Growth trajectory and neurodevelopmental outcome in infants with congenital diaphragmatic hernia

PURPOSE

The purpose of this study was to evaluate the impact of impaired growth on short-term neurodevelopmental (ND) outcomes in CDH survivors.

METHODS

Between 9/2005-12/2014, 84 of 215 (39%) CDH survivors underwent ND assessment at 12months of age using the BSID-III.

RESULTS

Mean cognitive, language, and motor scores were 92.6±13.5, 87.1±11.6, and 87.0±14.4, respectively (normal 100±15). 51% of patients scored 1 SD below the population mean in at least one domain, and 13% scored 2 SD below the population mean. Group-based trajectory analysis identified two trajectory groups ('high' and 'low') for weight, length, and head circumference (HC) z-scores. (Fig. 1) 74% of the subjects were assigned to the 'high' trajectory group for weight, 77% to the 'high' height group, and 87% to the 'high' HC group, respectively. In multivariate analysis, longer NICU stay (p<0.01) was associated with lower cognitive scores. Motor scores were 11 points higher in the 'high' HC group compared to the 'low' HC group (p=0.05). Motor scores were lower in patients with longer NICU length of stay (p<0.001).

CONCLUSIONS

At 1 year, half of CDH survivors had a mild delay in at least one developmental domain. Low HC trajectory was associated with worse neurodevelopmental outcomes.

TYPE OF STUDY

Prognosis Study/Retrospective Study.

LEVEL OF EVIDENCE

Level II.

Evaluation of Magnetic Resonance Imaging Safety and Imaging Issues Associated with the Occlusion Balloon Used during Fetoscopic Endoluminal Tracheal Occlusion

INTRODUCTION

Congenital diaphragmatic hernias can be successfully treated by fetoscopic tracheal occlusion (FETO), a minimally invasive procedure that may improve postnatal survival. The endoluminal balloon utilized for FETO contains a metallic component that may pose possible risks for the fetus and mother related to the use of magnetic resonance imaging (MRI). The objective of this study is to evaluate MRI-related imaging and safety issues (magnetic field interactions, heating, and artifacts) for the occlusion balloon used in FETO.

MATERIALS AND METHODS

Using well-established techniques, tests were performed to assess magnetic field interactions (translational attraction and torque) and MRI-related heating and artifacts that occurred when exposing the occlusion balloon typically used for FETO (Goldbal2, Balt, www.balt.fr) to a 3-T magnet. MRI-related heating was determined by placing the occlusion balloon in a gelled-saline-filled, head-torso phantom and conducting MRI at relatively high, whole-body-averaged specific absorption rate (2.9 W/kg) for 15 min. Artifacts were measured in association with the use of T1-weighted, spin-echo and gradient-echo pulse sequences.

RESULTS

The balloon displayed minor magnetic field interactions and physiologically inconsequential heating (highest temperature rise: 0.1°C above background). Artifacts extended approximately 10 mm from the occlusion balloon on the gradient-echo pulse sequence, suggesting that anatomy located at a position greater than this distance may be visualized on MRI.

DISCUSSION

In this paper, we demonstrate that the risks of performing MRI at 3 T or less in a patient who has this occlusion balloon in place are acceptable (or MR conditional, using current terminology).

An extra-uterine system to physiologically support the extreme premature lamb

In the developed world, extreme prematurity is the leading cause of neonatal mortality and morbidity due to a combination of organ immaturity and iatrogenic injury. Until now, efforts to extend gestation using extracorporeal systems have achieved limited success. Here we report the development of a system that incorporates a pumpless oxygenator circuit connected to the fetus of a lamb via an umbilical cord interface that is maintained within a closed 'amniotic fluid' circuit that closely reproduces the environment of the womb. We show that fetal lambs that are developmentally equivalent to the extreme premature human infant can be physiologically supported in this extra-uterine device for up to 4 weeks. Lambs on support maintain stable haemodynamics, have normal blood gas and oxygenation parameters and maintain patency of the fetal circulation. With appropriate nutritional support, lambs on the system demonstrate normal somatic growth, lung maturation and brain growth and myelination.

Neurodevelopmental outcomes at 5years of age in congenital diaphragmatic hernia

OBJECTIVE

To evaluate neurodevelopmental sequelae in congenital diaphragmatic hernia (CDH) children at 5years of age.

MATERIALS AND METHODS

The study cohort of 35 CDH patients was enrolled in our follow-up program between 06/2004 and 09/2014. The neurodevelopmental outcomes assessed at a median of 5years (range, 4-6) included cognition (Wechsler Preschool and Primary Scale of Intelligence [WPPSI], n=35), Visual-Motor-Integration (n=35), academic achievement (Woodcock-Johnson Tests of Achievement, n=25), and behavior problems (Child Behavior Check List [CBCL], n=26). Scores were grouped as average, borderline, or extremely low by SD intervals.

RESULTS

Although mean Full (93.9±19.4), Verbal (93.4±18.4), and Performance (95.2±20.9) IQ were within the expected range, significantly more CDH children had borderline (17%) and extremely low (17%) scores in at least one domain compared to normative cohorts (P<0.02). The Visual-Motor-Integration score was below population average (P<0.001). Academic achievement scores were similar to expected means for those children who were able to complete testing. CBCL scores for the emotionally reactive (23%) and pervasive developmental problems scales (27%) were more likely to be abnormal compared to normal population scores (P=0.02 and P=0.0003, respectively). Autism was diagnosed in 11%, which is significantly higher than the general population (P<0.01). Univariate analysis suggests that prolonged NICU stay, prolonged intubation, tracheostomy placement, pulmonary hypertension, autism, hearing impairment, and developmental delays identified during infancy are associated with worse cognitive outcomes (P<0.05).

CONCLUSION

The majority of CDH children have neurodevelopmental outcomes within the average range at 5years of age. However, rates of borderline and extremely low IQ scores are significantly higher than in the general population. CDH survivors are also at increased risk for developing symptoms of emotionally reactive and pervasive developmental problems. Risk of autism is significantly elevated. Disease severity and early neurological dysfunction appear to be predictive of longer-term impairments.

Induction of Immune Tolerance to Foreign Protein via Adeno-Associated Viral Vector Gene Transfer in Mid-Gestation Fetal Sheep

A major limitation to adeno-associated virus (AAV) gene therapy is the generation of host immune responses to viral vector antigens and the transgene product. The ability to induce immune tolerance to foreign protein has the potential to overcome this host immunity. Acquisition and maintenance of tolerance to viral vector antigens and transgene products may also permit repeat administration thereby enhancing therapeutic efficacy. In utero gene transfer (IUGT) takes advantage of the immunologic immaturity of the fetus to induce immune tolerance to foreign antigens. In this large animal study, in utero administration of AAV6.2, AAV8 and AAV9 expressing green fluorescent protein (GFP) to ~60 day fetal sheep (term: ~150 days) was performed. Transgene expression and postnatal immune tolerance to GFP and viral antigens were assessed. We demonstrate 1) hepatic expression of GFP 1 month following in utero administration of AAV6.2.GFP and AAV8.GFP, 2) in utero recipients of either AAV6.2.GFP or AAV8.GFP fail to mount an anti-GFP antibody response following postnatal GFP challenge and lack inflammatory cellular infiltrates at the intramuscular site of immunization, 3) a serotype specific anti-AAV neutralizing antibody response is elicited following postnatal challenge of in utero recipients of AAV6.2 or AAV8 with the corresponding AAV serotype, and 4) durable hepatic GFP expression was observed up to 6 months after birth in recipients of AAV8.GFP but expression was lost between 1 and 6 months of age in recipients of AAV6.2.GFP. The current study demonstrates, in a preclinical large animal model, the potential of IUGT to achieve host immune tolerance to the viral vector transgene product but also suggests that a single exposure to the vector capsid proteins at the time of IUGT is inadequate to induce tolerance to viral vector antigens.

