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Dütemeyer V, Schaible T, Badr DA, Cordier AG, Weis M, Perez-Ortiz A, Carriere D, Cannie MM, Vuckovic A, Persico N, Cavallaro G, Benachi A, Jani JC. Fetoscopic endoluminal tracheal occlusion vs expectant management for fetuses with severe left-sided congenital diaphragmatic hernia. Am J Obstet Gynecol MFM 2024; 6:101248. [PMID: 38070678 DOI: 10.1016/j.ajogmf.2023.101248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/14/2023] [Accepted: 12/02/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The treatment of fetuses with a congenital diaphragmatic hernia is challenging, but there is evidence that fetoscopic endoluminal tracheal occlusion has a benefit over expectant care. In addition, standardization and expertism have a great impact on survival and are probably crucial in centers that rely on expectant management with extracorporeal membrane oxygenation after birth. OBJECTIVE This study aimed to examine the survival and morbidity rates of fetuses with a severe isolated left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion vs expectant management in high-volume centers. STUDY DESIGN This was a multicenter, retrospective study that included all consecutive fetuses with severe isolated left-sided congenital diaphragmatic hernia who were expectantly managed in a German center or who underwent fetoscopic endoluminal tracheal occlusion in 3 other European centers (Belgium, France, and Italy). Severe congenital diaphragmatic hernia was defined as having an observed to expected total fetal lung volume ≤35% with intrathoracic position of the liver diagnosed with magnetic resonance imaging. All magnetic resonance images were centralized, and lung volumes were measured by 2 experienced operators who were blinded to the pre- and postnatal data. Multiple logistic regression analyses were performed to examine the effect of the management strategy in the 2 groups on the short- and long-term outcomes. RESULTS A total of 147 patients who were managed expectantly and 47 patients who underwent fetoscopic endoluminal tracheal occlusion were analyzed. Fetuses who were managed expectantly had lower observed to expected total fetal lung volumes (20.6%±7.5% vs 23.7%±6.8%; P=.013), higher gestational age at delivery (median weeks of gestation, 37.4; interquartile range, 36.6-38.00 vs 35.1; interquartile range, 33.1-37.2; P<.001), and more frequent use of extracorporeal membrane oxygenation (55.8% vs 4.3%; P<.001) than the fetuses who underwent fetoscopic endoluminal tracheal occlusion. The survival rates at discharge and at 2 years of age in the expectant management group were higher than the survival rates of the fetoscopic endoluminal tracheal occlusion group (74.3% vs 44.7%; P=.001 and 72.8% vs 42.5%; P=.001, respectively). After adjustment for maternal age, gestational age at birth, observed to expected total fetal lung volume, and birth weight Z-score, the odds ratios were 4.65 (95% confidence interval, 1.9-11.9; P=.001) and 4.37 (95% confidence interval, 1.8-11.0; P=.001), respectively. CONCLUSION Fetuses with a severe isolated left-sided congenital diaphragmatic hernia had a higher survival rate when treated in an experienced center in Germany with antenatal expectant management and frequent use of extracorporeal membrane oxygenation during the postnatal period than fetuses who were treated with fetoscopic endoluminal tracheal occlusion in 3 centers in Belgium, France, and Italy.
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Affiliation(s)
- Vivien Dütemeyer
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (Drs Dütemeyer)
| | - Thomas Schaible
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani)
| | - Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Meike Weis
- Department of Radiology, Universitätsklinikum Mannheim, Mannheim, Germany (Dr Weis)
| | - Alba Perez-Ortiz
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Diane Carriere
- Service de Réanimation Pédiatrique, Hôpital Bicêtre- AP-HP, Université Paris Saclay, Le Kremlin Bicêtre, France (Dr Carriere)
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Dr Cannie)
| | - Aline Vuckovic
- Neonatal Intensive Care Unit, Queen Fabiola Children's Hospital-ULB, Brussels, Belgium (Dr Vuckovic)
| | - Nicola Persico
- Fetal Medicine and Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Persico); Department of Clinical Science and Community Health, University of Milan, Milan, Italy (Dr Persico)
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Cavallaro)
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani).
