and pathology data, 10.3% of all fetal masses completely regressed. The positive predictive value and negative predictive value of prenatal ultrasound for detecting lung malformations in late gestation were 96% and 43%, respectively. All infants with vanishing fetal lesions were asymptomatic at birth and were more likely to be managed nonoperatively (75% vs. 22%, p<0.0001) when compared to infants with persistent fetal masses. CONCLUSIONS Vanishing lung lesions late in gestation are relatively common and are associated with a low CVR and microcystic disease.
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Choudhry M, Drake D. Antenatally diagnosed lung malformations: a plea for long-term outcome studies. Pediatr Surg Int 2015; 31:439-44. [PMID: 25556419 DOI: 10.1007/s00383-014-3654-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Abstract
There is a wide variation in the management of infants with antenatally diagnosed lung malformations, with many paediatric surgeons and respiratory paediatricians recommending early investigations for all infants and a surgical excision for the majority of lesions, while others favour a conservative management for all asymptomatic infants. The benefits and risks of a surgical intervention have to be compared with the natural history of the untreated malformation and cohort studies from foetal diagnosis to adult life are required to provide the relevant evidence. Careful and repeated surveillance of identified foetuses is essential as recent advances in foetal medicine and surgery have improved the outcomes for the small minority, who are at risk of developing hydrops.
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Affiliation(s)
- Muhammad Choudhry
- Department of Paediatric Surgery, Mater Dei Hospital, L-Imsida, Malta,
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Patient characteristics are important determinants of neurodevelopmental outcome during infancy in giant omphalocele. Early Hum Dev 2015; 91:187-93. [PMID: 25676186 DOI: 10.1016/j.earlhumdev.2014.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/26/2014] [Accepted: 12/28/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine patient-specific factors as potential predictors of neurodevelopmental (ND) outcome in children with giant omphalocele (GO). MATERIALS Between 06/2005 and 07/2012, 31 consecutive GO survivors underwent ND assessment using the BSID-III at a median of 24months (range 6-35). ND delay was defined by a score of ≤84 in any composite score. Severe impairments were defined as a score of ≤69 in at least one domain. Correlations between ND outcome and patient-specific factors were analyzed by one-way ANOVA, chi-square, or logistic regression as appropriate. RESULTS The mean cognitive score (86.8±16.8) was in the low average range. Mean language (83.2±21.1) and motor (81.5±16.2) scores were below average. Forty-six-percent scored within the average range for all scales. Mild deficits were found in 19%, and 35% had severe delays in at least one domain. Hypotonicity was present in 55%. Autism was suspected/confirmed in 13%. Predictors of lower ND scores were prolonged ventilator support (P<0.01), high-frequency oscillatory ventilation (P<0.01), tracheostomy placement (P<0.001), O2 supplementation at day of life 30 (P<0.02), pulmonary hypertension (P<0.02), delayed enteral feeding (P=0.01), need for feeding tube (P<0.001), GERD (P=0.05), abnormal BAER hearing screen (P<0.006), prolonged hospitalization (P=0.01), and failure to thrive (P=0.001). Autism was associated with delays in cognitive and language outcomes (P<0.03). Delayed staged closure (P=0.007), older age at final repair (P=0.03), and hypotonicity (P=0.02) were associated with motor dysfunction. CONCLUSIONS Neurological impairments were present in more than half of GO survivors. Disease severity was associated with ND dysfunction. Autism and hypotonicity were often co-morbidities with ND delays and poor motor function.
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Abstract
The management of congenital lung malformations is controversial both in the prenatal and postnatal periods. This article attempts to inform best practice by reviewing the level of evidence with regard to prenatal diagnosis, prognosis, and management and postnatal management, including imaging, surgical indication, surgical approach, and risk of malignancy. We present a series of clinically relevant statements along those topics and analyze the evidence for each. In the end, we make a plea for an adequate description of the lesions, both before and after birth, which will allow future comparisons between management options and the initiation of prospective registries.
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Affiliation(s)
- Robert Baird
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada
| | - Pramod S Puligandla
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada; Department of Pediatrics, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada.