Prenatal growth characteristics of lymphatic malformations

PURPOSE

The natural history of prenatally diagnosed lymphatic malformations (LM) remains unknown. The ability to predict growth of a lesion is important to prenatal counseling and any future prenatal intervention. We describe the prenatal growth patterns of LMs as they relate to gestational age, anatomical location, and postnatal management.

METHODS

A retrospective review of fetuses prenatally diagnosed with an LM who were followed with serial ultrasounds from 2003 to 2014 was performed with attention to the growth of the lesion as indicated by the lesion volume ratio (LVR).

RESULTS

Thirty patients with LM had serial ultrasound measurements between 19 and 39weeks gestation. The LVR increased in 53%, decreased in 23%, and remained stable in 23% of fetuses from the initial to the final ultrasound. Unlike other locations that demonstrated both positive and negative growth profiles, axillary lesions only demonstrated increased growth. Lesions with positive growth increased throughout gestation (peak LVR at 35±3weeks). Twenty-four patients had postnatal interventions, including surgical resection, sclerotherapy, and surgery + sclerotherapy.

CONCLUSION

LMs have variable prenatal growth profiles. The majority of lesions, especially axillary LMs, will continue to grow throughout gestation and will not reach a growth plateau until the end of gestation.

LEVEL OF EVIDENCE

Level III (Retrospective cohort study).

Fetal intrapericardial teratoma: natural history and management including successful in utero surgery

BACKGROUND

Intrapericardial teratoma is a rare, lethal tumor often detected in fetal life. Tumor mass and pericardial effusion cause cardiac tamponade that, if relieved, could be life-saving. Optimal timing of intervention and methods for effective fetal treatment are unknown.

OBJECTIVE

We describe our single-center experience with fetal intrapericardial teratoma including the first report of successful in utero surgical resection with survival to term.

STUDY DESIGN

We reviewed our database for suspected fetal intrapericardial teratoma. On fetal ultrasound and echocardiography tumor size was estimated by calculation of an ellipse and analyzed in relation to Doppler-derived fetal cardiac output, venous flow patterns, hydrops, and outcome.

RESULTS

Eight fetuses with suspected intrapericardial teratoma were seen from 2009 through 2015. Gestational age at initial presentation ranged from 21-34 (median 26) weeks. Two cases mimicked the appearance of intrapericardial teratoma, but had no serial change in cardiac output over time and were ultimately determined to be other types of tumor. In 6 cases of true intrapericardial teratoma, tumor growth was extremely rapid and associated with progressive decline in cardiac output (to <400 mL/kg/min) manifesting in hydrops and death if left untreated. One case was treated successfully at 31 weeks through ex utero intrapartum delivery with tumor resection while on placental support. Another case underwent open fetal surgery and resection at 24 weeks, with resumption of gestation until delivery at 37 weeks with excellent outcome.

CONCLUSION

Fetal intrapericardial teratoma can be successfully managed utilizing serial surveillance and by treatment in a timely manner prior to the predictable onset of hydrops, determined through increasing tumor size and a declining cardiac output. Surgical resection in utero is possible, with good results.

Management and outcomes of scoliosis in children with congenital diaphragmatic hernia

PURPOSE

The purpose of this study was to evaluate the management and outcomes of CDH patients with scoliosis.

METHODS

From January 1996 to August 2015, 26 of 380 (7%) CDH patients were diagnosed with scoliosis. Six (23%) were prenatally diagnosed by ultrasound, and 9 (35%) were diagnosed postnatally. The remaining 11 (42%) developed scoliosis after discharge. Mean follow-up was 6.6years.

RESULTS

Among the 15 patients with congenital scoliosis, there were 2 (13%) perinatal deaths. Five of the 13 (38%) survivors required orthopedic surgery, and 2 have required bracing. The mean age at initial surgery was 7years. These five children underwent an average of 2.8 (range 1-7) expansions or revisions. All surgical patients required supplemental oxygen at 28days of life, and 1 required a tracheostomy. None of the 11 patients who developed scoliosis later in life required surgery, but 3 have required bracing. Six of the 11 (55%) required a patch repair for CDH compared to 158 of 264 (60%) CDH patients without scoliosis (p=0.73).

CONCLUSIONS

Early diagnosis of scoliosis in CDH patients is associated with a high rate of surgery. There was not a higher incidence of patch repair among patients who developed scoliosis.

LEVEL OF EVIDENCE

Prognosis. Retrospective study, level II.

Immediate operative management of the fetus with airway anomalies resulting from congenital malformations

Prenatal diagnosis has transformed the outcome of fetuses with airway obstruction. The thorough evaluation of prenatal imaging allows for categorizing fetuses with airway compromise into those who will require a special mode of delivery and those who can be delivered without any special resources. The ex-utero intrapartum treatment (EXIT) approach allows accessing the airway while the fetus is under placental support, converting a potentially catastrophic situation into a controlled one. An expert multidisciplinary team is the key to success.

Younger gestational age is associated with increased risk of adverse neurodevelopmental outcome during infancy in congenital diaphragmatic hernia

BACKGROUND

The purpose of the study was to investigate the impact of gestational age (GA) on short-term neurodevelopmental (ND) outcomes in congenital diaphragmatic hernia survivors.

MATERIALS

Between 6/2004 and 2/2013, 135 consecutive CDH patients underwent ND assessment using the Bayley Scales of Infant Development-III at a median follow-up age of 13months (range, 5-36). ND delay was defined by a score of ≤85 in any of the composite scales. Severe impairment was defined as a score of ≤69 in at least one domain. The effect of GA was evaluated as continuous and categorical variables. GA at delivery was grouped into full term (39-41weeks), near term (37-38), late preterm (34-36), and preterm (24-33).

RESULTS

Median GA at delivery was 38weeks (range, 24-41). Fifty (37%) patients were delivered full term, 59 (44%) near term, 16 (12%) late preterm, and 10 (7%) preterm. CDH children born before 39weeks' gestation were more likely to score below average (P=0.005) with corrected age for at least one composite score compared to full term peers. Cognitive (P=0.06) and language (P=0.08) scores tended to be lower in the near-term and late-preterm group compared to full-term CDH infants. Patients born near term and late preterm had significantly lower motor composite and fine motor scores compared to full-term children (P=0.009 and P<0.01, respectively). Preterm children scored the lowest in all composite scales (P<0.05).

CONCLUSIONS

Compared to term infants, not only preterm but also late preterm and near-term CDH children carry an increased risk of ND delays. Motor performance appears most susceptible to earlier delivery.

Rate of increase of lung-to-head ratio over the course of gestation is predictive of survival in left-sided congenital diaphragmatic hernia

PURPOSE

Congenital diaphragmatic hernia (CDH) is associated with high postnatal mortality because of pulmonary hypoplasia. The prognostic utility of serial lung-to-head circumference measurements as a marker of lung growth has not been described. Our objective was to examine the relationship between the rate of interval increase of LHR and postnatal survival in left-sided CDH.

METHODS

We retrospectively reviewed charts of all left-sided CDH patients from January 2004 to July 2014. All ultrasound studies performed at our institution (n=473) were reviewed. Categorical and continuous data were analyzed by chi-square and Mann-Whitney t-test, respectively, and slope analysis was performed by linear regression analysis (p<0.05).

