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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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2
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The Rearing of Maternal-Fetal Surgery: The Maturation of a Field from Conception to Adulthood. Clin Perinatol 2022; 49:799-810. [PMID: 36328599 DOI: 10.1016/j.clp.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Maternal-fetal surgery is fraught with inherent controversy from within the medical community and general public. Despite these challenges, the field of maternal-fetal surgery evolved into an international enterprise. Carefully nurtured by pioneers with foresight and resilience, the field navigated ethical dilemmas with rigorous scientific methodology, collaboration, transparency, and accordance. These central pillars are consistent throughout the brief but momentous history of maternal-fetal surgery, serving as the catalyst for its success. The maturation of fetal intervention is an exemplar of technological innovation propelling clinical innovation, as well as a celebration of mastering the delicate balance between caution and optimism.
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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Perrone EE, Deprest JA. Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: a narrative review of the history, current practice, and future directions. Transl Pediatr 2021; 10:1448-1460. [PMID: 34189104 PMCID: PMC8192998 DOI: 10.21037/tp-20-130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Fetal intervention for fetuses with congenital diaphragmatic hernia (CDH) has been investigated for over 30 years and is summarized in this manuscript. The review begins with a discussion of the history of fetal intervention for this severe congenital anomaly beginning with open fetal surgery with repair of the anatomical defect, shifting towards tracheal occlusion via open surgery techniques, and finally fetoscopic endoluminal balloon tracheal occlusion using a percutaneous approach. The current technique of fetal endoscopic tracheal occlusion (FETO) is described in detail with steps of the procedure and complementary figures. The main outcomes of single-institutional studies and multiple systematic reviews are examined and discussed. Despite these studies, the fetal community agrees that FETO remains investigational at this time as there is insufficient evidence to recommend it as the standard of care for CDH. A randomized controlled trial, The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial, has been designed to attempt to answer this question in an elaborate, international, multi-institutional study and is described in the text. Finally, future directions of fetal intervention for antenatally diagnosed CDH are discussed, including options for non-isolated CDH, the Smart-TO balloon for nonoperative reversal of occlusion, and transplacental sildenafil for treatment of pulmonary hypertension prior to birth.
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Affiliation(s)
- Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Jan A Deprest
- Clinical Department of Obstetrics and Gynecology, Academic Department of Development and Regeneration, Woman and Child, Leuven, Belgium.,Institute of Women's Health, University College London, London, UK
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Basurto D, Sananès N, Bleeser T, Valenzuela I, De Leon N, Joyeux L, Verbeken E, Vergote S, Van Der Veeken L, Russo FM, Deprest J. Safety and efficacy of smart tracheal occlusion device in diaphragmatic hernia lamb model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:105-112. [PMID: 33012007 PMCID: PMC7613565 DOI: 10.1002/uog.23135] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH). METHODS DH was created in fetal lambs on gestational day 70 (term, 145 days). Fetuses were allocated to either pregnancy continuation until term (DH group) or fetoscopic endoluminal tracheal occlusion (TO), performed using the Smart-TO balloon on gestational day 97 (DH + TO group). On gestational day 116, the presence of the balloon was confirmed on ultrasound, then the ewe was walked around a 3.0-Tesla magnetic resonance scanner for balloon deflation, which was confirmed by ultrasound immediately afterwards. At term, euthanasia was performed and the fetus retrieved. Efficacy of occlusion was assessed by the lung-to-body-weight ratio (LBWR) and lung morphometry. Safety parameters included tracheal side effects assessed by morphometry and balloon location after deflation. The unoccluded DH lambs served as a comparator. RESULTS Six fetuses were included in the DH group and seven in the DH + TO group. All balloons deflated successfully and were expelled spontaneously from the airways. In the DH + TO group, in comparison to controls, the LBWR at birth was significantly higher (1.90 (interquartile range (IQR), 1.43-2.55) vs 1.07 (IQR, 0.93-1.46); P = 0.005), while on lung morphometry, the alveolar size was significantly increased (mean linear intercept, 47.5 (IQR, 45.6-48.1) vs 41.9 (IQR, 38.8-46.1) μm; P = 0.03); whereas airway complexity was lower (mean terminal bronchiolar density, 1.56 (IQR, 1.0-1.81) vs 2.23 (IQR, 2.14-2.40) br/mm2 ; P = 0.005). Tracheal changes on histology were minimal in both groups, but more noticeable in fetal lambs that underwent TO than in unoccluded lambs (tracheal score, 2 (IQR, 1-3) vs 0 (0-1); P = 0.03). CONCLUSIONS In fetal lambs with DH, TO using the Smart-TO balloon is effective and safe. Occlusion can be reversed non-invasively and the deflated intact balloon expelled spontaneously from the fetal upper airways. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D. Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. Sananès
- INSERM 1121 Biomaterials and Bioengineering, Strasbourg University, Strasbourg, France
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - T. Bleeser
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I. Valenzuela
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. De Leon
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L. Joyeux
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E. Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - S. Vergote
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - L. Van Der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - F. M. Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J. Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women’s Health, University College London, London, UK
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6
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Basurto D, Sananès N, Verbeken E, Sharma D, Corno E, Valenzuela I, Van der Veeken L, Favre R, Russo FM, Deprest J. New device permitting non-invasive reversal of fetal endoscopic tracheal occlusion: ex-vivo and in-vivo study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:522-531. [PMID: 32602968 DOI: 10.1002/uog.22132] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/05/2020] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE One of the drawbacks of fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to re-establish airway patency. The 'Smart-TO' device is a new balloon for FETO that deflates spontaneously when placed in a strong magnetic field, therefore overcoming the need for a second procedure. The safety and efficacy of this device have not yet been demonstrated. The aim of this study was to investigate the reversibility, local side effects and occlusiveness of the Smart-TO balloon, both in a simulated in-utero environment and in the fetal lamb model. METHODS First, the reversibility of tracheal occlusion by the Smart-TO balloon was tested in a high-fidelity simulator. Following videoscopic tracheoscopic balloon insertion, the fetal mannequin was placed within a 1-L water-filled balloon to mimic the amniotic cavity. This was held by an operator in front of their abdomen, and different fetal and maternal positions were simulated to mimic the most common clinical scenarios. Following exposure to the magnetic field generated by a 1.5-T magnetic resonance (MR) machine, deflation of the Smart-TO balloon was assessed by tracheoscopy. In cases of failed deflation, the mannequin was reinserted into a water-filled balloon for additional MR exposure, up to a maximum of three times. Secondly, reversibility, occlusiveness and local effects of the Smart-TO balloon were tested in vivo in fetal lambs. Tracheal occlusion was performed in fetal lambs on gestational day 95 (term, 145 days), either using the balloon currently used in clinical practice (Goldbal2) (n = 5) or the Smart-TO balloon (n = 5). On gestational day 116, the presence of the balloon was assessed by tracheoscopy. Deflation was performed by puncture (Goldbal2) or MR exposure (Smart-TO). Six unoccluded fetal lambs served as controls. Following euthanasia, the lung-to-body-weight ratio (LBWR), lung morphometry and tracheal circumference were assessed. Local tracheal changes were measured using a hierarchical histologic scoring system. RESULTS Ex vivo, Smart-TO balloon deflation occurred after a single MR exposure in 100% of cases in a maternal standing position with the mannequin at a height of 95 cm (n = 32), 55 cm (n = 8) or 125 cm (n = 8), as well as when the maternal position was 'lying on a stretcher' (n = 8). Three out of eight (37.5%) balloons failed to deflate at first exposure when the maternal position was 'sitting in a wheelchair'. Of these, two balloons deflated after a second MR exposure, but one balloon remained inflated after a third exposure. In vivo, all Smart-TO balloons deflated successfully. The LBWR in fetal lambs with tracheal occlusion by a Smart-TO balloon was significantly higher than that in unoccluded controls, and was comparable with that in the Goldbal2 group. There were no differences in lung morphometry and tracheal circumference between the two balloon types. Tracheal histology showed minimal changes for both balloons. CONCLUSIONS In a simulated in-utero environment, the Smart-TO balloon was effectively deflated by exposure of the fetus in different positions to the magnetic field of a 1.5-T MR system. There was only one failure, which occurred when the mother was sitting in a wheelchair. In healthy fetal lambs, the Smart-TO balloon is as occlusive as the clinical standard Goldbal2 system and has only limited local side effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Basurto
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N Sananès
- INSERM 1121 'Biomaterials and Bioengineering', Strasbourg University, Strasbourg, France
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - E Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - D Sharma
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Corno
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I Valenzuela
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - R Favre
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - F M Russo
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J Deprest
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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7
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Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia. Ann Surg 2020; 275:e586-e595. [PMID: 33055583 DOI: 10.1097/sla.0000000000003943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effect of combining antenatal sildenafil with fetal tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). BACKGROUND Although antenatal sildenafil administration rescues vascular abnormalities in lungs of fetal rabbits with CDH, it only partially improves airway morphometry. We hypothesized that we could additionally stimulate lung growth by combining this medical treatment with fetal TO. METHODS CDH was created on gestational day (GD)23 (n=54). Does were randomized to receive either sildenafil 10 mg/kg/d or placebo by subcutaneous injection from GD24 to GD30. On GD28, fetuses were randomly assigned to TO or sham neck dissection. At term (GD30) fetuses were delivered, ventilated, and finally harvested for histological and molecular analyses. Unoperated littermates served as controls. RESULTS The lung-to-body-weight ratio was significantly reduced in sham-CDH fetuses either (1.2 ± 0.3% vs 2.3 ± 0.3% in controls, P=0.0003). Sildenafil had no effect on this parameter, while CDH fetuses undergoing TO had a lung-to-body-weight ratio comparable to that of controls (2.5 ± 0.8%, P<0.0001). Sildenafil alone induced an improvement in the mean terminal bronchiolar density (2.5 ± 0.8 br/mm vs 3.5 ± 0.9 br/mm, P=0.043) and lung mechanics (static elastance 61 ± 36 cmH2O /mL vs 113 ± 40 cmH2O/mL, P=0.008), but both effects were more pronounced in fetuses undergoing additional TO (2.1 ± 0.8 br/mm, P=0.001 and 31 ± 9 cmH2O/mL, P<0.0001 respectively). Both CDH-sham and CDH-TO fetuses treated with placebo had an increased medial wall thickness of peripheral pulmonary vessels (41.9 ± 2.9% and 41.8 ± 3.2%, vs 24.0 ± 2.9% in controls, P<0.0001). CDH fetuses treated with sildenafil, either with or without TO, had a medial thickness in the normal range (29.4% ± 2.6%). Finally, TO reduced gene expression of vascular endothelial growth factor and surfactant protein A and B, but this effect was counteracted by sildenafil. CONCLUSION In the rabbit model for CDH, the combination of maternal sildenafil and TO has a complementary effect on vascular and parenchymal lung development.
