1
|
Gigola F, Morini F, Libro G, Morabito A, Grimaldi C. Congenital hepatoblastoma: Expanding knowledge, improving outcomes. Pediatr Blood Cancer 2024; 71:e31132. [PMID: 38952263 DOI: 10.1002/pbc.31132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/13/2024] [Accepted: 05/19/2024] [Indexed: 07/03/2024]
Abstract
Hepatoblastoma (HB) is a rare liver tumour, and its congenital counterpart (CHB) is even less frequent. CHB has a clinically challenging management and a generally perceived worse outcome. This study aims to review the literature on CHB to better define presentation, diagnosis, available treatments and management options. The analysis of outcomes suggests that a significant portion of mortality is unrelated to the malignant nature of the tumour. Key factors influencing overall outcomes were identified: mortality linked to the 'mass effect' during both the prenatal (22%) and perinatal (32%) stages, as well as 'oncological' mortality encompassing tumour and/or treatment-related factors (46%). Overall, after birth, CHB does not seem to confer a worse oncological prognosis per se, and should be managed similarly to older children, if patients are stable enough to undergo proper staging and treatment. A deeper knowledge and better outcomes would come from a large, homogeneous, collection of data possibly allowing a global protocol, focusing on a comprehensive management of CHB.
Collapse
Affiliation(s)
- Francesca Gigola
- School of Pediatric Surgery, University of Florence, Florence, Italy
- Department of Pediatric and Neonatal Surgery, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesco Morini
- Department of Pediatric and Neonatal Surgery, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Giorgia Libro
- School of Pediatric Surgery, University of Florence, Florence, Italy
- Department of Pediatric and Neonatal Surgery, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Antonino Morabito
- Department of Pediatric and Neonatal Surgery, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Chiara Grimaldi
- Department of Pediatric and Neonatal Surgery, Meyer Children's Hospital IRCCS, Florence, Italy
| |
Collapse
|
2
|
Konno H, Okpaise OO, Sbragia L, Tonni G, Ruano R. Perinatal Outcomes of Intrauterine Interventions for Fetal Sacrococcygeal Teratoma Based on Different Surgical Techniques-A Systematic Review. J Clin Med 2024; 13:2649. [PMID: 38731178 PMCID: PMC11084939 DOI: 10.3390/jcm13092649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/16/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Background: This study aims to evaluate the outcomes of fetal sacrococcygeal teratoma (SCT) submitted to prenatal interventions. Methods: We performed a systematic literature review of fetal SCT patients and compared the outcomes between open fetal surgery and percutaneous intervention. In addition, we also compared the results of SCT fetuses who did not undergo any surgical intervention (NI). Results: We identified 16 cases of open fetal surgery (OS), 48 cases of percutaneous fetal intervention (PI), and 93 NI patients. The survival rate was 56.2% in OS, 45.8% in PI (p = 0.568), and 71.0% in NI patients. The gestational age at delivery was earlier in cases where there was no survival compared to cases where the fetuses did survive across all evaluated cohorts (OS: p = 0.033, PI: p < 0.001, NI: p < 0.001). The gestational weeks at delivery in OS and PI fetuses were more similar; however, OS tended to be performed later on in pregnancy, and the affected fetuses had more severe presented findings. In our evaluation, we determined that the presence of fetal hydrops and cardiac failure had no significant impact on survival in SCT cases. In NI patients, polyhydramnios was much higher in fetuses who did not survive compared to their surviving cohorts (p < 0.001). Conclusions: In conclusion, gestational age at delivery can affect the short-term prognosis of fetuses affected with sacrococcygeal teratomas. Regardless of the mode of delivery or the necessity for intervention during the fetal period, monitoring for complications, including polyhydramnios, can prevent premature delivery.