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2
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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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3
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Schwab ME, Lee H, Tsao K. In Utero Therapy for Congenital Diaphragmatic Hernia. Clin Perinatol 2022; 49:863-872. [PMID: 36328604 DOI: 10.1016/j.clp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital diaphragmatic hernia is an anomaly that is often prenatally diagnosed and spans a wide spectrum of disease, with high morbidity and mortality associated with fetuses with severe defects. Congenital diaphragmatic hernia is thus an ideal target for fetal intervention. We review the literature on prenatal diagnosis, describe the history of fetal intervention for congenital diaphragmatic hernia, and discuss fetal endoscopic tracheal occlusion and the Tracheal Occlusion To Accelerate Lung growth trial results. Finally, we present preclinical studies for potential future directions.
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Affiliation(s)
- Marisa E Schwab
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA; Department of Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Hanmin Lee
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA.
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4
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The Rearing of Maternal-Fetal Surgery: The Maturation of a Field from Conception to Adulthood. Clin Perinatol 2022; 49:799-810. [PMID: 36328599 DOI: 10.1016/j.clp.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Maternal-fetal surgery is fraught with inherent controversy from within the medical community and general public. Despite these challenges, the field of maternal-fetal surgery evolved into an international enterprise. Carefully nurtured by pioneers with foresight and resilience, the field navigated ethical dilemmas with rigorous scientific methodology, collaboration, transparency, and accordance. These central pillars are consistent throughout the brief but momentous history of maternal-fetal surgery, serving as the catalyst for its success. The maturation of fetal intervention is an exemplar of technological innovation propelling clinical innovation, as well as a celebration of mastering the delicate balance between caution and optimism.
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5
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Dahl MJ, Lavizzari A, Davis JW, Noble PB, Dellacà R, Pillow JJ. Impact of fetal treatments for congenital diaphragmatic hernia on lung development. Anat Rec (Hoboken) 2022. [PMID: 36065499 DOI: 10.1002/ar.25059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022]
Abstract
The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.
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Affiliation(s)
- Mar Janna Dahl
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Anna Lavizzari
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jonathan W Davis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Peter B Noble
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Raffaele Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - J Jane Pillow
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
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6
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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7
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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8
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Olutoye Ii OO, Short WD, Gilley J, Hammond Ii JD, Belfort MA, Lee TC, King A, Espinoza J, Joyeux L, Lingappan K, Gleghorn JP, Keswani SG. The Cellular and Molecular Effects of Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:925106. [PMID: 35865706 PMCID: PMC9294219 DOI: 10.3389/fped.2022.925106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a complex disease associated with pulmonary hypoplasia and pulmonary hypertension. Great strides have been made in our ability to care for CDH patients, specifically in the prenatal improvement of lung volume and morphology with fetoscopic endoluminal tracheal occlusion (FETO). While the anatomic effects of FETO have been described in-depth, the changes it induces at the cellular and molecular level remain a budding area of CDH research. This review will delve into the cellular and molecular effects of FETO in the developing lung, emphasize areas in which further research may improve our understanding of CDH, and highlight opportunities to optimize the FETO procedure for improved postnatal outcomes.