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Braga ADFDA, da Silva Braga FS, Nascimento SP, Verri B, Peralta FC, Bennini Junior J, Jorge K. [Fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: retrospective study]. Rev Bras Anestesiol 2016; 67:331-336. [PMID: 27157206 DOI: 10.1016/j.bjan.2015.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/29/2015] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The temporary fetal tracheal occlusion performed by fetoscopy accelerates lung development and reduces neonatal mortality. The aim of this paper is to present an anesthetic experience in pregnant women, whose fetuses have diaphragmatic hernia, undergoing fetoscopic tracheal occlusion (FETO). METHOD Retrospective, descriptive study, approved by the Institutional Ethics Committee. Data were obtained from medical and anesthetic records. RESULTS FETO was performed in 28 pregnant women. Demographic characteristics: age 29.8±6.5; weight 68.64±12.26; ASA I and II. Obstetric: IG 26.1±1.10 weeks (in FETO); 32.86±1.58 (reversal of occlusion); 34.96±2.78 (delivery). Delivery: cesarean section, vaginal delivery. Fetal data: Weight (g) in the occlusion and delivery times, respectively (1045.82±222.2 and 2294±553); RPC in FETO and reversal of occlusion: 0.7±0.15 and 1.32±0.34, respectively. Preoperative maternal anesthesia included ranitidine and metoclopramide, nifedipine (VO) and indomethacin (rectal). Preanesthetic medication with midazolam IV. Anesthetic techniques: combination of 0.5% hyperbaric bupivacaine (5-10mg) and sufentanil; continuous epidural predominantly with 0.5% bupivacaine associated with sufentanil, fentanyl, or morphine; general. In 8 cases, there was need to complement via catheter, with 5 submitted to PC and 3 to BC. Thirteen patients required intraoperative sedation; ephedrine was used in 15 patients. Fetal Anesthesia: fentanyl 10 to 20mg·kg-1 and pancuronium 0,1-0,2mg·kg-1 (IM). Neonatal survival rate was 60.7%. CONCLUSION FETO is a minimally invasive technique for severe congenital diaphragmatic hernia repair. Combined blockade associated with sedation and fetal anesthesia proved safe and effective for tracheal occlusion.
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Affiliation(s)
| | - Franklin Sarmento da Silva Braga
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brasil
| | | | - Bruno Verri
- Hospital Vivalle, São José dos Campos, SP, Brasil
| | - Fabio C Peralta
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
| | - João Bennini Junior
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
| | - Karina Jorge
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
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Carlon MS, Engels AC, Bosch B, Joyeux L, Mori da Cunha MGMC, Vidović D, Debyser Z, De Boeck K, Neyrinck A, Deprest JA. A novel translational model for fetoscopic intratracheal delivery of nanoparticles in piglets. Prenat Diagn 2016; 36:926-934. [DOI: 10.1002/pd.4915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Marianne S. Carlon
- Molecular Virology and Gene Therapy, Department of Pharmaceutical and Pharmacological Sciences; KU Leuven; Leuven Belgium
| | - Alexander C. Engels
- Department of Development and Regeneration, Organ System Cluster; KU Leuven; Leuven Belgium
- Clinical Department of Obstetrics and Gynecology, Division Woman and Child; University Hospitals Leuven; Leuven Belgium
| | - Barbara Bosch
- Department of Development and Regeneration, Organ System Cluster; KU Leuven; Leuven Belgium
- Department of Pediatric Pulmonology; University Hospitals Leuven; Leuven Belgium
| | - Luc Joyeux
- Department of Development and Regeneration, Organ System Cluster; KU Leuven; Leuven Belgium
| | | | - Dragana Vidović
- Molecular Virology and Gene Therapy, Department of Pharmaceutical and Pharmacological Sciences; KU Leuven; Leuven Belgium
| | - Zeger Debyser
- Molecular Virology and Gene Therapy, Department of Pharmaceutical and Pharmacological Sciences; KU Leuven; Leuven Belgium
| | - Kris De Boeck
- Department of Pediatric Pulmonology; University Hospitals Leuven; Leuven Belgium
| | - Arne Neyrinck
- Laboratory of Anesthesiology and Algology, Department of Cardiovascular Sciences; KU Leuven; Leuven Belgium
| | - Jan A. Deprest
- Department of Development and Regeneration, Organ System Cluster; KU Leuven; Leuven Belgium
- Clinical Department of Obstetrics and Gynecology, Division Woman and Child; University Hospitals Leuven; Leuven Belgium
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10
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Gregoir C, Engels AC, Gomez O, DeKoninck P, Lewi L, Gratacos E, Deprest JA. Fertility, pregnancy and gynecological outcomes after fetoscopic surgery for congenital diaphragmatic hernia. Hum Reprod 2016; 31:2024-30. [PMID: 27378767 DOI: 10.1093/humrep/dew160] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 06/01/2016] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the impact of fetoscopic surgery for isolated Congenital Diaphragmatic Hernia (CDH) on future reproductive and gynecological outcomes? SUMMARY ANSWER We did not observe an increase of obstetric or gynecological problems after fetoscopic surgery nor was there an increased risk for subsequent infertility. WHAT IS KNOWN ALREADY The reproductive and gynecological outcomes of patients undergoing open maternal-fetal surgery are known. The most relevant counseling items are the elevated risk for uterine dehiscence and rupture (up to 14%). STUDY DESIGN, SIZE, DURATION Bi-centric study over a 10-year period including 371 women carrying a fetus with isolated CDH either managed expectantly (n = 167) or operated in utero (n = 204). PARTICIPANTS/MATERIALS, SETTING, METHODS Consenting patients filled out a survey with 23 questions (2 open and 21 multiple choice). Questionnaires were custom designed to obtain information on subsequent reproductive or gynecological problems as well as psychological impact. MAIN RESULTS AND THE ROLE OF CHANCE The response rate was 40% (147/371). More women in the FETO group attempted a subsequent pregnancy: 70% (62/89) when compared with 47% (27/58) in controls (P = 0.009). This coincided with a longer follow-up in the FETO group (76 versus 59 months; P < 0.001) and a lower survival rate in the index pregnancy (53 versus 72%; P = 0.028). There was no difference in the number of nulliparous or parous women, neither in the conception rate. In total, there were 129 subsequent pregnancies. Nobody reported secondary fertility problems. Four women in the FETO group and one in the control reported a congenital anomaly in a subsequent pregnancy. Twenty-one pregnancies were reported with at least one complication (FETO: 23% (14/60), controls 27% (7/26)). During delivery or in the post-partum period 11 patients reported at least 1 complication (FETO 17% (10/59), controls 4% (1/24)). New onset gynecological problems occurred in 14 participants (10%). None of these events were more likely in one or the other group. Psychological and emotional impacts were frequent in both the FETO (41%) and the control groups (46%) (P = 0.691). LIMITATIONS, REASONS FOR CAUTION The response rate was 40% (147/371), less than desired. The use of unvalidated self-reported outcomes may skew exact determination of the nature and severity of medical complications. The number of observations for uncommon events was low. The mean follow-up period to detect gynecological complications may be too short. WIDER IMPLICATIONS OF THE FINDINGS This is the first evidence that fetoscopic surgery for CDH does not compromise future reproductive potential or obstetrical outcome when compared with expectant management. A pregnancy complicated by a serious congenital birth defect, such as CDH, frequently has a measurable psychological impact. STUDY FUNDING/COMPETING INTEREST The authors have no conflicts to declare. J.D. receives a fundamental clinical research grant of the Fonds Wetenschappelijk Onderzoek - Vlaanderen (FWO; 18.01207). A.C.E. is supported by the Erasmus+Program of the European Union (Framework agreement number 2013-0040; contract 1011990). This was presented at the 61st meeting of the Society of Gynaecologic Investigation, in Florence, March 2014 (F-111).