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Olutoye OA. Anaesthesia for the EXIT procedure: A review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2009.10872582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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García-Díaz L, de Agustín JC, Ontanilla A, Marenco ML, Pavón A, Losada A, Antiñolo G. EXIT procedure in twin pregnancy: a series of three cases from a single center. BMC Pregnancy Childbirth 2014; 14:252. [PMID: 25078677 PMCID: PMC4124143 DOI: 10.1186/1471-2393-14-252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 07/16/2014] [Indexed: 11/16/2022] Open
Abstract
Background Indications for the ex utero intrapartum therapy (EXIT) procedure have evolved and nowadays in addition to secure the airway, obtain vascular access, administer surfactant and other resuscitation medications, EXIT is used to resect cervical or thoracic masses, for extracorporeal membrane circulation (ECMO) cannulation, as well as to rescue maximum intra-thoracic space for ventilation of the remaining functional lung tissue or in cases in which resuscitation of the neonate may be compromised. EXIT procedure in twin pregnancy has been rarely reported and some doubts have been raised about its strategy and safety in such cases. Methods We reviewed the medical records of 3 twin pregnancy cases where the EXIT procedure have been performed in our center. Results The mean gestational age at EXIT procedure was 34 + 4 weeks. In two out the three EXIT procedures, the affected twin was delivered first. The average time on placental bypass was 9 minutes. There were no fetal or maternal complications related to the EXIT procedure. All newborns are currently doing well. Conclusion In twin pregnancies, prenatal diagnosis combined with the EXIT procedure permits the formulation of a controlled delivery strategy to secure both newborns outcome. In those pregnancies, if intervention can be accomplished without compromise of the normal twin, EXIT can be considered. Our results support that EXIT procedure, if properly planned, safely provides a good outcome for both the fetuses as well as the mother.
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Affiliation(s)
| | | | | | | | | | | | - Guillermo Antiñolo
- Unidad de Gestión Clínica de Genética, Reproducción y Medicina Fetal, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41003 Sevilla, Spain.
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Zamora IJ, Sheikh F, Cassady CI, Olutoye OO, Mehollin-Ray AR, Ruano R, Lee TC, Welty SE, Belfort MA, Ethun CG, Kim ME, Cass DL. Fetal MRI lung volumes are predictive of perinatal outcomes in fetuses with congenital lung masses. J Pediatr Surg 2014; 49:853-8; discussion 858. [PMID: 24888822 DOI: 10.1016/j.jpedsurg.2014.01.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/27/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate fetal magnetic resonance imaging (MRI) as a modality for predicting perinatal outcomes and lung-related morbidity in fetuses with congenital lung masses (CLM). METHODS The records of all patients treated for CLM from 2002 to 2012 were reviewed retrospectively. Fetal MRI-derived lung mass volume ratio (LMVR), observed/expected normal fetal lung volume (O/E-NFLV), and lesion-to-lung volume ratio (LLV) were calculated. Multivariate regression and receiver operating characteristic analyses were applied to determine the predictive accuracy of prenatal imaging. RESULTS Of 128 fetuses with CLM, 93% (n=118) survived. MRI data were available for 113 fetuses. In early gestation (<26weeks), MRI measurements of LMVR and LLV correlated with risk of fetal hydrops, mortality, and/or need for fetal intervention. In later gestation (>26weeks), LMVR, LLV, and O/E-NFLV correlated with neonatal respiratory distress, intubation, NICU admission and need for neonatal surgery. On multivariate regression, LMVR was the strongest predictor for development of fetal hydrops (OR: 6.97, 1.58-30.84; p=0.01) and neonatal respiratory distress (OR: 12.38, 3.52-43.61; p≤0.001). An LMVR >2.0 predicted worse perinatal outcome with 83% sensitivity and 99% specificity (AUC=0.94; p<0.001). CONCLUSION Fetal MRI volumetric measurements of lung masses and residual normal lung are predictive of perinatal outcomes in fetuses with CLM. These data may assist in perinatal risk stratification, counseling, and resource utilization.
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Affiliation(s)
- Irving J Zamora
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Fariha Sheikh
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Christopher I Cassady
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Rodrigo Ruano
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Stephen E Welty
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Cecilia G Ethun
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Michael E Kim
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.
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Chatterjee D, Hawkins JL, Somme S, Galan HL, Prager JD, Crombleholme TM. Ex utero intrapartum treatment to resection of a bronchogenic cyst causing airway compression. Fetal Diagn Ther 2013; 35:137-40. [PMID: 24281263 DOI: 10.1159/000355661] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/16/2013] [Indexed: 11/19/2022]
Abstract
We present a case report of a 28-year-old primigravida with a singleton pregnancy complicated by a fetal bronchogenic cyst compressing the left mainstem bronchus with resultant hyperinflation of the entire left lung and rightward mediastinal shift. An ex utero intrapartum treatment to resection of the fetal bronchogenic cyst via a fetal thoracotomy was performed at 36 weeks' gestational age, circumventing a potentially complicated neonatal airway emergency at birth.