Collapse
Affiliation(s)
- Hiroko Konno
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu 430-0906, Japan;
| | | | - Lourenço Sbragia
- Division of Pediatric Surgery, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto 14049-900, SP, Brazil;
| | - Gabriele Tonni
- Prenatal Diagnostic Centre, Department of Obstetrics and Neonatology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami, Miami, FL 33136, USA
| |
Collapse
|
3
|
Creden SP, Portuondo J, Cheng LS, Halaweish I, Keswani SG, King AL, Lee TC, Sun RC. Approach and Technique for Cesarean Section to Immediate Resection for High-Risk Sacrococcygeal Teratomas. J Surg Res 2023; 292:38-43. [PMID: 37579714 DOI: 10.1016/j.jss.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Ex-utero intrapartum treatment has been established as an option for fetal and perinatal surgeons to deliver patients with sacrococcygeal teratomas (SCTs) which are causing significant fetal distress and possible in-utero fetal demise. However, ex-utero intrapartum treatment procedures carry significant maternal risk and morbidity. Herein, we report an alternative technique of Cesarean section to immediate resection (CSIR) for managing high-risk SCTs. METHODS A retrospective institutional review board-approved review was performed on all SCTs evaluated at our fetal center from May 2014 to September 2020. Demographics; prenatal imaging characteristics; prenatal interventions; and postnatal surgery data including operative time, estimated blood loss, pathology, and outcomes were collected. Outcomes of interest included surveillance serum alpha-fetoprotein levels, imaging surveillance, developmental milestones, and the presence or absence of constipation or fecal incontinence. RESULTS A total of 20 patients with prenatal diagnosis of SCT were evaluated. Mothers who transferred their care to another institution after diagnosis were excluded from this study. Twelve neonates underwent standard postnatal resection. Three neonates underwent emergent CSIR for high output cardiac failure, fetal anemia, or concerns for in-utero hemorrhagic rupture. The median (interquartile range) operative time was 231.5 (113) minutes for the standard operative group versus 156 min in the CSIR group. We present three patients who underwent immediate resection after emergent Cesarean section. We report 100% survival for the three consecutive cases. CONCLUSIONS CSIR is a safe and feasible approach for managing appropriately selected high-risk SCTs with signs of hydrops, fetal distress, or fetal anemia. Despite patient prematurity, we demonstrated 100% survival of three consecutive cases. We suggest that CSIR be considered an option in the management algorithm for high-risk SCTs.
Collapse
Affiliation(s)
- Samuel P Creden
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jorge Portuondo
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lily S Cheng
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ihab Halaweish
- Division of Pediatric Surgery, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Alice L King
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Raphael C Sun
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.
| |
Collapse
|
4
|
Menchaca AD, Olutoye OO, Cass DL, Marwan AI. Percutaneous versus Open Fetal Surgical Intervention for Sacrococcygeal Teratomas: Is Less Really More? Fetal Diagn Ther 2023; 50:313-331. [PMID: 37604120 DOI: 10.1159/000533634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Sacrococcygeal teratomas (SCTs) may require in utero intervention for survival. Open surgical intervention (OSI) was first described, but increasing reports of percutaneous intervention (PI) with variable indications and outcomes exist. We reviewed the literature for all published cases of fetal SCT intervention and compared OSI to PI cohorts. METHODS A keyword search of PubMed was conducted. Inclusion criteria were as follows: data available per individual fetus including gestational age at intervention, type of intervention, primary indication, survival, gestational age at birth, and complications. Complications were grouped into categories: placenta/membrane, procedural, or hemorrhagic. Failure was defined as little/no improvement or recurrence of the primary indication. χ2 analysis was performed for solid tumor PI versus OSI to assess significant trends in these intervention groups. A meta-analysis was not feasible due to small numbers and heterogeneity. RESULTS Twenty-seven articles met inclusion criteria. In the PI group, 38 fetuses underwent intervention for solid tumors, 21 for cystic tumors, and 3 for solid and cystic tumor components. Among fetuses with solid tumors, OSI was associated with lower need for multiple interventions (0% vs. 31.6%, p = 0.01) and higher survival to discharge (50% vs. 39.5%, p = 0.02). A fetal intervention was performed in the absence of hydrops/early hydrops in 45% of fetuses receiving PI, compared to 21% receiving OSI. Failure to resolve the primary indication was higher in the PI group (55.9% vs. 11.1% OSI, p = 0.02). The overall complication rates were high in both groups (90% OSI, 87% PI), though bleeding was unique to the PI group (26.5%). Preemptive cyst drainage, for purely cystic tumors, was universally successful and associated with a low complication risk (18.2%). CONCLUSIONS For solid tumors, OSI appears to be superior with regard to survival to discharge, fewer interventions, and lower failure rates. PIs to drain a cyst may facilitate delivery or preempt future complications, though consideration should be given to long-term oncologic outcomes.