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Affiliation(s)
- Oluyinka O Olutoye Ii
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Walker D Short
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jamie Gilley
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - J D Hammond Ii
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Luc Joyeux
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jason P Gleghorn
- Department of Biomedical Engineering, University of Delaware, Newark, DE, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
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9
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Van der Veeken L, Emam D, Bleeser T, Valenzuela I, Van der Merwe J, Rex S, Deprest J. Fetal surgery has no additional effect to general anesthesia on brain development in neonatal rabbits. Am J Obstet Gynecol MFM 2022; 4:100513. [PMID: 34706302 DOI: 10.1016/j.ajogmf.2021.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fetal surgery is part of modern fetal medicine, and some procedures, such as fetal spina bifida repair, are performed under general anesthesia. Fetuses are operated on in a time window when the developing brain is extremely vulnerable to external, potentially harmful factors. To date, little is known about the effect of fetal surgery on fetal brain development. OBJECTIVE This study aimed to assess the effect of fetal surgery on the developing fetal brain in the rabbit model. STUDY DESIGN This was a randomized, sham-controlled study in time-mated pregnant does at 28 days' gestation (term, 31 days), which corresponds to the start of the peak of brain development and end of the second trimester of pregnancy in humans. We included 4 different groups in this experiment: no-surgery, general anesthesia, general anesthesia+hysterotomy, and general anesthesia+fetal surgery. In 11 does, anesthesia was induced using propofol and maintained for 75 minutes with 3.6 vol% (4% is the equivalent of 1 minimum alveolar concentration) sevoflurane. Maternal blood pressure, heart rate, oxygen saturation, temperature, end-tidal CO2 were continuously monitored. For each operated doe, 6 fetuses were part of the experiment. Randomization determined which cornual sac and what opposing third sac were assigned to fetal surgery: hysterotomy, fetal injection (atropine, fentanyl, and cisatracurium), fetal skin incision, and suturing. Only hysterotomy was performed on the opposing cornual and third amniotic sacs of the does. The fetus in these experimental sacs was used as internal unmanipulated control (general anesthesia). All fetuses (n=38) from unmanipulated does (n=4) served as external controls (no-surgery). At term, the does were delivered by cesarean delivery under ketamine-medetomidine sedation and local anesthesia. The pups underwent standardized motoric and sensory neurologic testing on day 1 followed by euthanasia and brain harvesting for histologic assessment of neurons, synapses, proliferation, and glial cells. RESULTS Maternal vital signs were stable during surgery. Survival was similar in the 4 groups (75%-94%), and brain-to-body weight ratio was comparable; only the no-surgery pups had a higher brain weight. On postnatal day 1, the pups in the 4 groups had a comparable neurobehavioral outcome on both motoric and sensory testing. In the prefrontal cortex, no-surgery pups had significantly higher neuron density than pups who underwent maternal surgery, but there was no difference among pups that underwent general anesthesia, hysterotomy, or fetal surgery. The measurements of proliferation had a similar outcome: a higher proliferation rate in the prefrontal cortex of no-surgery pups. Moreover, synaptic density values were higher in the no-surgery pups, but there was no difference observed among pups who underwent general anesthesia, hysterotomy, and fetal surgery. Lastly, there was no difference in gliosis among the 4 groups. CONCLUSION In rabbits, fetal surgery through hysterotomy under maternal general anesthesia did not affect brain development, in addition to the effects of general anesthesia per se.
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Affiliation(s)
- Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Van der Veeken, Emam, and Valenzuela, Dr Van der Merwe, and Dr Deprest); Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium (Drs Van der Veeken and Valenzuela, Dr Van der Merwe, and Dr Deprest); Departement of Obstetrics and Gynecology, University Hospital Antwerp, Belgium (Dr Van der Veeken)
| | - Doaa Emam
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Van der Veeken, Emam, and Valenzuela, Dr Van der Merwe, and Dr Deprest); Department Obstetrics and Gynaecology, University Hospitals Tanta, Tanta, Egypt (Dr Emam)
| | - Tom Bleeser
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium (Drs Bleeser and Rex); Department of Cardiovascular Sciences, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Bleeser and Rex)
| | - Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Van der Veeken, Emam, and Valenzuela, Dr Van der Merwe, and Dr Deprest); Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium (Drs Van der Veeken and Valenzuela, Dr Van der Merwe, and Dr Deprest)
| | - Johannes Van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Van der Veeken, Emam, and Valenzuela, Dr Van der Merwe, and Dr Deprest); Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium (Drs Van der Veeken and Valenzuela, Dr Van der Merwe, and Dr Deprest)
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium (Drs Bleeser and Rex); Department of Cardiovascular Sciences, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Bleeser and Rex)
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, Catholic University of Leuven, Leuven, Belgium (Drs Van der Veeken, Emam, and Valenzuela, Dr Van der Merwe, and Dr Deprest); Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium (Drs Van der Veeken and Valenzuela, Dr Van der Merwe, and Dr Deprest); Institute for Women's Health, University College London, London, United Kingdom (Dr Deprest).