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Affiliation(s)
- C Gregoir
- Department of Obstetrics and Gynecology, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - A C Engels
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - O Gomez
- Maternal-Fetal Medicine Department, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia (ICGON), Hospital Clínic, Institut d'Investigacions Biomèdiques Augusto Pi i Sunyer (IDIBAPS), University of Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, Spain
| | - P DeKoninck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, B-3000 Leuven, Belgium Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, B-3000 Leuven, Belgium Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - E Gratacos
- Maternal-Fetal Medicine Department, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia (ICGON), Hospital Clínic, Institut d'Investigacions Biomèdiques Augusto Pi i Sunyer (IDIBAPS), University of Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, Spain
| | - J A Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, B-3000 Leuven, Belgium Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, KU Leuven, Leuven, Belgium Research Department of Maternal Fetal Medicine, University College London, Institute of Women's Health, London, UK
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DeKoninck P, Endo M, Deprest JA, De Catte L. Experimental Evaluation of Tracheo-Amniotic Shunting for Induced Congenital High Airway Obstruction in a Sheep Model. Fetal Diagn Ther 2015; 38:282-7. [DOI: 10.1159/000381145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objective: To evaluate the feasibility of tracheo-amniotic shunting in a sheep model for congenital high airway obstruction syndrome. Material and Methods: High airway obstruction was induced around day 95 (term = 145 days) in 10 lamb fetuses by tracheal clipping. Five days later, ultrasound-guided tracheoamniotic shunting was done using either the Harrison double-pigtail bladder stent (HS) or a double-basket device (BS). Caesarean section (CS) was done around day 110. At each time point, the cardiothoracic index (CTI) was measured. Lung-to-body weight ratio (LBWR) was calculated at fetal necropsy. The primary endpoint was successful shunting defined as anatomically correct placement and functional airway decompression; the secondary endpoint was survival until CS. Results: Two sheep aborted 3 fetuses after tracheal occlusion. Overall, the median CTI at CS was significantly smaller compared to baseline [0.52 (interquartile range, IQR: 0.52-0.54) vs. 0.58 (IQR: 0.54-0.63); p = 0.01]. In the HS group (n = 4), none of the shunts were correctly positioned. In the BS group (n = 3), there was 1 correct shunt placement; however, this fetus was stillborn. Median LBWR suggested pulmonary overgrowth [0.10 (IQR: 0.08-0.11)]. Conclusion: In our hands, using this model with a long and mobile neck and relative oligohydramnios, tracheoamniotic shunting for airway obstruction has a high failure rate. If further pursued, alternative techniques or different models should be considered.
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Deprest J, Brady P, Nicolaides K, Benachi A, Berg C, Vermeesch J, Gardener G, Gratacos E. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med 2014; 19:338-48. [PMID: 25447987 DOI: 10.1016/j.siny.2014.09.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, and Academic Department of Development and Regeneration, Organ System Cluster, Leuven, Belgium; TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial).
| | - Paul Brady
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Kypros Nicolaides
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Harris Birthright Centre, King's College Hospital, London, UK
| | - Alexandra Benachi
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine Beclere, University Paris Sud, Clamart, France
| | - Christoph Berg
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, and Department of Obstetrics and Gynecology, University of Cologne, Germany
| | - Joris Vermeesch
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Glenn Gardener
- Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Eduard Gratacos
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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13
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Windrim R, Ryan G, LeBouthillier F, Campisi P, Kelly EN, Baud D, Yoo SJ, Deprest J. Development and use of a high-fidelity simulator for fetal endotracheal balloon occlusion (FETO) insertion and removal. Prenat Diagn 2013; 34:180-4. [DOI: 10.1002/pd.4284] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 10/30/2013] [Accepted: 11/18/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Rory Windrim
- Fetal Medicine Unit; Mount Sinai Hospital; Toronto Canada
- University of Toronto; Ontario Canada
| | - Greg Ryan
- Fetal Medicine Unit; Mount Sinai Hospital; Toronto Canada
- University of Toronto; Ontario Canada
| | | | - Paolo Campisi
- University of Toronto; Ontario Canada
- Department of Otolaryngology - Head and Neck Surgery; Hospital for Sick Children; Toronto Canada
| | - Edmond N. Kelly
- University of Toronto; Ontario Canada
- Department of Neonatology; Mount Sinai Hospital; Toronto Canada
| | - David Baud
- Fetal Medicine Unit; Mount Sinai Hospital; Toronto Canada
- University of Toronto; Ontario Canada
| | - Shi-Joon Yoo
- University of Toronto; Ontario Canada
- Department of Diagnostic Imaging; Hospital for Sick Children; Toronto Canada
| | - Jan Deprest
- Fetal Medicine Unit of the Department of Obstetrics and Gynaecology; University Hospital Gasthuisberg; Leuven Belgium
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- Perelman School of Medicine at the University of Pennsylvania, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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15
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Quintero RA, Kontopoulos EV, Quintero LF, Landy DC, Gonzalez R, Chmait RH. The observed vs. expected lung-to-head ratio does not correct for the effect of gestational age on the lung-to-head ratio. J Matern Fetal Neonatal Med 2012; 26:552-7. [DOI: 10.3109/14767058.2012.736000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Shue EH, Harrison M, Hirose S. Maternal-fetal surgery: history and general considerations. Clin Perinatol 2012; 39:269-78. [PMID: 22682378 DOI: 10.1016/j.clp.2012.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reviews fetal intervention for congenital anomalies, which has evolved from a mere concept to a medical specialty over the past 3 decades. Advances in surgical techniques have paralleled developments in fetal imaging, fetal diagnosis, and the advent of maternal tocolysis to prevent preterm labor. Fetal intervention has become an important option for fetuses who would otherwise not survive gestation or who would endure significant morbidity and mortality after birth. However, there were many trials and tribulations as fetal surgery developed into a medical specialty.
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Affiliation(s)
- Eveline H Shue
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, 513 Parnassus Avenue, HSW-1601, San Francisco, CA 94143-0570, USA
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Shue EH, Miniati D, Lee H. Advances in prenatal diagnosis and treatment of congenital diaphragmatic hernia. Clin Perinatol 2012; 39:289-300. [PMID: 22682380 DOI: 10.1016/j.clp.2012.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a common birth anomaly. Absence or presence of liver herniation and determination of lung-to-head ratio are the most accurate predictors of prognosis for fetuses with CDH. Though open fetal CDH repair has been abandoned, fetal endoscopic balloon tracheal occlusion promotes lung growth in fetuses with severe CDH. Although significant improvements in lung function have not yet been shown in humans, reversible or dynamic tracheal occlusion is promising for select fetuses with severe CDH. This article reviews advances in prenatal diagnosis of CDH, the experimental basis for tracheal occlusion, and its translation into human clinical trials.