Collapse
Affiliation(s)
- Alicia D Menchaca
- Center for Regenerative Medicine, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA,
- Department of General Surgery, Indiana University, Indianapolis, Indiana, USA,
| | - Oluyinka O Olutoye
- Center for Regenerative Medicine, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Darrell L Cass
- Fetal Care Center, Section of Pediatric Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ahmed I Marwan
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital, University of Missouri School of Medicine, Columbia, Missouri, USA
| |
Collapse
|
5
|
Fulati A, Uto K, Iwanaga M, Watanabe M, Ebara M. Smart Shape-Memory Polymeric String for the Contraction of Blood Vessels in Fetal Surgery of Sacrococcygeal Teratoma. Adv Healthc Mater 2022; 11:e2200050. [PMID: 35385611 DOI: 10.1002/adhm.202200050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/01/2022] [Indexed: 12/19/2022]
Abstract
Shape-memory polymers (SMPs) are promising materials in numerous emerging biomedical applications owing to their unique shape-memory characteristics. However, simultaneous realization of high strength, toughness, stretchability while maintaining high shape fixity (Rf ) and shape recovery ratio (Rr ) remains a challenge that hinders their practical applications. Herein, a novel shape-memory polymeric string (SMP string) that is ultra-stretchable (up to 1570%), strong (up to 345 MPa), tough (up to 237.9 MJ m-3 ), and highly recoverable (Rf averagely above 99.5%, Rr averagely above 99.1%) through a facile approach fabricated solely by tetra-branched poly(ε-caprolactone) (PCL) is reported. Notably, the shape-memory contraction force (up to 7.97 N) of this SMP string is customizable with the manipulation of their energy storage capacity by adjusting the string thickness and stretchability. In addition, this SMP string displays a controllable shape-memory response time and demonstrates excellent shape-memory-induced contraction effect against both rigid silicone tubes and porcine carotids. This novel SMP string is envisioned to be applied in the contraction of blood vessels and resolves the difficulties in the restriction of blood flow in minimally invasive surgeries such as fetoscopic surgery of sacrococcygeal teratoma (SCT).
Collapse
Affiliation(s)
- Ailifeire Fulati
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
- Graduate School of Science and Technology University of Tsukuba Tsukuba 3058577 Japan
| | - Koichiro Uto
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
| | - Masanobu Iwanaga
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
| | - Miho Watanabe
- Department of Pediatric Surgery Graduate School of Medicine Osaka University Osaka 5650871 Japan
| | - Mitsuhiro Ebara
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
- Graduate School of Science and Technology University of Tsukuba Tsukuba 3058577 Japan
- Graduate School of Advanced Engineering Tokyo University of Science Tokyo 1258585 Japan
| |
Collapse
|
6
|
Lin TY, Wataganara T, Shaw SW. From non-invasive to invasive fetal therapy: A comprehensive review and current update. Taiwan J Obstet Gynecol 2021; 60:595-601. [PMID: 34247794 DOI: 10.1016/j.tjog.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
"Fetus as patient" indicates fundamental concept of fetal therapy. With advance in maternal serum analysis and fetal imaging, prenatal screening has become standard of care. Accurate diagnosis in early gestation allows intervention to reverse pathophysiology and delay progression immediately. Non-invasive, minimally invasive and invasive therapies demonstrate their therapeutic potential in certain diseases. Recently, stem cell and gene therapies have been developed to avoid irreversible impairment. To elevate efficacy of treatment modality, extensive studies should be conducted according to regulatory authority. Striking a balance between scientific and ethical integrity is essential, so long-term follow up should be arranged for protecting mother and fetus.