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10
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Evans LL, Harrison MR. Modern fetal surgery-a historical review of the happenings that shaped modern fetal surgery and its practices. Transl Pediatr 2021; 10:1401-1417. [PMID: 34189101 PMCID: PMC8192985 DOI: 10.21037/tp-20-114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The history of fetal surgery is one of constant evolution. Over the last 50 years, fetal surgery has progressed from a mere idea to an internationally respected innovative field of surgery. This article aims to provide a historical review of how the enterprise of maternal-fetal surgery came to be its modern version. This review is less focused on the history of specific therapies for a relatively small number of conditions, and more on how the whole field of maternal-fetal surgery evolved. The various internal and external influences that steered the field's evolution are discussed in chronologic order. Since the start of modern fetal surgery in the 1980s, large paradigm shifts have characterized the growth of the field as a whole. Innovative interventions are now based on physiologic manipulation as opposed to simple anatomic repair, fetoscopy has become the more frequently preferred surgical approach, and rigorous scientific evaluation with randomized controlled trials is now the standard expected by the community. In a very similar fashion to when the field first began in the early 1980s, recently community's leaders have risen to protect the integrity of maternal-fetal surgery by publishing ethical guidelines for innovation and clinical practice. This incredible history of innovation, rigorous science and ethical contemplation is the foundation on which modern maternal-fetal surgery rests.
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
| | - Michael R Harrison
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
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11
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Perrone EE, Deprest JA. Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: a narrative review of the history, current practice, and future directions. Transl Pediatr 2021; 10:1448-1460. [PMID: 34189104 PMCID: PMC8192998 DOI: 10.21037/tp-20-130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/14/2020] [Indexed: 11/06/2022] Open
Abstract
Fetal intervention for fetuses with congenital diaphragmatic hernia (CDH) has been investigated for over 30 years and is summarized in this manuscript. The review begins with a discussion of the history of fetal intervention for this severe congenital anomaly beginning with open fetal surgery with repair of the anatomical defect, shifting towards tracheal occlusion via open surgery techniques, and finally fetoscopic endoluminal balloon tracheal occlusion using a percutaneous approach. The current technique of fetal endoscopic tracheal occlusion (FETO) is described in detail with steps of the procedure and complementary figures. The main outcomes of single-institutional studies and multiple systematic reviews are examined and discussed. Despite these studies, the fetal community agrees that FETO remains investigational at this time as there is insufficient evidence to recommend it as the standard of care for CDH. A randomized controlled trial, The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial, has been designed to attempt to answer this question in an elaborate, international, multi-institutional study and is described in the text. Finally, future directions of fetal intervention for antenatally diagnosed CDH are discussed, including options for non-isolated CDH, the Smart-TO balloon for nonoperative reversal of occlusion, and transplacental sildenafil for treatment of pulmonary hypertension prior to birth.
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Affiliation(s)
- Erin E. Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Jan A. Deprest
- Clinical Department of Obstetrics and Gynecology, Academic Department of Development and Regeneration, Woman and Child, Leuven, Belgium
- Institute of Women’s Health, University College London, London, UK
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12
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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13
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Deprest J. Prenatal treatment of severe congenital diaphragmatic hernia: there is still medical equipoise. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:493-497. [PMID: 33001496 DOI: 10.1002/uog.22182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 06/11/2023]
Affiliation(s)
- J Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Woman's Health, University College London, London, UK
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14
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Congenital lung overinflation secondary to a unilateral obstructing mediastinal bronchogenic cyst. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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15