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Affiliation(s)
- Debnath Chatterjee
- Department of Anesthesiology, Colorado Institute for Maternal and Fetal Health, University of Colorado School of Medicine, Aurora, Colo., USA
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Zamora IJ, Ethun CG, Evans LM, Olutoye OO, Ivey RT, Haeri S, Belfort MA, Lee TC, Cass DL. Maternal morbidity and reproductive outcomes related to fetal surgery. J Pediatr Surg 2013; 48:951-5. [PMID: 23701766 DOI: 10.1016/j.jpedsurg.2013.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this manuscript was to examine the maternal morbidity and reproductive outcomes following maternal-fetal surgery with an emphasis on the EXIT procedure. METHODS The medical records of all women who underwent an ex-utero intrapartum treatment (EXIT) procedure or mid-gestation open maternal fetal surgery (OMFS) at our center from December 2001 to December 2011 were reviewed retrospectively. Future reproductive outcomes were obtained via telephone questionnaire. RESULTS Thirty-three women underwent maternal-fetal surgery. Twenty-six had EXIT, and seven had OMFS. The questionnaire response was 82% (27/33). Eighty-one percent (17/21) of the EXIT cohort desired future pregnancy. All who attempted (13/13) were successful. The majority (85%) conceived spontaneously and within 2.5 years on average. In the OMFS group, 40% experienced complications. One had uterine dehiscence, and another had uterine rupture requiring urgent delivery at 36 weeks. In subsequent pregnancies, 20% of OMFS cases were complicated by uterine rupture, and 8% of EXIT patients had uterine dehiscence. All had good maternal-fetal outcome. CONCLUSION Future reproductive capacity and complication rates in subsequent pregnancies following EXIT procedure are similar to those seen in the general population. In contrast, mid-gestation OMFS remains associated with relatively morbid complications. This evidence can help guide in counseling expectant mothers who are faced with the challenge of considering fetal surgery.
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Affiliation(s)
- Irving J Zamora
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
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47
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Abstract
The Ex Utero Intrapartum Therapy (EXIT) procedure was initially developed to secure the airway in fetuses at delivery after they had undergone in utero tracheal occlusion for congenital diaphragmatic hernia. Indications for the EXIT procedure have been expanded to include any delivery in which prenatal diagnosis is concerned for neonatal airway compromise, such as large neck masses and Congenital High Airway Obstruction Syndrome, or when a difficult resuscitation is anticipated such as with large lung lesions. Uteroplacental blood flow and gas exchange are maintained through the use of inhalational anesthetics to allow optimal uterine relaxation with partial delivery of the fetus and amnioinfusion to sustain uterine distension. Using the EXIT procedure, sufficient time is provided on placental bypass to perform life-saving procedures such as bronchoscopy, laryngoscopy, endotracheal intubation, tracheostomy, cannulation for extracorporeal membrane oxygenation, and resection of lung masses or resection of neck masses in a controlled setting, thus avoiding a potential catastrophe.
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Affiliation(s)
- Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA.
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48
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Abstract
Prenatal diagnosis provides insight into the in utero evolution of fetal thoracic lesions such as congenital cystic adenomatoid malformation (CCAM), bronchopulmonary sequestration (BPS), or hybrid lesions. Serial sonographic study of fetuses with thoracic lesions has helped define the natural history of these lesions, determine the pathophysiologic features that affect clinical outcome, and formulate in utero and postnatal management based on prognosis.
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Affiliation(s)
- Nahla Khalek
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Fetal lung lesions: can we start to breathe easier? Am J Obstet Gynecol 2013; 208:151.e1-7. [PMID: 23159697 DOI: 10.1016/j.ajog.2012.11.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/28/2012] [Accepted: 11/13/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth. STUDY DESIGN We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes. RESULTS Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth (P < .01). Based on a maximum CVR >1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively. CONCLUSION Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.
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Abstract
Fetal surgery pushes the limits of knowledge and therapy beyond conventional paradigms by treating the developing fetus as a patient. Providing anesthesia for fetal surgery is challenging for many reasons. It requires integration of both obstetric and pediatric anesthesia practice. Two patients must be anesthetized for the benefit of one, and there is little margin for error. Many disciplines are involved, and communication must be effective among all of them. Conducting anesthetic research with vulnerable populations, such as the pregnant woman carrying a fetus with a birth defect is difficult, and many questions remain to be answered. Work is needed to study possible neurotoxicity caused by exposure of the developing brain to anesthetic agents. The effects of stress on the developing fetus also must be further delineated. Anesthetic techniques vary by institution, and prospective studies to determine optimal anesthetic regimens are warranted.
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Affiliation(s)
- Elaina E Lin
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, and Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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