RESULTS

A total of 226 patients were studied, with 154 long-term survivors and 72 non-survivors. Established markers of CDH severity, including intrathoracic liver position and requirement for patch repair, were significantly increased in non-survivors (p<0.0001). The rate of LHR increase as measured by linear regression and slope analysis was significantly increased in long-term survivors (p=0.0175).

CONCLUSIONS

Our findings indicate that the interval increase in LHR levels over the course of gestation correlate with survival in left-sided CDH patients. Regular ultrasonographic re-evaluation of LHR throughout gestation following diagnosis of CDH may provide prognostic insight and help guide patient management.

Delayed abdominal closure after congenital diaphragmatic hernia repair

PURPOSE

We present our experience with CDH patients who required delayed abdominal closure following CDH repair.

METHODS

A retrospective review of all CDH repairs from 2004 to 2014 was performed.

RESULTS

233 patients underwent CDH repair, of which 21 required delayed abdominal closure defined as the inability to close the abdominal fascia at the time of CDH repair. The incidence of delayed closure was higher in those undergoing CDH repair on ECMO vs. not on ECMO (40% [17/43] vs. 2% [4/190]; P<0.001). The abdominal wound was temporarily covered by skin only (n=2), skin+prosthetic mesh sutured to the fascia (n=3), preformed silo (n=9), or vacuum assisted closure (VAC®) device (n=7). The mean time to fascial closure was 14.5±7 and 6±3days for patients repaired on ECMO and not on ECMO, respectively. In patients repaired on ECMO, the "primary closure" and "delayed closure" groups were not different in prenatal predictors (liver up, lung-to-head ratio [LHR]), total days on ECMO, ECMO days prior to CDH repair, and survival. In patients repaired on ECMO, the "delayed closure" group had a significantly higher requirement for blood transfusions compared to the "primary closure" group (mean 87±35 vs. 62±27ml of packed RBCs per ECMO day; P=0.01).

CONCLUSION

Delayed abdominal closure was required in 40% of CDH repairs done on ECMO but was rarely required in CDH repairs performed off ECMO. Although associated with an increased need for blood transfusions, delayed closure following CDH repair on ECMO was not associated with increased mortality.

Effect of single and multiple courses of maternal betamethasone on prenatal congenital lung lesion growth and fetal survival

PURPOSE

Administration of maternal betamethasone (BMZ) is a therapeutic option for fetuses with large microcystic congenital lung lesions at risk for, or causing, hydrops. Not all fetuses respond to a single course of BMZ. We review our experience with the use of single and multiple courses of maternal BMZ for the management of these patients.

METHODS

A retrospective review of fetuses with congenital lung lesions managed with maternal BMZ from 2003 to 2014 was performed.

RESULTS

Forty-three patients were managed with prenatal steroids (28 single course, 15 multiple courses). Single course recipients demonstrated a reduction in lesion size and resolution of hydrops in 82% and 88% of patients respectively compared to 47% and 56% in recipients of multiple steroid courses. Survival of multiple course patients (86%) was comparable to that of single course patients (93%) and improved compared to non-treated historical controls. Multiple course recipients demonstrated an increased need for open fetal surgery and postnatal surgery at a younger age.

CONCLUSION

Fetuses who fail to respond to a single course of BMZ may benefit, as indicated by hydrops resolution and improved survival, from additional courses. However, failure to respond is indicative of a lesion which may require fetal or immediate neonatal resection.

The first 100 infant thoracoscopic lobectomies: Observations through the learning curve and comparison to open lobectomy

OBJECTIVE

The objective of the study is to describe our initial 100 attempted infant thoracoscopic lobectomies for asymptomatic, prenatally diagnosed lung lesions, and compare the results to contemporaneous age-matched patients undergoing open lobectomy.

BACKGROUND

Infant thoracoscopic lobectomy is a technically challenging procedure, which has only gained acceptance worldwide in recent years.

METHODS

This is a retrospective review of all patients undergoing thoracoscopic or open lung lobectomy between March 2005 and January 2014. Included were all asymptomatic infants younger than 4months. Excluded were patients undergoing emergent lobectomy and patients with isolated extralobar bronchopulmonary sequestrations.

RESULTS

A total of 100 attempted thoracoscopic lobectomies were compared with 188 open lobectomies. In the thoracoscopic group, mean age and weight at surgery were 7.3weeks and 4.8kg, mean operative time was 185minutes, and mean hospital stay was 3days. Twelve cases were converted to open (12%). Ten conversions occurred within the first third of the series and none in the last third. There were no mortalities. There were no differences between the thoracoscopic and open groups in perioperative complications or hospital stay. There was a significant difference in the operative time: 111minutes vs. 185minutes (open vs. thoracoscopic; p<0.001). There was a higher mean end-tidal carbon dioxide (ETCO2) and lower mean peripheral capillary oxygen saturation (SpO2) in the thoracoscopic group versus the open group (51.7 versus 38.6mmHg and 97.5 versus 99.1%, respectively).

CONCLUSION

In high volume centers, the learning curve of thoracoscopic lobectomy can be overcome and the procedure can be performed with equivalent outcomes and, in our opinion, superior cosmetic results to open lobectomy.

Frequency and complications of inguinal hernia repair in giant omphalocele

PURPOSE

Giant omphalocele (GO) is a challenging problem owing to aberrant anatomy and complex comorbidities. Large inguinal hernias (IH) are known to occur in this population, but have not been well described in the literature. We sought to characterize rates and complications of IH in GO patients.

METHODS

A retrospective chart review was performed on all patients with the diagnosis of GO from 2004 to 2012, with a minimum follow-up period of 12 months. Statistical significance was calculated using Fisher's exact test and Mann-Whitney test (p<0.05).

RESULTS

A total of 51 giant omphalocele patients were born during the 8-year study period, with IH diagnosed in 21 patients (41%). IH was not associated with gestational age, birth weight, or method of GO closure, but was significantly associated with male gender (p<0.0001). Incarceration occurred in 4 patients (19%). Recurrence was noted in 7 cases, with 6/7 recurrences following repair by high ligation of the sac alone. All recurrences were repaired with the Bassini repair. Postoperative complications were noted in 7 patients (33%) and included prolonged ileus following incarceration, testicular tethering, testicular atrophy, persistent hydrocele, and death following acute incarceration.

CONCLUSIONS

Our study suggests a high incidence of IH in GO patients. The prevalance of incarceration and recurrences in these patients support a role for inguinal herniorrhaphy via a Bassini repair prior to initial hospital discharge.

Lung function over the first 3 years of life in children with congenital diaphragmatic hernia

OBJECTIVES

Infants with congenital diaphragmatic hernia (CDH) have variable degrees of pulmonary hypoplasia at birth. Few reports of lung function over the first years of life exist in this group of children.

HYPOTHESIS

Pulmonary function abnormalities correlate with severity of neonatal disease and intensity of neonatal therapies needed. We also hypothesized that longitudinal measurements of lung function over the usual period of rapid lung growth would lend some insight into how the lung remodels in CDH infants.

METHODOLOGY

Ninety-eight infants with CDH between 11 days and 44 months of age underwent pulmonary function testing (PFT) on 1-5 occasions using the raised volume rapid thoracic compression technique. Demographic data were also collected.

MAIN RESULTS

Forced expiratory flows were below normal. Total lung capacity was normal, but residual volume and functional residual capacity were elevated. Children requiring patch closure, ECMO, or pulmonary vasodilators generally had lower lung functions at follow up. Additionally, longer duration of mechanical ventilation correlated with worse lung function.