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Single-Center Outcome of Fetoscopic Tracheal Balloon Occlusion for Severe Congenital Diaphragmatic Hernia. Obstet Gynecol 2020; 135:511-521. [PMID: 32028493 DOI: 10.1097/aog.0000000000003692] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess feasibility and maternal and infant outcome after fetoscopic tracheal balloon occlusion in patients with severe congenital diaphragmatic hernia. METHODS We conducted a prospective cohort study of fetuses with congenital diaphragmatic hernia and observed/expected lung/head ratio less than 30%. Eligible women had planned fetoscopic tracheal balloon occlusion at 26 0/7-29 6/7 weeks of gestation and balloon removal 4-6 weeks later. Standardized prenatal and postnatal care was at a single institution. Fetoscopic tracheal balloon occlusion details, lung growth, obstetric complications, birth outcome, and infant outcome details until discharge were evaluated. RESULTS Of 57 women screened, 14 (25%) were enrolled between 2015 and 2019. The congenital diaphragmatic hernia was left in 12 (86%); the pre-fetoscopic tracheal balloon occlusion observed/expected lung/head ratio was 23.2% (range 15.8-29.0%). At a median gestational age of 28 5/7 weeks (range 27 3/7-29 6/7), fetoscopic tracheal balloon occlusion was successful in all cases, and balloons remained in situ. Removal was elective in 10 (71%) patients, by ultrasound-guided needle puncture in eight (57%), and occurred at a median of 33 4/7 weeks of gestation (range 32 1/7-34 4/7; median occlusion 34 days, range 17-44). The post-fetoscopic tracheal balloon occlusion observed/expected lung/head ratio increased to a median of 62.8% (44.0-108) and fell to a median of 46.6% (range 30-92) after balloon removal (all Mann Whitney U, P<.003). For prevention of preterm birth, all patients received vaginal progesterone; 11 (79%) required additional tocolytics, three (21%) had vaginal pessary placement for cervical shortening, and five (36%) had amnioreduction for polyhydramnios. Median gestational age at birth was 39 2/7 weeks (range 33 6/7-39 4/7), with term birth in eight (57%) patients. Twelve (86%) neonates required high-frequency ventilation, and seven (50%) required extracorporeal membrane oxygenation for a median of 7 days (range 3-19). All neonates needed patch repair. Neonatal survival was 93% (n=13, 95% CI 49-100%), and survival to hospital discharge was 86% (n=12, 95% CI 44-100%). CONCLUSION Fetoscopic tracheal balloon occlusion for severe congenital diaphragmatic hernia was feasible in our single-center setting, with few obstetric complications and favorable infant outcome. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02710968.
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16
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Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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17
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Fetoscopic Tracheal Occlusion for Severe Congenital Diaphragmatic Hernia: The State of the Evidence. Obstet Gynecol 2020; 135:509-510. [PMID: 32028510 DOI: 10.1097/aog.0000000000003732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Abstract
Congenital diaphragmatic hernia (CDH) remains one of the most elusive birth defects to treat. Despite greater knowledge of disease and advances in technology, approximately one-third of CDH children born today still die. Consequently, clinicians and researchers have struggled to find the optimal treatment strategies for CDH. Without further innovations in postnatal treatment, many have focused an antenatal approach to improve pulmonary function. Fetoscopic Endoluminal Tracheal Occlusion (FETO) for CDH has evolved to the bedside after decades of research. While still under clinical investigation, FETO remains a promising adjunct to the treatment of CDH.
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Affiliation(s)
- KuoJen Tsao
- Departments of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
| | - Anthony Johnson
- Departments Obstetrics, Gynecology & Reproductive Sciences and Pediatric Surgery, Division of Maternal-Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
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19
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Gimenez A, Kopkin R, Chang DK, Belfort M, Reece EM. Advances in Fetal Surgery: Current and Future Relevance in Plastic Surgery. Semin Plast Surg 2019; 33:204-212. [PMID: 31384237 DOI: 10.1055/s-0039-1693431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Scarless healing has long been the holy grail for plastic surgery. While historically fetal surgery has tempted plastic surgeons with the allure of scarless correction of congenital abnormalities, the risks far outweighed the benefits and these interventions never materialized. Current advances in fetal surgery with minimally invasive fetoscopic surgery have made these early fetal interventions safer, leading to expanding applications. While the plastic surgeon's role is limited as of yet, this article provides a review of the history of fetal surgery and the advances that may become relevant to the future plastic surgeon.
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Affiliation(s)
- Alejandro Gimenez
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rachel Kopkin
- School of Medicine, Health Sciences Center, Louisiana State University, New Orleans, Louisiana.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Daniel K Chang
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michael Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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20
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Abstract
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
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Affiliation(s)
- Mark L Kovler
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States
| | - Eric B Jelin
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States.