Collapse
Affiliation(s)
- Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Steven W Shaw
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom.
| |
Collapse
|
7
|
Jha P, Feldstein VA, Revzin MV, Katz DS, Moshiri M. Role of Imaging in Obstetric Interventions: Criteria, Considerations, and Complications. Radiographics 2021; 41:1243-1264. [PMID: 34115536 DOI: 10.1148/rg.2021200163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2021.
Collapse
Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| |
Collapse
|
8
|
Abstract
This article reviews the contemporary diagnosis and management of the most common abdominal neoplasms and cystic lesions diagnosed in the fetus. Fetal tumors discussed include teratomas (sacrococcygeal, cervical or mediastinal), mesoblastic nephroma, nephroblastoma (Wilms' tumor), neuroblastoma, and hepatoblastoma. Fetal abdominal cystic lesions discussed include ovarian cyst, choledochal cyst, intestinal duplication cyst, mesenteric cyst, simple hepatic cyst, and meconium pseudocyst. We discuss the rare indications for fetal intervention or fetal surgery and other perinatal management, including prenatal interventions and fetal surgery for sacrococcygeal teratoma. The lesions reviewed are detected by widespread use of screening ultrasonography during pregnancy. Work-up for these abnormalities may include fetal MRI which enhances the diagnostic accuracy of abdominal tumors and cystic lesions and can aid in characterization of the lesion in relationship to surrounding anatomic structures. Accurate prenatal diagnosis of such lesions permits recommendations for optimal location and timing of delivery, and inclusion of appropriate caregivers and expertise to facilitate postnatal management. Perinatal management of the fetus with a neoplasm requires consideration of the optimal timing and mode of delivery, and pediatric oncology and surgical specialty care. The majority of tumors diagnosed antenatally have good prognosis with current multimodality treatment.
Collapse
|
9
|
Phi JH. Sacrococcygeal Teratoma : A Tumor at the Center of Embryogenesis. J Korean Neurosurg Soc 2021; 64:406-413. [PMID: 33906346 PMCID: PMC8128526 DOI: 10.3340/jkns.2021.0015] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
Sacrococcygeal teratoma (SCT) is an extragonadal germ cell tumor (GCT) that develops in the fetal and neonatal periods. SCT is a type I GCT in which only teratoma and yolk sac tumors arise from extragonadal sites. SCT is the most common type I GCT and is believed to originate through epigenetic reprogramming of early primordial germ cells migrating from the yolk sac to the gonadal ridges. Fetal SCT diagnosed in utero presents many obstetrical problems. For high-risk fetuses, fetal interventions (devascularization and debulking) are under development. Most patients with SCT are operated on after birth. Complete surgical resection is the key for tumor control, and the anatomical location of the tumor determines the surgical approaches. Incomplete resection and malignant histology are risk factors for recurrence. Approximately 10-15% of patients have a tumor recurrence, which is frequently of malignant histology. Long-term surveillance with monitoring of serum alpha fetoprotein and magnetic resonance imaging is required. Survivors of SCT may suffer anorectal, urological, and sexual sequelae later in their life, and comprehensive evaluation and care are required.