CONCLUSIONS

Lung functions of survivors of CDH remain abnormal throughout the first 3 years of life. The degree of pulmonary function impairment correlated both with markers of the initial degree of pulmonary hypoplasia and the duration of mechanical ventilation. Understanding the relationship between the phenotypic presentation of CDH and the potential for subsequent lung growth could help refine both pre- and postnatal therapies to optimize lung growth in CDH infants.

Neurodevelopmental outcome at one year of age in congenital diaphragmatic hernia infants not treated with extracorporeal membrane oxygenation

BACKGROUND

We evaluated the neurodevelopmental (ND) outcome at one year of age for congenital diaphragmatic hernia (CDH) children who have not undergone extracorporeal membrane oxygenation (ECMO) treatment during the neonatal period.

MATERIAL AND METHODS

Between 01/2005 and 06/2012, 63 consecutive CDH patients underwent ND assessment using the BSID-III at a median age of 12 months. ND delay was defined by a score of ≤ 85 in any of the composite scales. Severe impairment was defined as a score of ≤ 69 in at least one domain.

RESULTS

Mean ± SD cognitive, language, and motor functions were 94 ± 14, 86 ± 14, 90 ± 15, respectively (normal 100 ± 15, P<0.01 for each). Forty-three-percent scored within the average range for all scales. Forty-four-percent had mild, and 13% had severe delays in at least one domain. Prolonged NICU stay, intubation and O2 requirement, fundoplication, abnormal BAERs, and tracheostomy were associated with lower scores in all domains. Right-sided CDH, male gender, lower 5 min APGAR, pulmonary hypertension, and delayed start of enteral feeding were predictive of lower cognitive and/or language scores.

CONCLUSION

At one year of age, a high percentage of CDH children whose illness did not necessitate ECMO have below normal ND scores. Modifiable and non-modifiable factors are significant determinants of adverse outcomes.

Prenatal diagnosis of esophageal bronchus--first report of a rare foregut malformation in utero

AIM OF THE STUDY

Esophageal bronchus is a rare bronchopulmonary foregut malformation in which an isolated portion of the respiratory system communicates with the esophagus. There are no reports of prenatal diagnosis of an esophageal bronchus in the literature. We present 5 cases of esophageal bronchus and describe unique imaging findings.

METHODS

Following IRB approval, 5 cases of pathologically proven esophageal bronchus were identified from a single center fetal therapy surgical database. Prenatal magnetic resonance and ultrasound studies were scored for the presence of bronchoceles, cysts, vascular feeders, and location. Five control cases were selected from a radiology database, with lesions determined to represent bronchial atresia prenatally and located at the lung bases. All imaging was reviewed blinded to outcome.

MAIN RESULTS

A tubular T2 hyperintense structure (bronchocele) directed from the lung lesion to the gastroesophageal junction was seen in all cases of esophageal bronchus, but in none of the control cases. In all control cases, the bronchocele was directed to the pulmonary hilum. The presence of cysts or vascular feeding vessels was not statistically significant in identifying an esophageal bronchus lesion. All patients were delivered at term and underwent surgical resection between 5 to 19 weeks of age. No postoperative complications occurred.

CONCLUSION

Prenatal diagnosis of an esophageal bronchus can be strongly suggested by the presence of a T2 hyperintense structure arising from a lung lesion and directed towards the GE junction. These findings may be helpful for better counseling of parents and improved surgical planning.

Brain-type natriuretic peptide levels correlate with pulmonary hypertension and requirement for extracorporeal membrane oxygenation in congenital diaphragmatic hernia

PURPOSE

B-type natriuretic peptide (BNP), an established biomarker of ventricular pressure overload, is used in the assessment of children with pulmonary hypertension (PH). PH is commonly observed in congenital diaphragmatic hernia (CDH). However, the use of BNP levels to guide treatment in this patient population has not been well defined. In this study, we investigate BNP levels in a large cohort of CDH patients treated at a single institution.

METHODS

We retrospectively reviewed charts of all CDH patients enrolled in our pulmonary hypoplasia program from 2004-2013. PH was assessed by echocardiography using defined criteria, and patients were further stratified into the following cohorts: no PH, short-term PH (requiring nitric oxide but no additional vasodilatory therapy), long-term PH (requiring continued vasodilatory therapy post-discharge), and ECMO (requiring ECMO therapy).

RESULTS

A total of 132 patients were studied. BNP levels were significantly increased in patients with PH compared to patients with normal pulmonary pressures (P<0.01). BNP levels were not significantly different between the ST-PH, LT-PH, and ECMO cohorts, but all levels in all three cohorts were significantly increased compared to patients who did not develop PH.

CONCLUSION

Our findings indicate that plasma BNP levels correlate with pulmonary hypertension as well as the requirement for ECMO in CDH patients. Monitoring of serial BNP levels may provide a useful prognostic tool in the management of CDH.

Thoracoamniotic shunts for the management of fetal lung lesions and pleural effusions: a single-institution review and predictors of survival in 75 cases

PURPOSE

Hydrops and pulmonary hypoplasia are associated with significant morbidity and mortality in the setting of a congenital lung lesion or pleural effusion (PE). We reviewed our experience using in utero thoracoamniotic shunts (TA) to manage fetuses with these diagnoses.

METHODS

A retrospective review of fetuses diagnosed with a congenital lung lesion or pleural effusion who underwent TA shunt placement from 1998-2013 was performed.

RESULTS

Ninety-seven shunts were placed in 75 fetuses. Average gestational age (±SD) at shunt placement and birth was 25±3 and 34±5 weeks. Shunt placement resulted in a 55±21% decrease in macrocystic lung lesion volume and complete or partial drainage of the PE in 29% and 71% of fetuses. 69% of fetuses presented with hydrops, which resolved following shunt placement in 83%. Survival was 68%, which correlated with GA at birth, % reduction in lesion size, unilateral pleural effusions, and hydrops resolution. Surviving infants had prolonged NICU courses and often required either surgical resection or tube thoracostomy in the perinatal period.

CONCLUSION

TA shunts provide a therapeutic option for select fetuses with large macrocystic lung lesions or PEs at risk for hydrops and/or pulmonary hypoplasia. Survival following shunting depends on GA at birth, reduction in mass size, and hydrops resolution.

Ex utero intrapartum treatment (EXIT) in the management of cervical lymphatic malformation

PURPOSE

The purpose of this study was to review the outcomes and technical details of EXIT procedures performed in fetuses with large cervical lymphatic malformations.

METHODS

A retrospective chart review of fetuses with a prenatal diagnosis of cervical lymphatic malformation evaluated at our center between 1995 and 2013 was performed.

RESULTS

We evaluated a total of 112 fetuses with a prenatal diagnosis of cervical lymphatic malformation. Thirteen of the 112 fetuses (11%) were delivered by an EXIT procedure. Criteria to deliver by EXIT were: 1) deviation/compression/obstruction of the airway, and 2) involvement of the floor of the mouth. Two fetuses developed hydrops. Five fetuses developed polyhydramnios. Eleven EXITs were performed electively at term (n=7; 37-38 weeks) or late pre-term (n=4; 34-36/6 weeks), whereas two patients underwent emergency EXIT at 33 and 38 weeks, respectively. The airway was accessed successfully in 12 of 13 cases. Laryngoscopy only was sufficient in 7, rigid bronchoscopy was required in 4, and 1 required a tracheostomy. In one case with a massive lymphatic malformation of the face, neck, and airway, a tracheostomy was not attempted, and the fetus expired. Four patients had invasion of the larynx by the lymphatic malformation. Five patients required a tracheostomy later. Median time from fetal exposure to intubation was 8 (2-29) min. Median total EXIT time was 105.5 (67-142) min. Median maternal blood loss was 800 (300-1000) ml. Median maternal hospital stay was 4 (3-6) days.