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Affiliation(s)
- Eveline H Shue
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center University of California, San Francisco, 513 Parnassus Avenue, HSW-1601, San Francisco, CA 94143-0570, USA
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18
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Quintero RA, Quintero LF, Chmait R, Gómez Castro L, Korst LM, Fridman M, Kontopoulos EV. The quantitative lung index (QLI): a gestational age-independent sonographic predictor of fetal lung growth. Am J Obstet Gynecol 2011; 205:544.e1-8. [PMID: 21944224 DOI: 10.1016/j.ajog.2011.07.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 07/08/2011] [Accepted: 07/16/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We sought to develop a gestational age-independent sonographic parameter to characterize lung growth. STUDY DESIGN Reported descriptors of lung growth, including lung-to-head circumference (HC) ratio (LHR) and observed/expected LHR, were examined. A new index, the quantitative lung index (QLI) was derived using published data on HC and the area of the base of the right lung. RESULTS Neither the LHR nor the observed/expected LHR proved to be gestational age independent. Right lung growth can be expressed using the following formula: QLI = lung area/(HC/10)^2. The 50th percentile of the QLI remained constant at approximately 1.0 for the gestational age between 16-32 weeks. A small lung (<1st percentile) was defined as a QLI <0.6. CONCLUSION Fetal right lung growth can be adequately described using the QLI, independent of gestational age. Further studies are needed to assess the clinical accuracy of the QLI in characterizing fetal right lung growth.
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Jani J, Valencia C, Cannie M, Vuckovic A, Sellars M, Nicolaides K. Tracheal diameter at birth in severe congenital diaphragmatic hernia treated by fetal endoscopic tracheal occlusion. Prenat Diagn 2011; 31:699-704. [DOI: 10.1002/pd.2806] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 05/16/2011] [Accepted: 05/16/2011] [Indexed: 11/11/2022]
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20
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Luks FI. New and/or improved aspects of fetal surgery. Prenat Diagn 2011; 31:252-8. [PMID: 21294135 DOI: 10.1002/pd.2706] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 12/10/2010] [Accepted: 12/20/2010] [Indexed: 11/11/2022]
Abstract
Open fetal surgery through a wide hysterotomy is no longer a real option for prenatal intervention, but a minimally invasive approach has emerged as treatment for a small number of indications. Endoscopic ablation of placental vessels is the preferred treatment for severe twin-to-twin transfusion syndrome and it may be the only chance to salvage the most severe forms of congenital diaphragmatic hernia. Several other indications are currently under review and may become justified in the future, provided that diagnostic accuracy and patient selection become more accurate. Before invasive fetal intervention becomes widely accepted, however, we need to better define outcome. It is no longer acceptable to express results in terms of survival at birth. Survival at discharge and long-term morbidity must be considered as well.
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Affiliation(s)
- François I Luks
- Division of Pediatric Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Deprest J, Nicolaides K, Done' E, Lewi P, Barki G, Largen E, DeKoninck P, Sandaite I, Ville Y, Benachi A, Jani J, Amat-Roldan I, Gratacos E. Technical aspects of fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia. J Pediatr Surg 2011; 46:22-32. [PMID: 21238635 DOI: 10.1016/j.jpedsurg.2010.10.008] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
In isolated congenital diaphragmatic hernia, prenatal prediction is made based on measurements of lung size and the presence of liver herniation into the thorax. A subset of fetuses likely to die in the postnatal period is eligible for fetal intervention that can promote lung growth. Rather than anatomical repair, this is now attempted by temporary fetal endoscopic tracheal occlusion (FETO). Herein we describe purpose-designed instruments that were developed thanks to a grant from the European Commission. The feasibility and safety of FETO have now been demonstrated in several active fetal surgery programs. The most frequent complication of the procedure is preterm premature rupture of the membranes, which is probably iatrogenic in nature. It does have an impact on gestational age at delivery and complicates balloon removal. FETO is associated with an apparent increase in survival compared with same severity controls, although this needs to be evaluated in a formal trial. The time has come to do so.
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Affiliation(s)
- Jan Deprest
- Division of Woman and Child, University Hospital Leuven, Leuven, Belgium.
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Deprest JA, Flake AW, Gratacos E, Ville Y, Hecher K, Nicolaides K, Johnson MP, Luks FI, Adzick NS, Harrison MR. The making of fetal surgery. Prenat Diagn 2010; 30:653-67. [PMID: 20572114 DOI: 10.1002/pd.2571] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospitals KU Leuven, Leuven, Belgium.
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly consisting of a posterolateral defect in the diaphragm also known as a Bochdalek hernia. It occurs in 1 in 2000 to 3000 newborns and is associated with a variable degree of pulmonary hypoplasia (PH) and persistent pulmonary hypertension (PPH). Despite remarkable advances in neonatal resuscitation and intensive care and the new postnatal treatment strategies, many newborns with CDH continue to have high rates of mortality and morbidity as the result of severe respiratory failure secondary to PH and PPH. The pathogenesis of CDH and associated PH and PPH is poorly understood. Herein, we aim to review diaphragm and pulmonary development and correlate this to the abnormalities found in CDH.
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Affiliation(s)
- Richard Keijzer
- Department of Pediatric Surgery, Erasmusmc-Sophia, Rotterdam, The Netherlands
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25
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Indications and outcomes of intrauterine surgery for fetal malformations. Curr Opin Obstet Gynecol 2010; 22:159-65. [DOI: 10.1097/gco.0b013e3283374ab5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hedrick HL. Management of prenatally diagnosed congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2010; 15:21-7. [PMID: 19884051 DOI: 10.1016/j.siny.2009.07.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. The most important prenatal predictor of outcome in left-sided CDH is liver position. More precise and reproducible prenatal predictive parameters need to be developed to allow standardization of results between centers and appropriate design of clinical trials in CDH. Thus far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with balloon tracheal occlusion (and release) are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow-up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- University of Pennsylvania, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Deprest JA, Flemmer AW, Gratacos E, Nicolaides K. Antenatal prediction of lung volume and in-utero treatment by fetal endoscopic tracheal occlusion in severe isolated congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2009; 14:8-13. [PMID: 18845492 DOI: 10.1016/j.siny.2008.08.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe malformation with an overall survival between 30% and 90%. Survival in the presence of associated malformations is very low. The condition should be detected in ultrasound screening programmes, but whether and how prenatal imaging can accurately predict outcome remains a matter of debate. Predictions based on the lung area:head circumference ratio and liver position are best studied. This information is highly relevant in counselling patients, leaving to severe cases the option of termination of pregnancy as experimental prenatal intervention aiming to reverse pulmonary hypoplasia. The purpose of this review is to update current knowledge regarding predictive value of prenatal assessment in terms of neonatal survival. We will also discuss experimental evidence and clinical data regarding fetal tracheal occlusion.
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Affiliation(s)
- Jan A Deprest
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Minderbroedersstraat 17, B-3000 Leuven, Belgium
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Doné E, Gucciardo L, Van Mieghem T, Jani J, Cannie M, Van Schoubroeck D, Devlieger R, Catte LD, Klaritsch P, Mayer S, Beck V, Debeer A, Gratacos E, Nicolaides K, Deprest J. Prenatal diagnosis, prediction of outcome and in utero therapy of isolated congenital diaphragmatic hernia. Prenat Diagn 2008; 28:581-91. [PMID: 18634116 DOI: 10.1002/pd.2033] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be associated with genetic or structural anomalies with poor prognosis. In isolated cases, survival is dependent on the degree of lung hypoplasia and liver position. Cases should be referred in utero to tertiary care centers familiar with this condition both for prediction of outcome as well as timed delivery. The best validated prognostic indicator is the lung area to head circumference ratio. Ultrasound is used to measure the lung area of the index case, which is then expressed as a proportion of what is expected normally (observed/expected LHR). When O/E LHR is < 25% survival chances are < 15%. Prenatal intervention, aiming to stimulate lung growth, can be achieved by temporary fetal endoscopic tracheal occlusion (FETO). A balloon is percutaneously inserted into the trachea at 26-28 weeks, and reversal of occlusion is planned at 34 weeks. Growing experience has demonstrated the feasibility and safety of the technique with a survival rate of about 50%. The lung response to, and outcome after FETO, is dependent on pre-existing lung size as well gestational age at birth. Early data show that FETO does not increase morbidity in survivors, when compared to historical controls. Several trials are currently under design.