Collapse
Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
10
|
Fetal anesthesia: intrauterine therapies and immediate postnatal anesthesia for noncardiac surgical interventions. Curr Opin Anaesthesiol 2020; 33:368-373. [PMID: 32324666 DOI: 10.1097/aco.0000000000000862] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review describes maternal and fetal anesthetic management for noncardiac fetal surgical procedures, including the management of lower urinary tract obstruction, congenital diaphragmatic hernia (CDH), myelomeningocele, sacrococcygeal teratoma, prenatally anticipated difficult airway and congenital lung lesions. RECENT FINDINGS Fetal interventions range from minimally invasive fetoscopic procedures to mid-gestation open surgery, to ex-utero intrapartum treatment procedure. Anesthetic management depends on the fetal intervention and patient characteristics. Anesthesia for most minimally invasive procedures can consist of intravenous sedation and local anesthetic infiltration in clinically appropriate maternal patients. Open fetal and ex-utero intrapartum treatment procedures require maternal general anesthesia with volatile anesthetic and other medications to maintain uterine relaxation. Tracheal balloons are a promising therapy for CDH and can be inserted via minimally invasive techniques. Management of the prenatally anticipated difficult airway during delivery and removal of tracheal balloons from patients with CDH during delivery can be clinically dynamic and require flexibility, seamless communication and a high-functioning, multidisciplinary care team. SUMMARY Maternal and fetal anesthetic management is tailored to the fetal intervention and the underlying health of the fetus and mother.
Collapse
|
11
|
Litwińska M, Litwińska E, Janiak K, Piaseczna-Piotrowska A, Szaflik K. Percutaneous Intratumor Laser Ablation for Fetal Sacrococcygeal Teratoma. Fetal Diagn Ther 2019; 47:138-144. [PMID: 31291630 DOI: 10.1159/000500775] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the efficiency of percutaneous intratumor laser ablation for fetal solid sacrococcygeal teratoma (SCT). SUBJECTS AND METHODS We carried out percutaneous ultrasound-guided intratumor laser ablation through a 17-gauge needle using an output of 40 W in 7 fetuses with large solid SCT and reviewed the literature for minimally invasive therapy for this condition. RESULTS Laser ablation was carried out at a median gestational age of 20 (range 19-23) weeks, and in all cases there was elimination of obvious vascularization within the tumor and improvement in cardiac function. Three (43%) babies survived and had surgical excision of the tumor within 2 days of birth, 3 liveborn babies died within 5 days of birth and before surgery, and 1 fetus died within 2 weeks after the procedure. In previous series of various percutaneous interventions for predominantly solid SCT the survival rate was 33% (2/6) (95% CI 9.7-70%) for endoscopic laser to superficial vessels, 57% (4/7) (95% CI 25-84%) for intratumor laser, 67% (8/12) (95% CI 39-86%) for intratumor radiofrequency ablation, and 20% (1/5) (95% CI 3.6-62%) for intratumor injection of alcohol. CONCLUSIONS In solid SCT, the reported survival from intratumor laser or radiofrequency ablation is about 50%, but survival does not mean success, and it remains uncertain whether such interventions are beneficial or not because the number of fetuses is small and there were no controls that were managed expectantly.
Collapse
Affiliation(s)
- Magdalena Litwińska
- Department of Gynecology, Fertility, and Fetal Surgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland,
| | - Ewelina Litwińska
- Department of Perinatology and Gynecology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Katarzyna Janiak
- Department of Gynecology, Fertility, and Fetal Surgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Anna Piaseczna-Piotrowska
- Department of Pediatric Surgery and Urology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Krzysztof Szaflik
- Department of Gynecology, Fertility, and Fetal Surgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| |
Collapse
|
12
|
Gebb J, Khalek N, Qamar H, Johnson M, Oliver E, Coleman B, Peranteau W, Hedrick H, Flake A, Adzick N, Moldenhauer J. High Tumor Volume to Fetal Weight Ratio Is Associated with Worse Fetal Outcomes and Increased Maternal Risk in Fetuses with Sacrococcygeal Teratoma. Fetal Diagn Ther 2018; 45:94-101. [DOI: 10.1159/000486782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022]
|
13
|
Abstract
Fetal surgery corrects severe congenital anomalies in utero to prevent their severe consequences on fetal development. The significant risk of open fetal operations to the pregnant mother has driven innovation toward minimally invasive procedures that decrease the risks inherent to hysterotomy. In this article, we discuss the basic principles of minimally invasive fetal surgery, the general history of its development, specific conditions and procedures used to treat them, and the future of the field.
Collapse
Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA
| | - Michael R Harrison
- University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA.
| |
Collapse
|