1
|
Joyeux L, Belfort MA, De Coppi P, Basurto D, Valenzuela I, King A, De Catte L, Shamshirsaz AA, Deprest J, Keswani SG. Complex gastroschisis: a new indication for fetal surgery? Ultrasound Obstet Gynecol 2021; 58:804-812. [PMID: 34468062 DOI: 10.1002/uog.24759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Surgery, Queen Fabiola Children's University Hospital, Brussels, Belgium
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit and NIHR Biomedical Research Center, Great Ormond Street Hospital, and Great Ormond Street Institute of Child Health, University College London, London, UK
| | - D Basurto
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - I Valenzuela
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - A King
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - L De Catte
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A A Shamshirsaz
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
| | - S G Keswani
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
2
|
Cruz-Martínez R, Martínez-Rodríguez M, Gámez-Varela A, Luna-García J, López-Briones H, Chávez-González E, Villalobos-Gómez R, Juárez-Martínez I. Fetoscopic urethral meatotomy in fetuses with lower urinary tract obstruction by congenital megalourethra. Prenat Diagn 2021; 41:772-777. [PMID: 33792084 DOI: 10.1002/pd.5946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND To describe the perinatal outcomes of fetoscopic urethral meatotomy (FUM) in fetuses with lower urinary tract obstruction (LUTO) by congenital megalourethra. STUDY DESIGN Between 2012 and 2020, 226 cases with LUTO were referred to our fetal surgery center in Queretaro, Mexico. We report the perinatal outcome of cases with LUTO by congenital megalourethra that were selected for FUM in an attempt to release the penile urethral obstruction. RESULTS Congenital megalourethra was diagnosed in 10 cases (4.4%) but only 3 cases (30%) with obstructive megalourethra and megacystis were selected for fetal surgery. Fetoscopic urethral metatotomy was successfully performed in all three cases at a median gestational age (GA) of 21.4 (18.0-26.7) weeks and with a median surgical time of 27 (12-43) min. A resolution of urethral dilatation and subsequent reduction of the penile length and normalization of both the bladder size and amniotic fluid were observed in all cases. The median GA at delivery was 35.2 (range: 30.6-38.0) weeks. There were no fetal deaths but one neonatal death (33%) secondary to renal failure and preterm delivery. CONCLUSION In fetuses with LUTO by congenital obstructive megalourethra, FUM is feasible and is associated with good perinatal outcomes.
Collapse
Affiliation(s)
- Rogelio Cruz-Martínez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
- Instituto de Ciencias de la Salud (ICSa), Universidad Autónoma del Estado de Hidalgo (UAEH), Hidalgo, México
| | - Miguel Martínez-Rodríguez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
- Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez Lara", Querétaro, México
| | - Alma Gámez-Varela
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| | - Jonahtan Luna-García
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| | - Hugo López-Briones
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| | - Erendira Chávez-González
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| | - Rosa Villalobos-Gómez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| | - Israel Juárez-Martínez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal México and Fetal Medicine Foundation of Mexico, Queretaro, México
| |
Collapse
|
3
|
Bergh EP, Mann LK, Jain RR, Donepudi R, Moise KJ, Johnson A, Papanna R. Effect of intra-amniotic fluid pressure from polyhydramnios on cervical length in patients with twin-twin transfusion syndrome undergoing fetoscopic laser surgery. Ultrasound Obstet Gynecol 2019; 54:774-779. [PMID: 30693576 DOI: 10.1002/uog.20228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the relationship between intra-amniotic pressure and cervical length (CL) in patients with twin-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP), and to identify pre- or intraoperative factors associated with increased intra-amniotic pressure in this population. METHODS This was a prospective cohort study of patients undergoing FLP for TTTS. Exclusion criteria were triplet or higher-order gestation and prior cervical cerclage, amnioreduction or FLP procedure. CL was assessed using preprocedure transvaginal ultrasound. Intra-amniotic pressure measurements were obtained on initial placement of the trocar into the amniotic cavity, using a direct hydrostatic pressure gauge. The relationship between intra-amniotic pressure and CL was assessed using multivariate linear regression analysis, including relevant preoperative and intraoperative variables. RESULTS In total, 283 pregnancies met the inclusion criteria. Quintero stage of TTTS was I in 33 pregnancies, II in 88, III in 150 and IV in 12. Mean gestational age (GA) at FLP was 20.7 ± 3 weeks. Mean intra-amniotic pressure was 23.1 ± 9 mmHg. On unadjusted linear regression analysis, there was no significant association between intra-amniotic pressure and preoperative CL (P = 0.24) or GA at delivery (P = 0.22). On multivariate analysis, the factors associated significantly with intra-amniotic pressure were: number of prior term deliveries (P = 0.03), recipient maximum vertical pocket (P < 0.0001), Quintero stage IV (P = 0.01) and type of anesthesia (sedation vs general anesthesia; P = 0.01). CONCLUSION In pregnancies with TTTS, intra-amniotic pressure is not associated with CL or GA at delivery. This novel finding suggests that cervical shortening in this population is not mechanically driven. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- E P Bergh
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - L K Mann
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R R Jain
- Department of Anesthesiology, McGovern Medical School, Houston, TX, USA
| | - R Donepudi
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - K J Moise
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - A Johnson
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R Papanna
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| |
Collapse
|
8
|
Abstract
Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. An overview of prenatal therapy for obstructive uropathy, the limitations of the early published experience, advances of recent years, and future directions for treatment are reviewed. The clinical approach and outcomes of the Fetal Treatment Program of Hutzel Hospital and Wayne State University are presented. Patient selection for antenatal treatment is based on the existence of a significant threat of neonatal death due to pulmonary hypoplasia, pending exclusion criteria such as anatomical structural anomalies and chromosomal defects. Ultrasonography, karyotyping, and sequential urinary electrolyte analysis are essential. Current treatment involves the placement under ultrasonic guidance of a Rodeck vesicoamniotic shunt. Recent technical advances include the use of amnioinfusion for fetal visualization, temporary fetal paralysis, routine antibiotics, and more-precise catheter placement. The establishment of standardized short- and long-term outcome measures and the documentation of fetal and maternal complications are in progress. Procedural refinement, development of fetoscopic techniques and equipment, identification of urinary markers to aid patient selection, and the collection of multicenter outcome data will assist the future management of prenatally detected obstructive uropathy.
Collapse
Affiliation(s)
- A L Freedman
- Department of Pediatric Urology, Children's Hospital of Michigan, Michigan, USA.
| | | | | |
Collapse
|