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Affiliation(s)
- Elisa Doné
- Fetal Medicine Unit of University Hospitals Leuven, Leuven, Belgium
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Prédiction anténatale de l’hypoplasie pulmonaire et traitement in-utero par occlusion trachéale fœtale endoscopique (FETO) dans la hernie diaphragmatique congénitale isolée sévère. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2008. [DOI: 10.1016/s0001-4079(19)32665-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Main bronchus occlusion for treatment of congenital diaphragmatic hernia in fetal lambs. J Pediatr Surg 2008; 43:620-6. [PMID: 18405706 DOI: 10.1016/j.jpedsurg.2007.09.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 09/19/2007] [Accepted: 09/19/2007] [Indexed: 11/21/2022]
Abstract
PURPOSE The present study investigates a new surgical approach in the treatment of left diaphragmatic hernia in fetal sheep. We postulated that unlike tracheal occlusion where both lungs are occluded, selective left main bronchus occlusion (LMBO) would accelerate growth of only the left lung, reduce left visceral herniation, and recover space in the both thoraces necessary for lung development. METHODS Left-sided congenital diaphragmatic hernia (CDH) was surgically created in 8 fetal lambs at approximately 65 days of gestation; in 4 of these animals, LMBO was performed at approximately 118 days. Four sham-operated animals served as controls. Lambs were delivered by hysterotomy at 137 days. We measured lung-to-body weight ratios, alveolar surface area, septal wall thickness, and AE2 cell density in the left and right lungs. RESULTS Left main bronchus occlusion increased (P < .05) left lung growth causing severe right mediastinal shift but failed to reduce herniated abdominal viscera in 3 of 4 lambs. Wet lung-to-body weight ratio in LMBO group was similar to that of the control group; however, this was achieved by overgrowth of left lung, whereas the right wet lung-to-body weight ratio remained low. In the LMBO group, right lung AE2 cell density was higher than that of control group and not different to that of the CDH group. CONCLUSIONS Left main bronchus occlusion failed to restore normal pulmonary development in CDH.
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Gucciardo L, Deprest J, Done' E, Van Mieghem T, Van de Velde M, Gratacos E, Jani J, Peralta F, Nicolaides K. Prediction of outcome in isolated congenital diaphragmatic hernia and its consequences for fetal therapy. Best Pract Res Clin Obstet Gynaecol 2008; 22:123-38. [DOI: 10.1016/j.bpobgyn.2007.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Advances in prenatal ultrasound have revealed the poor natural history of fetal congenital diaphragmatic hernia (CDH) and its hidden mortality during gestation and immediately after birth. Attempts to improve this poor outcome led to the development of prenatal surgical intervention for severe CDH by Harrison and his colleagues at the University of California San Francisco. Prenatal surgical intervention for CDH has seen four phases: open fetal surgical repair, open surgical tracheal occlusion, endoscopic external tracheal occlusion, and endoscopic endoluminal tracheal occlusion. After extensive work in the laboratory, prenatal intervention has been applied in humans since 1984. With the most recent techniques, maternal risk is significantly reduced as is the incidence of preterm labor. In the meantime, the survival rate of fetuses with CDH without fetal intervention has improved mainly due to the minimization of iatrogenic lung injury by gentle ventilation, first described in 1985. However, the morbidity of the survivors with severe CDH remains high. Prenatal intervention for CDH will be justified if improvement in survival or morbidity can be demonstrated when compared to planned delivery and postnatal management with gentle ventilation strategy.
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Affiliation(s)
- Yoshihiro Kitano
- Division of General Surgery, Saitama Children's Medical Center, Saitama, Japan.
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Hellmeyer L, Exner C, Folz B, Hiller M, Sierra F, Lukasewitz P, Steinfeld T, Werner JA, Heldmaier G, Schmidt S. Telemetric monitoring of tracheal pressure after tracheal occlusion for treatment of severe congenital diaphragmatic hernia. Arch Gynecol Obstet 2006; 275:245-8. [PMID: 17021771 DOI: 10.1007/s00404-006-0252-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Accepted: 08/29/2006] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Prenatal tracheal occlusion using endoscopic techniques obstructs the normal egress of lung fluid during pulmonary development and stimulates lung growth in cases of congenital diaphragmatic hernia (CDH). Although FETO might be an effective strategy for treatment of CDH, the mechanism especially due to the supposed increasing transpulmonary pressure is unknown. OBJECTIVE The purpose of this study was to monitor the pressure below the attached balloon in the fetal lamb telemetrically. METHODS Four time-dated pregnant Merino ewes underwent fetal and maternal surgery. A special prepared silicone catheter was placed below the epiglottis by laryngoscopy on day 110 or 140 of gestation. The tracheal pressure below the fixed catheter could be monitored telemetrically using the Data Sciences TA11-PA-C40 pressure device. Hundred and twenty measurement points were recorded over a period of 2 min. RESULTS A maximum of lung pressure rate was found immediately after implantation (23.7 +/- 4.6 mm Hg). During the first hour, the pressure decreased to an average value of 16.9 mmHg. About 70 h after the block, this value decreased to a minimum level of 8.3 +/- 0.4 mmHg. CONCLUSION Decreasing pressure variation might indicate that lung growth has stopped and that the ideal point of time to remove the balloon is achieved. Increasing pressure has to be related to the morphometric analysis of the lung's structural development and maturation, comparing the efficacy of FETO in preventing or reversing pulmonary hypoplasia. Further investigation of continuous telemetric monitoring of tracheal pressure in the fetal lamb is required.
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Affiliation(s)
- L Hellmeyer
- Department of Obstetrics and Perinatal Medicine, Philipps-University of Marburg, Baldingerstrasse, 35033 Marburg, Germany.
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Deprest J, Jani J, Cannie M, Debeer A, Vandevelde M, Done E, Gratacos E, Nicolaïdes K. Prenatal intervention for isolated congenital diaphragmatic hernia. Curr Opin Obstet Gynecol 2006; 18:355-67. [PMID: 16735838 DOI: 10.1097/01.gco.0000193000.12416.80] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We aim to review the recent literature regarding early prenatal prediction of outcome in babies diagnosed with isolated congenital diaphragmatic hernia, as well as results of fetal therapy for this condition. RECENT FINDINGS Current survival rates in population-based studies are around 55-70%. Highly specialized centers report 80% and more, but discount the hidden mortality, mainly in the antenatal period. Fetuses presenting with liver herniation and a lung-to-head ratio of less than 1.0 measured in midgestation have a poor prognosis. Other volumetric techniques are being evaluated for use in midtrimester. Recently, a randomized trial failed to show benefit from prenatal therapy, but lacked power to document the potential advantage of prenatal therapy in severe cases. We proposed percutaneous fetal endoluminal tracheal occlusion with a balloon at 26-28 weeks through a 3.3 mm incision. In severe cases, fetal endoluminal tracheal occlusion increased lung size as well as survival, with an early (7 day) survival, late neonatal (28 day) survival and survival at discharge of 75, 58 and 50%, respectively, comparing favorably with 9% in contemporary controls. Airways can be restored prior to birth improving neonatal survival (83.3% compared with 33.3%). The procedure carries a risk for preterm prelabour rupture of the fetal membranes, although that may decrease with experience. SUMMARY Fetuses with severe congenital diaphragmatic hernia can be identified in the second trimester. Fetal endoluminal tracheal occlusion can be considered as a minimally invasive fetal therapy, improving outcome in such highly selected cases.
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Affiliation(s)
- Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium.
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Ward VL, Estroff JA, Nguyen HT, Lakshmanan Y, Hayward A, Jaramillo D, Zurakowski D, Dunning PS, Peters CA, Barnewolt CE. Fetal Sheep Development on Ultrasound and Magnetic Resonance Imaging: A Standard for the in utero Assessment of Models of Congenital Abnormalities. Fetal Diagn Ther 2006; 21:444-57. [PMID: 16912495 DOI: 10.1159/000093888] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Accepted: 10/26/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To establish normative data for the size, conspicuity, and imaging characteristics of normal developing fetal sheep organs on ultrasound (US) and magnetic resonance (MR) imaging. METHODS US and MR images of ten normal pregnant sheep, at 40, 65, 90, 115, and 140 gestational days (term = 145 days), were scored for organ conspicuity and imaging characteristics. Imaging biometry was correlated with specimens. Gestational age-based growth parameters were modeled using regression. RESULTS Imaging biometry showed excellent correlation with specimens. Kidney, bladder, stomach, lung, liver, and spine were seen well from 65 days to term by US. More organs were consistently visible from 90 days to term by MR than by US. Most organ imaging characteristics tended not to change throughout gestation. CONCLUSION Normal fetal sheep biometry, organ conspicuity, and imaging characteristics are established for US and MR and have potential use for the in utero assessment of sheep models of congenital abnormalities.
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Affiliation(s)
- Valerie L Ward
- Department of Radiology, Children's Hospital, Harvard Medical School, Boston, Mass. 02115, USA.