CONCLUSION

The EXIT procedure allows controlled airway access in fetuses with cervical lymphatic malformations and evidence of airway impairment on prenatal images.

Timing of repair of congenital diaphragmatic hernia in patients supported by extracorporeal membrane oxygenation (ECMO)

PURPOSE

The optimal timing of repair for congenital diaphragmatic hernia (CDH) in patients requiring extracorporeal membrane oxygenation (ECMO) is controversial. Repair during ECMO may improve respiratory function by restoring normal anatomy. However, there is increased risk of complications including surgical bleeding. The purpose of this study was to examine the impact of timing of CDH repair on outcomes in a large cohort of patients treated at a single institution.

METHODS

We retrospectively reviewed charts of all CDH patients in our Pulmonary Hypoplasia Program from 2004 to 2013. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p<0.05).

RESULTS

A total of 77 CDH patients required ECMO support during the study dates. Of these, 16 patients did not survive to repair, 3 patients were repaired prior to cannulation, 41 patients were repaired during ECMO, and 17 patients were repaired after decannulation. Survival was 67%, 43.9%, and 100% for those repaired prior to, during, or post ECMO, respectively, with statistical significance associated with repair after decannulation (P<0.0001). Operative bleeding requiring transfusion occurred in 12 patients repaired on ECMO, while no significant bleeding occurred in patients repaired after decannulation (P=0.003).

CONCLUSION

Outcomes were improved in CDH patients undergoing surgical repair following ECMO with significantly increased survival, lower rates of surgical bleeding, and decreased total duration of ECMO therapy compared to patients repaired on ECMO. In patients who can be successfully weaned from ECMO, our study supports a role for delayed repair off ECMO with reduced operative morbidity and increased survival.

Cardiovascular perforation during placement of an Avalon Elite® Bicaval dual lumen ECMO cannula in a newborn

Proper functioning of the Avalon Elite® bicaval dual lumen ECMO cannula (Maquet Cardiovascular, Wayne, NJ, USA) requires precise placement of the distal draining port within the lumen of the inferior vena cava (IVC). In order to advance the cannula to the correct position, a 0.038" guidewire is placed into the IVC under echocardiographic or fluoroscopic guidance. We report a case of perforation of the intrapericardiac section of the IVC by the guidewire in a neonate, not detected at the time of placement, resulting in cardiac tamponade and death. We recommend routine echocardiographic surveillance after placement of Avalon Elite® cannulas to rule out hemopericardium.

Controversies in the management of severe congenital diaphragmatic hernia

Despite years of progress in perinatal care, severe congenital diaphragmatic hernia (CDH) remains a clinical challenge. Controversies include almost every facet of clinical care: the definition of severe CDH by prenatal and postnatal criteria, fetal surgical intervention, ventilator management, pulmonary hypertension management, use of extracorporeal membrane oxygenation, surgical considerations, and long-term follow-up. Breakthroughs are likely only possible by sharing of experience, collaboration between institutions and innovative therapies within well-designed multicenter clinical trials.

Pulmonary hypertension in giant omphalocele infants

BACKGROUND

Pulmonary hypoplasia has been described in cases of giant omphalocele (GO), although pulmonary hypertension (PH) has not been extensively studied in this disorder. In the present study, we describe rates and severity of PH in GO survivors who underwent standardized prenatal and postnatal care at our institution.

METHODS

A retrospective chart review was performed for all patients in our pulmonary hypoplasia program with a diagnosis of GO. Statistical significance was calculated using Fisher's exact test and Mann-Whitney test (p<0.05).

RESULTS

Fifty-four patients with GO were studied, with PH diagnosed in twenty (37%). No significant differences in gender, gestational ages, birth weight, or Apgar scores were associated with PH. Patients diagnosed with PH were managed with interventions, including high frequency oscillatory ventilation, and nitric oxide. Nine patients required long-term pulmonary vasodilator therapy. PH was associated with increased length of hospital stay (p<0.001), duration of mechanical ventilation (p=0.008), and requirement for tracheostomy (p=0.0032). Overall survival was high (94%), with significantly increased mortality in GO patients with PH (p=0.0460). Prenatal imaging demonstrating herniation of the stomach into the defect was significantly associated with PH (p=0.0322), with a positive predictive value of 52%.

CONCLUSIONS

In this series, PH was observed in 37% of GO patients. PH represents a significant complication of GO, and management of pulmonary dysfunction is a critical consideration in improving clinical outcomes in these patients.

Outcomes of prenatally diagnosed lung lesions in multigestational pregnancies

BACKGROUND

The outcomes of prenatally diagnosed lung lesions in the context of multigestational pregnancies are unknown.

METHODS

Of 960 fetal lung lesion cases evaluated at a single tertiary center over 16 years, 30 occurred in multigestational pregnancies. We reviewed this series to aid in prenatal counseling of affected families and to provide prognostic information for decision making. Pre- and postnatal clinical characteristics were gathered for these pregnancies, and the morbidity and mortality were determined for both affected and normal fetuses, whether twins or triplets.

RESULTS

Mortality was found to be 3/30 (10%) for affected fetuses, and morbidity in normal co-twins was consistent with the degree of prematurity. No morbidity was seen in co-twins born at or after 36 weeks of gestation. Median gestational age at delivery was 35 5/7 weeks.

CONCLUSIONS

Outcomes for the affected fetus correlate with the size and pathophysiologic consequences of the lesion and are not worse than previously reported outcomes for similar lesions in singleton pregnancies, while morbidity in the normal co-twin is consistent with prematurity related to the fetal age of the multiple gestation at delivery, irrespective of the fetal lung lesion.

Fetal Myelomeningocele Repair: The Post-MOMS Experience at the Children's Hospital of Philadelphia

Background: Fetal myelomeningocele (fMMC) repair has become accepted as a standard of care option in selected circumstances. We reviewed our outcomes for fMMC repair from referral and evaluation through surgery, delivery and neonatal discharge. Material and Methods: All patients referred for potential fMMC repair were reviewed from January 1, 2011 through March 7, 2014. Maternal and neonatal data were collected on the 100 patients who underwent surgery. Results: 29% of those evaluated met the criteria and underwent fMMC repair (100 cases). The average gestational age was 21.9 weeks at evaluation and 23.4 weeks at fMMC repair. Complications included membrane separation (22.9%), preterm premature rupture of membranes (32.3%) and preterm labor (37.5%). Average gestational age at delivery was 34.3 weeks and 54.2% delivered at ≥35 weeks. The perinatal loss rate was 6.1% (2 intrauterine fetal demises and 4 neonatal demises); 90.8% of women delivered at the Children's Hospital of Philadelphia and 3.4% received transfusions. With regard to the neonates, 2 received ventriculoperitoneal shunts prior to discharge; 71.1% of neonates had no evidence of hindbrain herniation on MRI. Of the 80 neonates evaluated, 55% were assigned a functional level of one or more better than the prenatal anatomic level. Conclusion: In an experienced program, maternal and neonatal outcomes for patients undergoing fMMC repair are comparable to results of the MOMS trial.

The role of echocardiography in the intraoperative management of the fetus undergoing myelomeningocele repair

INTRODUCTION

Fetal surgery for myelomeningocele (MMC) results in better outcomes compared to postnatal treatment. However, risks are present. We describe our experience with intraoperative fetal echocardiography during repair of MMC and report on the management of serious cardiovascular events.