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Jani J, Gratacós E, Greenough A, Pieró JL, Benachi A, Harrison M, Nicolaïdes K, Deprest J. Percutaneous fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia. Clin Obstet Gynecol 2006; 48:910-22. [PMID: 16286838 DOI: 10.1097/01.grf.0000184774.02793.0c] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Jani
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium
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Deprest J, Jani J, Van Schoubroeck D, Cannie M, Gallot D, Dymarkowski S, Fryns JP, Naulaers G, Gratacos E, Nicolaides K. Current consequences of prenatal diagnosis of congenital diaphragmatic hernia. J Pediatr Surg 2006; 41:423-30. [PMID: 16481263 DOI: 10.1016/j.jpedsurg.2005.11.036] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Today, the diagnosis of congenital diaphragmatic hernia (CDH) can readily be made in the prenatal period during screening ultrasound examination. Patients ought to be referred to rule out associated anomalies, and in isolated cases, prognosis is poor when the liver is intrathoracic and the lung-to-head ratio (LHR) is less than 1. In these patients, prenatal intervention aiming to reverse pulmonary hypoplasia can be considered. METHODS We present our current algorithm for counselling patients presenting with CDH. Patients with a poor prognosis are offered percutaneous fetal endoluminal tracheal occlusion (FETO) with a balloon, inserted at 26 to 28 weeks. We report on the evolution of technique and results in a consecutive homogeneous case series and compare outcome in cases with similar severity managed in the postnatal period. RESULTS Within a period of 28 months, FETO was performed between 26 and 28 weeks in 24 fetuses with severe left-sided CDH. Under general (n = 5), epidural (n = 17) or local (n = 2) anesthesia, the balloon was successfully positioned at first surgery (23/24) with a mean operation time of 20 minutes (range, 3-60 minutes). There were no serious maternal complications or direct fetal adverse effects. In the first 2 weeks after FETO, LHR increased from 0.7 to 1.7. Premature prelabour rupture of the membrane (PPROM) occurred in 16.7% and 33.3% at 28 and 32 weeks or earlier, respectively. Gestational age at delivery was 33.5 weeks. Patency of airways was restored either in the prenatal (n = 12) or perinatal period (n = 12). Early (7 days) and late (28 days) survival, and survival at discharge were 75% (18/24), 58.3% (14/24) and 50% (12/24), respectively. Half of nonsurvivors (n = 6) died of pulmonary hypoplasia and hypertension, in combination with PPROM and preterm delivery (n = 4) and balloon dislodgement (n = 2), which coincided with a short tracheal occlusion (TO) period (12 days). In the other 6, TO period was comparable to that in the 12 survivors (47 vs 42 days, respectively). In that group of 6 babies, only 2 died of pulmonary problems. Late neonatal survival (28 days) was higher with prenatal vs perinatal balloon retrieval 83.3% vs 33.3% (P = .013). In a multicentre study validating the criteria, survival till discharge in 37 comparable cases was 9% (3/32) and 13% (5/37) of parents opted for termination. CONCLUSION Fetuses with isolated left-sided CDH, liver herniation, and LHR of less than 1 have a poor prognosis. Percutaneous FETO is minimally invasive and may improve the outcome in these highly selected cases. Airways can be restored before birth, allowing vaginal delivery and return to the referring tertiary unit and may improve survival rate. The procedure carries a risk for PPROM, although that may decrease with experience.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven B-3000, Belgium.
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Luks FI, Carr SR, De Paepe ME, Tracy TF. What--and why--the pediatric surgeon should know about twin-to-twin transfusion syndrome. J Pediatr Surg 2005; 40:1063-9. [PMID: 16034746 DOI: 10.1016/j.jpedsurg.2005.03.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract Endoscopic laser ablation of placental vessels is the most commonly performed fetal operation today. Herein, we review the pathophysiology of twin-to-twin transfusion syndrome and the challenges of its treatment. Pediatric surgeons, with their knowledge of fetal and congenital pathology, and their technical expertise with minimally invasive surgery, can be of great benefit to the patient and the medical team.
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Affiliation(s)
- Francois I Luks
- Division of Pediatric Surgery, Brown Medical School, Providence, RI 02912, USA
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Nelson SM, Hajivassiliou CA, Haddock G, Cameron AD, Robertson L, Olver RE, Hume R. Rescue of the Hypoplastic Lung by Prenatal Cyclical Strain. Am J Respir Crit Care Med 2005; 171:1395-402. [PMID: 15778486 DOI: 10.1164/rccm.200409-1284oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We determined the effects of sustained and cyclical prenatal mechanical strain on the hypoplastic lung of the ovine model of congenital diaphragmatic hernia. Over a period of 4 weeks in late gestation, repeated cyclical tracheal occlusion for 23 hours with 1-hour release stimulated minimal growth, but promoted maturation with the development of a saccular lung. In contrast, a cycle consisting of 47 hours with 1-hour release induced optimal lung growth and morphologic maturation of the hypoplastic lung parenchyma. Sustained occlusion resulted in exaggerated lung growth, exceeding that of unaffected controls, and abnormal alveolar development. The extent of induction of lung growth by mechanical strain was inversely proportional to the number of alveolar type II cells remaining in the lung epithelium. These studies show that, although mechanical strain is capable of inducing lung growth and differentiation, cyclical strain is a prerequisite for normal development and that mechanically induced growth occurs at the expense of the alveolar type II cell. We conclude that cyclical strain may allow optimal alveolar development while maintaining a population of alveolar type II cells and may thus facilitate an improvement in postnatal lung function in infants with congenital diaphragmatic hernia.
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Affiliation(s)
- Scott M Nelson
- Division of Maternal and Child Health Sciences, University of Dundee, Dundee, DD1 9SY Scotland UK
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40
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Deprest J, Jani J, Gratacos E, Vandecruys H, Naulaers G, Delgado J, Greenough A, Nicolaides K. Fetal intervention for congenital diaphragmatic hernia: the European experience. Semin Perinatol 2005; 29:94-103. [PMID: 16050527 DOI: 10.1053/j.semperi.2005.04.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fetuses with CDH presenting with liver herniation and a lung area-to-head circumference ratio of less than 1.0 have a high chance for neonatal death due to pulmonary hypoplasia. Fetal tracheal occlusion (TO) prevents egress of lung liquid, which triggers lung growth. In animal experiments, we were able to develop a minimally invasive technique for Fetoscopic Endoluminal Tracheal Occlusion (FETO) with a detachable balloon. In 2001, we demonstrated feasibility of FETO by percutaneous access in fetuses with severe CDH. In a retrospective multicenter review, we obtained LHR measurements and position of the liver in 134 cases of isolated left-sided CDH between 24 and 28 weeks. Eleven patients (8%) with LHR < 1.4 opted for termination. Overall survival of liveborn babies was 47% (58/123). LHR and position of the liver correlated both to survival. Combination of both variables predicted neonatal outcome better: liver up and LHR < 1.0 predicted a survival of 9%. When LHR < 0.6, there were no survivors irrespective of liver position. We could successfully perform endotracheal placement of the balloon in 20 cases at a median gestational age of 26 weeks. The mean duration of the operation was 22 (range 5-54) minutes. In 11 (55%) of these patients, there was postoperative prelabor (ie, <37 weeks) amniorrhexis. Membranes ruptured before 32 weeks in 35%, with a decreasing trend as experience increased. Ultrasound scans after FETO demonstrated an increase in the echogenicity of the lungs within 48 hours and improvement in the LHR from a median 0.7 (range 0.4-0.9) before FETO to 1.8 (range 1.1-2.9) within 2 weeks after surgery. The median gestation at delivery was 33.2 (range 27-38) weeks, and in 14 (70%) this occurred after 32 weeks. Surgical repair of the diaphragmatic hernia could be done in 13 babies, and in all but 1 the defect was extensive and required the insertion of a patch. Survival to discharge was 50%. These 10 long-term surviving babies are now aged 7 to 26 (median 19) months without known neurologic morbidity. Eight babies died in the neonatal period due to complications of the underlying disease. Two nonsurvivors died from other causes but with appropriately developed lungs. Improved survival coincided with increasing experience, in turn related to reduced incidence of postoperative amniorrhexis, later delivery, and a change in the policy on the timing of removal of the balloon from intrapartum to the prenatal period. Survival in eligible contemporary controls was 1/12 (8%). The presence of liver herniation and a low lung-to-head ratio (LHR <1.0) is a good predictor of poor prognosis at different tertiary centers around the world. Severe CDH may be successfully treated with FETO, which is minimally invasive and may improve postnatal survival.
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Affiliation(s)
- Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics, University Hospital Gasthuisberg, Leuven, Belgium.
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Tchirikov M, Hecher K, Deprest J, Verbeken E, Roubliova X, Schröder HJ. Pulmonary circulation of fetal sheep with lung hyperplasia following tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:277-281. [PMID: 15593362 DOI: 10.1002/uog.1789] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To determine the alteration of blood flow velocity profile in the pulmonary arteries (PAs) of fetal sheep after tracheal occlusion (TO). METHODS Doppler ultrasound investigations of the PAs, the pulmonary trunk and the ductus arteriosus were performed weekly in nine ewes (gestational age 92-98 days, term 145 days) with singleton pregnancies after TO (n = 5) and in control fetuses (n = 4). Histological examinations with morphometry of pulmonary arterial vessels and of airways were performed in both groups. RESULTS In the control group the experiments lasted 38 +/- 6 days (mean +/- SD), and in the TO group 25 +/- 7 days. Relative lung weight was significantly higher in the TO group compared with the control group (14.5 +/- 3.4% and 4.0 +/- 0.5% of body weight). There were no significant differences in the Doppler parameters (pulsatility index, resistance index, the systolic peak, the diastolic minimum, time averaged maximum velocity) between groups. When the Doppler values of PAs in TO and control fetuses were combined, no significant differences between the left and right PA could be detected. The external diameter of peripheral PAs was significantly higher in the TO group as compared to control group (105.7 +/- 2.5 microm vs. 96.9 +/- 1.3 microm). CONCLUSIONS We found a threefold increase of fetal lung volume after TO without significant changes of blood flow velocity profiles in the PAs of fetal sheep.
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Affiliation(s)
- M Tchirikov
- Universitätsklinikum Hamburg-Eppendorf, Department of Obstetrics and Fetal Medicine, Hamburg, Germany.
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Roubliova XI, Verbeken EK, Wu J, Vaast P, Jani J, Deprest JA. Effect of tracheal occlusion on peripheric pulmonary vessel muscularization in a fetal rabbit model for congenital diaphragmatic hernia. Am J Obstet Gynecol 2004; 191:830-6. [PMID: 15467550 DOI: 10.1016/j.ajog.2004.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the effects on peripheric pulmonary vessel muscularization by tracheal occlusion (TO) performed at different gestational ages in fetal rabbits with surgically induced diaphragmatic hernia. STUDY DESIGN In 23 New Zealand white does, both ovarian end fetuses underwent surgical creation of diaphragmatic hernia at 23 days of gestation (pseudoglandular phase). At 26, 27, or 28 days 1 fetus underwent TO, the contralateral one underwent a sham operation for a total of 46 fetuses. At 30 days (alveolar phase), fetuses were harvested together with 1 nonoperated internal control. Lungs were processed for vascular morphometry. Proportionate medial thickness and muscularization of intra-acinar vessels were evaluated. RESULTS Late TO (day 28; saccular phase) normalizes the lung-to-body weight ratio and causes significant medial thinning in vessels up to 35 microm diameter. CONCLUSION Tracheal occlusion decreases muscularization of intra-acinar pulmonary vessels in a gestational age-dependent fashion, with maximal effect when TO is performed at 28 days.
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MESH Headings
- Actins/analysis
- Animals
- Disease Models, Animal
- Female
- Gestational Age
- Hernia, Diaphragmatic/complications
- Hernias, Diaphragmatic, Congenital
- Ligation
- Lung/blood supply
- Lung/embryology
- Muscle, Smooth, Vascular/anatomy & histology
- Muscle, Smooth, Vascular/chemistry
- Muscle, Smooth, Vascular/embryology
- Pregnancy
- Rabbits
- Trachea/physiology
- Trachea/surgery
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Affiliation(s)
- Xenia I Roubliova
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Deprest J, Gratacos E, Nicolaides KH. Fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia: evolution of a technique and preliminary results. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 24:121-126. [PMID: 15287047 DOI: 10.1002/uog.1711] [Citation(s) in RCA: 282] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) with liver herniation and a lung area to head circumference ratio (LHR) < 1 [corrected] is associated with a high rate of neonatal death due to pulmonary hypoplasia. METHODS We report the development of a minimally invasive and reversible fetoscopic tracheal occlusion (FETO) with a balloon, carried out in 21 consecutive fetuses with severe CDH. RESULTS Endotracheal placement of the balloon was successfully performed in all 21 cases and the mean duration of the operation was 20 (range, 5-54) min. The median gestation at FETO was 26 (range, 25-33) weeks. There were no maternal complications such as hemorrhage, placental abruption or pulmonary edema. In 11 (52.4%) patients there was postoperative prelabor amniorrhexis, which occurred within 2 weeks in five patients and after 2 weeks in six patients. Ultrasound scans after FETO demonstrated an increase in the echogenicity of the lungs within 48 h and improvement in the LHR from a median 0.7 (range, 0.4-0.9) before FETO to 1.8 (range, 1.1-2.9) within 2 weeks following surgery. The median gestation at delivery was 34 (range, 27-38) weeks and in 17 (77.3%) patients delivery occurred after 32 weeks. Nine babies died in the neonatal period due to complications from pulmonary hypoplasia. Surgical repair of the diaphragmatic hernia was carried out in 12 babies and in all but one the defect was extensive and required the insertion of a patch. Ten of these babies survived, and at the time of writing were aged 6-25 (median, 18) months and were developing normally. Survival was 30% in the first group of 10 fetuses and 63.6% in the second group of 11 fetuses. The total number of cases was too small for definite conclusions to be drawn as to the causes of this apparent improvement in survival. Nevertheless, improved survival coincided with a shift in the timing of FETO from the third to the second trimester, the administration of epidural rather than general anesthesia, reduced incidence of postoperative amniorrhexis and a change in the policy on the timing of removal of the balloon from the intrapartum to the prenatal period. During the same period of study there were 17 cases examined in the participating centers that met the criteria for FETO but which declined prenatal therapy. In all cases there was isolated left-sided CDH with liver in the thorax and LHR of 0.4-0.9 (mean, 0.7). In five cases the parents elected to terminate the pregnancy. In the 12 cases with expectant management all babies were liveborn but 11 died in the neonatal period due to pulmonary hypoplasia and only one (8.3%) survived. CONCLUSION Severe CDH can be successfully treated with FETO, which is minimally invasive and may improve postnatal survival.
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Affiliation(s)
- J Deprest
- Fetal Medicine Unit of the Department of Obstetrics and Gynaecology of the University Hospital Gasthuisberg, Leuven, Belgium.
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Chang R, Komura M, Andreoli S, Jennings R, Wilson J, Fauza D. Rapidly polymerizing hydrogel prevents balloon dislodgement in a model of fetal tracheal occlusion. J Pediatr Surg 2004; 39:557-60. [PMID: 15065027 DOI: 10.1016/j.jpedsurg.2003.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE This study examined whether an injectable hydrogel could buttress the balloon used in fetal tracheal occlusion, thus preventing its displacement. METHODS Fetal lambs (n = 11) underwent tracheal occlusion through local delivery of a detachable silicone balloon and were divided in 2 groups: group I had no further manipulations, and group II received an intratracheal injection of a rapidly polymerizing hydrogel, cranially to the balloon. Near term, balloon placement was examined, the lung volume-to-body weight ratio (LV:BW) was determined, and tracheal histology was performed. Statistical analysis was by the Fisher's Exact test, with significance set at P <.05. RESULTS Complete tracheal occlusion was achieved in all fetuses intraoperatively. The rate of balloon dislodgement was significantly higher in group I (4 of 7, or 57.1%) than in group II (0 of 4). In group II, balloons were recovered in situ with a column of residual hydrogel reinforcing their cephalad position. Animals in which balloon occlusion was maintained had significantly higher LV:BW, with no evidence of tracheal damage. CONCLUSIONS Intratracheal delivery of a rapidly polymerizing hydrogel cephalad to detachable silicone balloons results in improved fetal tracheal occlusion, with no harmful effects to the trachea. This adjuvant principle may enhance minimally invasive balloon tracheal occlusion for treatment of severe fetal pulmonary hypoplasia.
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Affiliation(s)
- Robert Chang
- Department of Surgery, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Abstract
The development of fetal surgery has led to promising therapeutic options for a number of congenital malformations. However, preterm labor (PTL) and premature rupture of membranes continue to be ubiquitous risks for both mother and fetus. To reduce maternal morbidity and the risk of prematurity, minimal access surgical techniques were developed and are increasingly employed. Congenital diaphragmatic hernia (CDH), obstructive uropathy, twin-to-twin transfusion syndrome (TTTS), and sacrococcygeal teratoma have already been successfully treated using minimal access fetal surgical procedures. Other life-threatening diseases as well as severely disabling but not life-threatening conditions are potentially amenable to treatment. The wider application of minimal access fetal surgery depends on a continued improvement in technology and a better understanding of complications associated with fetal intervention.