MATERIAL AND METHODS

The subjects included fetuses with intent to repair MMC from January 2011 to February 2014. The protocol involved continuous echocardiography in a looping, sequential manner of systolic function, heart rate and tricuspid and mitral valve regurgitation.

RESULTS

A total of 101 cases intended fetal MMC repair; 100 completed surgery. Intraoperative ventricular dysfunction was present in 60% (20 mild, 25 moderate, 15 severe). Heart rate <100 bpm was noted in 11 cases. Tricuspid valve regurgitation was present in 35% (26 mild, 7 moderate, 2 severe); mitral valve regurgitation was present in 19% (15 mild, 4 moderate). Serious cardiovascular events were experienced in 7 cases, which affected the conduct of surgery and/or outcome. In 4 of these, medications were given via the umbilical vein and external cardiac compressions were performed. Fetal echocardiography was used to gauge the efficacy of compressions and to guide resuscitation.

DISCUSSION

Cardiovascular compromise is common during fetal surgery for MMC. Intraoperative fetal echocardiography is recommended as a growing number of centers contemplate offering this form of novel, but potentially risky, therapy.

Incidence and factors associated with sensorineural and conductive hearing loss among survivors of congenital diaphragmatic hernia

PURPOSE

The reported incidence of sensorineural hearing loss (SNHL) in long-term survivors of congenital diaphragmatic hernia varies widely in the literature. Conductive hearing loss (CHL) is also known to occur in CDH patients, but has been less widely studied. We sought to characterize the incidence and risk factors associated with SNHL and CHL in a large cohort of CDH patients who underwent standardized treatment and follow-up at a single institution.

METHODS

We retrospectively reviewed charts of all CDH patients in our pulmonary hypoplasia program from January 2004 through December 2012. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p≤0.05).

RESULTS

A total of 112 patients met study inclusion criteria, with 3 (2.7%) patients diagnosed with SNHL and 38 (34.0%) diagnosed with CHL. SNHL was significantly associated with requirement for ECMO (p=0.0130), prolonged course of hospitalization (p=0.0011), duration of mechanical ventilation (p=0.0046), requirement for tracheostomy (p=0.0013), and duration of loop diuretic (p=0.0005) and aminoglycoside therapy (p=0.0003).

CONCLUSIONS

We have identified hearing anomalies in over 30% of long-term CDH survivors. These findings illustrate the need for routine serial audiologic evaluations throughout childhood for all survivors of CDH and stress the importance of targeted interventions to optimize long-term developmental outcomes pertaining to speech and language.

The contribution of hiatal hernia to severe gastroesophageal reflux disease in patients with gastroschisis

BACKGROUND

A relationship between gastroschisis-associated gastroesophageal reflux (GER) and hiatal hernia (HH) has not been previously reported. In reviewing our experience with gastroschisis-related GER, we noted a surprising incidence of associated HH in patients requiring antireflux procedures.

METHODS

A single center retrospective chart review focused on GER in all gastroschisis patients repaired between January 1, 2000 and December 31, 2012 was performed.

RESULTS

Of the 141 patients surviving initial gastroschisis repair and hospitalization, 16 (11.3%) were noted to have an associated HH (12 Type I, 3 Type II, 1 Type III) on upper gastrointestinal series for severe reflux. Ten of the 13 (76.9%) patients who required an antireflux procedure had an associated HH. The time to initiation of feeds was similar in all patients, 19 and 23 days. However, time to full feedings and discharge was delayed until a median of 80 and 96 days, respectively, in HH patients.

CONCLUSIONS

This study describes a high incidence of associated HH in gastroschisis patients. The presence of large associated HH correlated with severe GER, delayed feeding, requirement for antireflux surgery, and a prolonged hospital stay. Patients with gastroschisis and clinically severe GER should undergo early assessment for associated HH.

Urologic and anorectal complications of sacrococcygeal teratomas: prenatal and postnatal predictors

PURPOSE

Anorectal and urologic sequelae are observed in long-term survivors of sacrococcygeal teratoma (SCT). In this study we evaluate the incidence and predictors of anorectal and urologic complications in SCT.

METHODS

A retrospective review was performed for all SCT patients who underwent resection at a single institution between 2000 and 2012. Enrollment criteria included a minimum of 12months follow-up. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann Whitney test (p<0.05).

RESULTS

Forty-five patients were studied. Anorectal complications occurred in 29%, including severe chronic constipation (n=13) and fecal incontinence (n=4). Urologic complications occurred in 33%, including neurogenic bladder (n=12), vesicoureteral reflux (n=5), and urinary incontinence (n=7). Prenatal imaging by fetal MRI demonstrated mass effect with obstruction of the bowel (n=4) or bladder and collecting system (n=7) in a subset of patients with postnatal complications (anorectal 4/4, PPV 100%; urologic 6/7, PPV 86%). Postnatal complications were associated with obstructive findings on prenatal imaging, prenatal therapeutic interventions, Altman classification, perineal reconstruction, and tumor recurrence. No anorectal or urologic complications occurred in patients with Altman type I tumors.

CONCLUSIONS

Urologic and anorectal complications are common in patients with SCT. Higher Altman classification and prenatal imaging suggestive of intestinal or urologic obstruction should prompt focused prenatal counseling and postnatal screening for anorectal and urologic dysfunction.

Longitudinal neurodevelopmental and neuromotor outcome in congenital diaphragmatic hernia patients in the first 3 years of life

OBJECTIVE

The objective of this study was to longitudinally evaluate the neurodevelopmental (ND) outcome in congenital diaphragmatic hernia (CDH) survivors during the first 3 years of life.

STUDY DESIGN

The study cohort consists of 47 CDH survivors that were enrolled in our prospective, follow-up program between July 2004 and September 2010, and underwent serial ND evaluations during the first 3 years of life. ND outcomes were evaluated using the Bayley Scales of Infant Development (BSID)-II or BSID-III. Persistent ND impairment was defined as a score that remained 79 for the cognitive, language and psychomotor domains at the most recent follow-up visit compared with the first assessment.

RESULT

The median age at first and last evaluation was 8 (range, 5 to 15) and 29 (range, 23 to 36) months, respectively. During the follow-up, ND scores improved to average in 17%, remained average in 60%, remained delayed in 10%, improved from severely delayed to mildly delayed in 2% and deteriorated from average to delayed in 15%. Motor scores improved to average in 26%, remained average in 55%, remained delayed in 8% and improved from severely delayed to mildly delayed in 11%. Intrathoracic liver position (P=0.004), preterm delivery (P=0.03), supplemental O2 requirement at day of life 30 (P=0.007), age at discharge (P=0.03), periventricular leukomalacia (PVL; P=0.004) and initial neuromuscular hypotonicity (P=0.01) were associated with persistent motor delays. No relationship was found between patient's characteristics and the risk of persistent cognitive and language delays.

CONCLUSION

(1) The majority of children with CDH are functioning in the average range by early preschool age, (2) most children who had early delays showed improvement in their ND outcome, (3) children showing delays in all the three domains were the least likely to show improvement and (4) CDH severity appears to be predictive of persistent psychomotor delays.

Perinatal management of congenital oropharyngeal tumors: the ex utero intrapartum treatment (EXIT) approach

PURPOSE

To present our experience in the perinatal management of fetuses with large oropharyngeal tumors by ex utero intrapartum treatment (EXIT).

METHODS

We performed a retrospective chart review of all patients with congenital oropharyngeal tumor who underwent an EXIT procedure between May 2006 and June 2012.