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Affiliation(s)
- Enrico Danzer
- Division of Pediatric Surgery, Department of Surgery, The Fetal Treatment Center, University of California, San Francisco, CA, USA
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Harrison MR, Albanese CT, Hawgood SB, Farmer DL, Farrell JA, Sandberg PL, Filly RA. Fetoscopic temporary tracheal occlusion by means of detachable balloon for congenital diaphragmatic hernia. Am J Obstet Gynecol 2001; 185:730-3. [PMID: 11568805 DOI: 10.1067/mob.2001.117344] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Occlusion of the fetal trachea blocks the egress of fetal lung fluid and stimulates the growth of hypoplastic lungs in fetuses with diaphragmatic hernia. Accomplishing temporary and reversible occlusion of the fetal trachea has proven difficult without invasive fetal surgery. Using simultaneous real-time ultrasonography and fetal bronchoscopy through a single uterine port, we placed a detachable balloon in the trachea of 2 fetuses with severe diaphragmatic hernia. In both fetuses the fetal lung subsequently enlarged, allowing survival after birth.
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Affiliation(s)
- M R Harrison
- Department of Surgery, and the Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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Flake AW, Crombleholme TM, Johnson MP, Howell LJ, Adzick NS. Treatment of severe congenital diaphragmatic hernia by fetal tracheal occlusion: clinical experience with fifteen cases. Am J Obstet Gynecol 2000; 183:1059-66. [PMID: 11084541 DOI: 10.1067/mob.2000.108871] [Citation(s) in RCA: 205] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our purpose was to determine whether prenatal tracheal occlusion improves survival in a selected population of fetuses affected by severe congenital diaphragmatic hernia. STUDY DESIGN Fetuses with isolated congenital diaphragmatic hernia were selected as candidates for fetal intervention by specific criteria designed to predict a 90% mortality rate with conventional postnatal treatment. RESULTS Fifteen fetuses underwent tracheal occlusion with 5 survivors (33%). Two fetuses were lost to early preterm labor. In 13 mothers, postoperative gestation ranged from 19 to 68 days, with a mean duration of pregnancy after tracheal occlusion of 38 days. The 5 survivors were hospitalized for an average of 76 days. Despite dramatic lung growth in some fetuses after tracheal occlusion, intensive management was required, and most deaths were caused by respiratory insufficiency. CONCLUSION Prenatal tracheal occlusion can result in impressive lung growth in a subset of fetuses with severe congenital diaphragmatic hernia. However, survival remains compromised by pulmonary functional abnormality and the consequences of prematurity.
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Affiliation(s)
- A W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, and the Departments of Surgery and Obstetrics, University of Pennsylvania School of Medicine, USA
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Gratacós E, Deprest J. Current experience with fetoscopy and the Eurofoetus registry for fetoscopic procedures. Eur J Obstet Gynecol Reprod Biol 2000; 92:151-9. [PMID: 10986450 DOI: 10.1016/s0301-2115(00)00440-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fetoscopy has consolidated its position in fetal medicine, thanks to a combination of insight into the pathophysiology of selected conditions that are amenable to fetal surgery and the technical innovations in endoscopic equipment. In clinical practice, two types of fetoscopy can be discerned: Obstetrical Endoscopy and Endoscopic Fetal Surgery. The first involves surgical interventions on the placenta, umbilical cord and fetal membranes. Nd:YAG laser coagulation of placental vessels in case of feto-fetal transfusion syndrome and cord occlusion in monochorionic pregnancy are the most typical procedures. The second type addresses some rare fetal conditions requiring in utero surgery; most experience has been gathered with congenital diaphragmatic hernia. Endoscopic fetal surgery has a different historical and experimental background than obstetrical endoscopy, but they both share technical aspects as well as potential side effects. In this review, we aimed at bringing together currently available experience. We suggest that future developments of fetal endoscopic operations will involve a mixture of concepts from both fetoscopy types to reduce maternal invasiveness and complications, eventually improving acceptance by parents and doctors. We encourage the registration of all experience in a yet available open registry for prospective data collection, supported by the European Commission, with as primary target the assessment of maternal and fetal safety.
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Affiliation(s)
- E Gratacós
- Department of Obstetrics & Gynaecology, Unit of Prenatal Diagnosis and Fetal Medicine, University Hospital Gasthuisberg, & Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.
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Abstract
Fetal surgery for congenital diaphragmatic hernia and other fetal conditions can only be considered if (1) the morbidity of antenatal intervention is acceptable, (2) the diagnosis of the condition can be made accurately, (3) the condition can be differentiated from other, non-surgical anomalies. In addition, (4) the natural evolution of the disease, if left untreated, should be predictable, and the condition should be lethal or severely debilitating, (5) there should not exist adequate postnatal treatment, and (6) the proposed in utero operation should be technically feasible. Open fetal surgery has proven too invasive to be justified for the treatment of diaphragmatic hernia, and progress in postnatal therapy (including ECMO) has dramatically improved the neonatal outcome in all but a severe subgroup of patients. Recently, advances in endoscopic fetal surgery (which appears to be less stressful for the fetus and the gravid uterus) and a new approach to accelerate fetal lung growth and maturation have renewed the feasibility of in utero intervention for diaphragmatic hernia.
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Affiliation(s)
- F I Luks
- Division of Pediatric Surgery and Program in Fetal Medicine, Brown University School of Medicine, Providence, RI, 02905, USA.
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Deprest JA, Evrard VA, Verbeken EK, Perales AJ, Delaere PR, Lerut TE, Flageole H. Tracheal side effects of endoscopic balloon tracheal occlusion in the fetal lamb model. Eur J Obstet Gynecol Reprod Biol 2000; 92:119-26. [PMID: 10986445 DOI: 10.1016/s0301-2115(00)00435-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate effects of in-utero endoluminal balloon tracheal occlusion (TO) as suggested for the treatment of Congenital Diaphragmatic Hernia (CDH) on the higher airways of a fetal lamb model. STUDY DESIGN Fetuses from time-dated pregnant ewes underwent at 94 days (term=145 days) in-utero tracheal occlusion. In study animals an endoluminal, detachable balloon was placed by tracheoscopy. For that purpose a 1.2mm fibre-optic, semi-rigid endoscope and a medically graded latex balloon were used. In group I (n=9) lambs were delivered after 2 weeks. In group II (n=8) the tracheal occlusion was released after 2 weeks, to allow in-utero recovery until term. In positive control animals (group III; n=5) the trachea was clipped at 98 days and fetuses were harvested near term by cesarean section. A total of 17 contralateral littermates in multiple pregnancies served as negative controls. After macroscopic inspection of the trachea, sections were evaluated by light microscopy. Alterations were scored with an empirical interval score for each of the different anatomical elements in the fetal trachea (epithelium, submucosa, cartilage, pars membranacea). RESULTS For the animal experiments in group I, all balloons were found in place and according to the pulmonary response they were obstructive. Tracheas were macroscopically dilated by the plug mainly due to elongation of the pars membranacea. The total histologic score was correlated to the increase in circumference (mean increase: 3.0mm). In nearly all cases, the tracheal epithelium at the level of the plug had lost its typical folding pattern. In 44% of cases, local epithelial defects were observed and in 33% of cases there was squamous metaplasia. A chronic inflammatory response was present in over half of the cases, sometimes with giant cell reaction. In group II (the in-utero recovery group) the total score was significantly lower than in group I, with much less prominent unfolding and absence of epithelial defects. Squamous metaplastia was still present in half of the cases; whereas inflammatory responses were less frequent. In group III the trachea expanded normally after removal of the clip. The epithelium had compacted folds, and cilia were well preserved. In two animals however, intraluminal synechia were observed. Below the level of occlusion animals of groups I and II all showed areas of unfolding, but without metaplasia or epithelial defects. CONCLUSION Tracheal obstruction by means of endoluminal plugging has been suggested as an alternative in-utero treatment for congenital diagphragmatic hernia. The balloon causes mild epithelial changes, such as unfolding, limited epithelial defects (<25% of the exposure surface) and local inflammatory changes. These changes disappear nearly completely following in-utero unplugging during the rest of gestation. Unfolding of the epithelium is also seen in the trachea under the plug.
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Affiliation(s)
- J A Deprest
- Centre for Surgical Technologies, Faculty of Medicine, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium.
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