RESULTS

Four patients were included in the series, three females and one male. The diagnoses were epignathus (n=2) and congenital epulis (n=2). Three EXITs were done at term and one at late preterm due to premature rupture of membranes. Median maternal time under anesthesia was 185 min (range: 166-281) and median maternal operative time was 99 min (range: 85-153). Median maternal blood loss was 550 ml (range: 350-2000); one mother required a blood transfusion. Mean maternal hospital stay was 4 days. Median hysterotomy-to-cord clamp time was 24 min (range: 18-66). Mean fetal birth weight was 2.7 kg (range: 2.4-3). The airway was successfully accessed and secured under placental circulation in all cases. In the two patients with congenital epulis the tumors were resected at the base of their pedicles and the airway accessed via direct laryngoscopy before the umbilical cord was clamped. One patient with epignathus underwent a retrograde tracheal intubation under placental circulation and had the tumor resected thereafter. The second patient with epignathus had a tracheostomy done under placental circulation and then had tumor debulking immediately after the EXIT. The maternal morbidity was minimal and there were no mortalities.

CONCLUSIONS

We conclude that the EXIT procedure is the ideal delivery strategy for fetuses with prenatally diagnosed oropharyngeal tumors and potential airway obstruction at birth. Patients with prenatally diagnosed oropharyngeal tumors should be promptly referred to a fetal treatment center with a dedicated multidisciplinary team and EXIT capabilities.

Management of prenatally diagnosed congenital diaphragmatic hernia

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.

Assessment of early pulmonary function abnormalities in giant omphalocele survivors

PURPOSE

Infants with giant omphalocele (GO) are at increased risk for persistent respiratory insufficiency, yet information regarding the systematic assessment of their lung function is limited. We performed a group of pulmonary function tests (PFTs) including spirometry, fractional lung volume measurements, assessment of bronchodilator responsiveness, and passive respiratory mechanics in GO survivors during infancy and early childhood to evaluate the nature and degree of pulmonary dysfunction.

MATERIAL AND METHODS

Between July 2004 and June 2008, 30 consecutive GO survivors were enrolled in our interdisciplinary follow-up program. Forty-seven percent (14/30) underwent PFT during follow-up evaluation using the raised volume rapid thoracic compression technique to measure forced expiratory flows and bronchodilator responsiveness, body plethysmography to calculate lung volumes, and the single breath occlusion technique to measure passive mechanics of the respiratory system.

RESULTS

The mean age at PFT assessment was 19.3 ± 19.7 months (range, 1.0-58). Mean forced vital capacity and mean forced expiratory volume in the first 0.5 second were significantly reduced compared with published normative values (P = .03 and P < .01, respectively). Total lung capacity was significantly reduced (P < .001), whereas functional residual capacity, residual volume, and residual volume to total lung capacity ratio were within the normative range (P = .21, P = .34, and P = .48, respectively). Among the 46% who demonstrated significant bronchodilator responsiveness, there were greater increases in the mean percentage changes in flow at 25% to 75% (P = .01), flow at 75% (P < .001), and flow at 85% (P < .001) compared with those participants that did not respond. Specific compliance was reduced, whereas specific conductance increased, compared with published normal results.

CONCLUSIONS

Abnormalities of pulmonary function in GO survivors include lung volume restriction without airway obstruction, an increased likelihood of airway hyperresponsivness, and reduced respiratory system specific compliance. Early recognition of pulmonary functional impairment in GO survivors could help to develop targeted treatment strategies to reduce the risk of subsequent pulmonary morbidity.

Ex utero intrapartum treatment in the management of giant cervical teratomas

PURPOSE

The purpose of this study is to present the outcome and technical details of the Ex Utero Intrapartum Treatment (EXIT) procedure performed in the management of the fetus with a giant cervical teratoma.

METHODS

A retrospective review of the medical records of patients undergoing the EXIT procedure between September 1995 and September 2010 was performed.

RESULTS

Eighty-seven EXIT procedures were performed. In 20% of cases (17/87), the indication was giant cervical teratoma. There were 10 females and 7 males. Polyhydramnios was present in 82%. Median gestational age at EXIT was 35 weeks (range, 30-39 weeks). Median birth weight was 2.5 kg (range, 1.7-3.7 kg). Access to the airway under placental support was established in all cases via direct laryngoscopy/bronchoscopy in 8 patients (47%) and via surgical exploration (tracheostomy or retrograde intubation) in 9 patients (53%). The mortality rate under placental support was zero. Seven patients had the tumors resected immediately after the EXIT, 6 patients had the resection later, and 4 patients died before resection. The neonatal mortality rate was 23% (4/17 patients). Patients who died had severe pulmonary hypoplasia that resulted from the upward traction by the giant cervical mass on the airway and compression of the lungs against the thoracic apex.

CONCLUSIONS

We conclude that the EXIT procedure continues to be the optimal delivery strategy for patients with prenatally diagnosed giant cervical teratomas and potential airway obstruction at birth. A thorough evaluation of the prenatal images and an experienced multidisciplinary team are key factors for an effective approach to the obstructed fetal airway.

Fetal MRI-calculated total lung volumes in the prediction of short-term outcome in giant omphalocele: preliminary findings

OBJECTIVE

To determine the value of fetal MRI-calculated total lung volumes (TLV) in the prediction of short-term outcome in patients with giant omphalocele (GO).

MATERIAL AND METHODS

We reviewed all cases of GO undergoing fetal MRI after 21 weeks' gestation and receiving postnatal care at our institution between 2003 and 2010. Observed/expected (O/E) TLV was calculated using age-matched TLV normograms [Radiology 2001;219:236-241]. Postnatal outcomes were stratified based on O/E TLV above or below 50% of expected.

RESULTS

Seventeen GO cases fulfilled the entry criteria. The mean age at fetal MRI evaluation was 25.8 ± 4.8 weeks' gestation. The mean GO TLV (21.0 ± 13.2) was lower than age-matched population norms (p < 0.001), resulting in a mean O/E TLV of 52.3 ± 16.8%. The mean gestational age at delivery was 36.8 ± 1.6 weeks. Overall survival was 94%. Fourteen (88%) infants underwent staged reduction, and 2 underwent silver sulfadiazine treatment and delayed repair. Infants with ≤50% of predicted O/E TLV (n = 11, 65%) had lower Apgar scores at birth (p = 0.03), prolonged ventilatory support (p = 0.004), delayed oral intake (p = 0.03), and longer hospitalization (p = 0.03) compared to patients with ≥50% of expected O/E TLV. Two infants (both O/E TLV <50%) required tracheostomy placement.

CONCLUSION

In the assessment of GO fetuses, MRI-based O/E TLV of <50% was predictive of increased postnatal morbidity.

Early neurodevelopmental outcome of infants with high-risk fetal lung lesions

OBJECTIVE

To evaluate the neurodevelopmental outcome of infants with high-risk fetal lung lesions defined as (1) requiring fetal intervention and/or ex utero intrapartum therapy (EXIT), or (2) acute respiratory decompensation postnatally necessitating emergent resection within 48 h of life.

METHODS

We reviewed the medical records of 13 consecutive patients with high-risk fetal lung lesions who were enrolled in our prospective interdisciplinary follow-up program. Neurodevelopmental status was evaluated using the Bayley Scales of Infant Development-III (children ≤3 years, n = 12), or the Wechsler Preschool and Primary Scale of Intelligence-III (children ≥4 years, n = 1).

RESULTS

Eight children (62%) underwent prenatal intervention (EXIT, n = 6; fetal resection, n = 1; intrauterine shunt placement, n = 1), and 5 (38%) required emergent resection postnatally. Median age at evaluation was 25 months (range: 5-80). Average scores for cognitive development were found in all children assessed under 3 years of age. The one child who was tested for cognitive ability at 6 years of age scored in the borderline range of intellectual functioning. For language outcome, 15% scored above average, 54% scored within the average range, and 31% had mild deficits. Overall, 77% scored within the average range for neuromotor outcome, while 23% scored within the mildly delayed range. None of the children had severe delays. Cognitive, language, and psychomotor scores were similar between both groups. Hypotonicity was found in 23%. Autism was suspected in one child who underwent an EXIT procedure and was postnatally diagnosed with mosaic trisomy 18.

CONCLUSION

The majority of children with high-risk fetal lung lesions have age-appropriate neurodevelopmental scores.

Abnormal brain development and maturation on magnetic resonance imaging in survivors of severe congenital diaphragmatic hernia

PURPOSE

The aim of the study was to evaluate the incidence of abnormal brain maturation in survivors of severe congenital diaphragmatic hernia (CDH).

MATERIAL AND METHODS

Between July 2004 and December 2009, 50 CDH survivors underwent detailed brain magnetic resonance (MR) imaging before discharge. Magnetic resonance images were analyzed to evaluate the presence of structural brain abnormalities and to calculate overall brain maturation using the total maturation score (TMS).

RESULTS

Thirty-two children (64%) underwent MR imaging between 39 and 43 weeks of gestation, allowing for evaluation of the TMS. Eighteen (36%) underwent MR imaging between 44 and 69 weeks of gestation, allowing for structural analysis of brain maturity only. The mean TMS was 14.1 ± 1.2 and significantly lower than reported age-matched normative data in infants without CDH (15.3 ± 1.0, P = .02). The TMS in 4 patients (12.5%) corresponded to a delay of 1 month in structural brain development. Eight infants (25%) demonstrated a 2-week delay. Periventricular leukomalacia was detected in 9 (18%), incomplete development of the opercula in 7 (14%), various degrees of intracranial hemorrhage in 24 (48%), and prominent extraaxial fluid spaces in 20 (40%) cases.

CONCLUSIONS

Brain maturation in infants with severe CDH appears to be delayed. Long-term neurodevelopmental follow-up is needed to determine the significance of a lower-than-expected TMS and the presence of structural brain abnormalities on functional outcomes in this population.

Hypertensive retinopathy in a child caused by pheochromocytoma: identification after a failed school vision screening

A 7-year-old girl was referred for ophthalmological examination after the result of a routine school vision screening identified unilateral vision loss. Fundus examination showed bilateral but markedly asymmetric macular exudates and optic disk edema. After the results of two blood pressure measurements were within normal limits, a third markedly elevated measurement revealed malignant hypertension and led to a diagnosis of pheochromocytoma, a rare catecholamine-secreting tumor. The tumor was resected, and 6 months later the patient's blood pressure had normalized; however, although visual acuity had improved to 20/20 in the right eye, it remained 20/200 in the left eye, with decreased disk edema but the persistence of the macular exudates. The identification of an abdominal malignancy through a school vision screening may have saved this child's life. The need for repeated blood pressure measurement is also highlighted.

Neurodevelopmental and neurofunctional outcomes in children with congenital diaphragmatic hernia

The objective of this review was to provide a critical overview of our current understanding on the neurocognitive, neuromotor, and neurobehavioral development in congenital diaphragmatic hernia (CDH) patients, focusing on three interrelated clinical issues: (1) comprehensive outcome studies, (2) characterization of important predictors of adverse outcome, and (3) the pathophysiological mechanism contributing to neurodevelopmental disabilities in infants with CDH. Improved survival for CDH has led to an increasing focus on longer-term outcomes. Neurodevelopmental dysfunction has been recognized as the most common and potentially most disabling outcome of CDH and its treatment. While increased neuromotor dysfunction is a common problem during infancy, behavioral problems, hearing impairment and quality of life related issues are frequently found in older children and adolescence. Intelligence appears to be in the low normal range. Patient and disease specific predictors of adverse neurodevelopmental outcome have been defined. Imaging studies have revealed a high incidence of structural brain abnormalities. An improved understanding of the pathophysiological pathways and the neurodevelopmental consequences will allow earlier and possibly more targeted therapeutic interventions. Continuous assessment and follow-up as provided by an interdisciplinary team of medical, surgical and developmental specialists should become standard of care for all CDH children to identify and treat morbidities before additional disabilities evolve and to reduce adverse outcomes.

Early delivery as an alternative management strategy for selected high-risk fetal sacrococcygeal teratomas

BACKGROUND

Large, prenatally diagnosed sacrococcygeal teratomas (SCTs) present a formidable challenge because of their unpredictable growth and propensity for complications. In our experience, even with aggressive serial imaging, many fetuses have died under a policy of "watchful waiting." We propose "early delivery" as the best option for selected cases of high-risk fetal SCT.

METHODS

The medical charts of all fetuses with SCT followed up at our institution and delivered before 32 weeks of gestation were reviewed for radiologic findings, fetal interventions, delivery information, perinatal inpatient course, and autopsy or discharge report.

RESULTS

Between 1996 and 2009, excluding those that underwent fetal surgery, 9 patients with fetal SCT were delivered before 32 weeks of gestation. Four had type I tumors, and 5 had type II tumors. Of the 9 fetuses, 4 survived the neonatal period. The only surviving patient delivered before 28 weeks underwent an ex utero intrapartum therapy procedure.

CONCLUSIONS

A significant number of pregnancies complicated by high-risk SCT will manifest signs of fetal or maternal decompensation, or both, between 27 and 32 weeks of gestation. In the absence of fulminant hydrops, preemptive early delivery can be associated with surprisingly good outcomes in appropriately selected fetuses with high-risk SCT.

Jaagsiekte sheep retrovirus pseudotyped lentiviral vector-mediated gene transfer to fetal ovine lung

Viral vector-mediated gene transfer to the postnatal respiratory epithelium has, in general, been of low efficiency due to physical and immunological barriers, non-apical location of cellular receptors critical for viral uptake and limited transduction of resident stem/progenitor cells. These obstacles may be overcome using a prenatal strategy. In this study, HIV-1-based lentiviral vectors (LVs) pseudotyped with the envelope glycoproteins of Jaagsiekte sheep retrovirus (JSRV-LV), baculovirus GP64 (GP64-LV), Ebola Zaire-LV or vesicular stomatitis virus (VSVg-LV) and the adeno-associated virus-2/6.2 (AAV2/6.2) were compared for in utero transfer of a green fluorescent protein (GFP) reporter gene to ovine lung epithelium between days 65 and 78 of gestation. GFP expression was examined on day 85 or 136 of gestation (term is ∼145 days). The percentage of the respiratory epithelial cells expressing GFP in fetal sheep that received the JSRV-LV (3.18 × 10(8)-6.85 × 10(9) viral particles per fetus) was 24.6±0.9% at 3 weeks postinjection (day 85) and 29.9±4.8% at 10 weeks postinjection (day 136). Expression was limited to the surface epithelium lining fetal airways <100 μm internal diameter. Fetal airways were amenable to VSVg-LV transduction, although the percentage of epithelial expression was low (6.6±0.6%) at 1 week postinjection. GP64-LV, Ebola Zaire-LV and AAV2/6.2 failed to transduce the fetal ovine lung under these conditions. These data demonstrate that prenatal lung gene transfer with LV engineered to target apical surface receptors can provide sustained and high levels of transgene expression and support the therapeutic potential of prenatal gene transfer for the treatment of congenital lung diseases.

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst

PURPOSE

Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures.

METHODS

A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests.

RESULTS

Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037).

CONCLUSIONS

In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.