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21
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Congenital diaphragmatic hernia and complete tracheal rings: The value of peri-operative ECMO. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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22
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Dobrinskikh E, Al-Juboori SI, Shabeka U, Reisz JA, Zheng C, Marwan AI. Heterogeneous Pulmonary Response After Tracheal Occlusion: Clues to Fetal Lung Growth. J Surg Res 2019; 239:242-252. [PMID: 30856517 DOI: 10.1016/j.jss.2019.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/15/2019] [Accepted: 02/06/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Understanding inconsistent clinical outcomes in infants with severe congenital diaphragmatic hernia (CDH) after tracheal occlusion (TO) is a crucial step for advancing neonatal care. The objective of this study is to explore the heterogeneous airspace morphometry and the metabolic landscape changes in fetal lungs after TO. METHODS Fetal lungs on days 1 and 4 after TO were examined using mass spectrometry-based metabolomics, fluorescence lifetime imaging microscopy (FLIM), the number of airspaces, and tissue-to-airspace ratio (TAR). RESULTS Two morphometric areas were identified in TO lungs compared with controls (more small airspaces at day 1 and a higher number of enlarged airspaces at day 4). Global metabolomics analysis revealed a significant upregulation of glycolysis and a suppression of the tricarboxylic acid cycle in day 4 TO lungs compared with day 1 TO lungs. In addition, there was a significant increase in polyamines involved in cell growth and proliferation. Locally, FLIM analysis on day 1 TO lungs demonstrated two types of heterogeneous zones-similar to control and with increased oxidative phosphorylation. FLIM on day 4 TO lungs demonstrated appearance of zones with enlarged airspaces and a metabolic shift toward glycolysis, accompanied by a decrease in the FLIM "lipid-surfactant" signal. CONCLUSIONS In normal fetal lungs, we report a novel temporal pattern of varied morphometric and metabolic changes. Initially, there is formation of zones with small airspaces, followed by airspace enlargement over time. Metabolically day 1 TO lungs have zones with increased oxidative phosphorylation, whereas day 4 TO lungs have a shift toward glycolysis in the enlarged airspaces. Based on our observations, we speculate that the "best responders" to tracheal occlusion should have bigger lungs with small airspaces and normal surfactant production.
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Affiliation(s)
- Evgenia Dobrinskikh
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Saif I Al-Juboori
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado
| | - Connie Zheng
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
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23
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Abstract
Congenital diaphragmatic hernia (CDH) is the result of incomplete formation of the diaphragm that occurs during embryogenesis. The defect in the diaphragm permits the herniation of abdominal organs into the thoracic cavity contributing to the impairment of normal growth and development of the fetal lung. In addition to the hypoplastic lung, anomalies of the pulmonary arterioles worsen the pulmonary hypertension that can have detrimental effects in severe cases. Most cases of CDH can be effectively managed postnatally. Advances in neonatal and surgical care have resulted in improved outcomes over the years. When available, extracorporeal membrane oxygenation can provide temporary cardiorespiratory support for those not effectively supported by mechanical ventilation. In spite of these advances, very severe cases of CDH still carry a very high mortality and morbidity rate. Advances in imaging and evaluation now allow for early and accurate prenatal diagnosis of CDH, thereby identifying those at greatest risk who may benefit from prenatal intervention. This review article discusses some of the surgical and non-surgical prenatal interventions in the management of isolated severe congenital diaphragmatic hernia.
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24
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Van der Veeken L, Russo FM, De Catte L, Gratacos E, Benachi A, Ville Y, Nicolaides K, Berg C, Gardener G, Persico N, Bagolan P, Ryan G, Belfort MA, Deprest J. Fetoscopic endoluminal tracheal occlusion and reestablishment of fetal airways for congenital diaphragmatic hernia. ACTA ACUST UNITED AC 2018; 15:9. [PMID: 29770109 PMCID: PMC5940711 DOI: 10.1186/s10397-018-1041-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 11/10/2022]
Abstract
Background Congenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and morbidity mainly due to pulmonary hypoplasia and hypertension. Temporary fetal tracheal occlusion to promote prenatal lung growth may improve survival. Entrapment of lung fluid stretches the airways, leading to lung growth. Methods Fetal endoluminal tracheal occlusion (FETO) is performed by percutaneous sono-endoscopic insertion of a balloon developed for interventional radiology. Reversal of the occlusion to induce lung maturation can be performed by fetoscopy, transabdominal puncture, tracheoscopy, or by postnatal removal if all else fails. Results FETO and balloon removal have been shown safe in experienced hands. This paper deals with the technical aspects of balloon insertion and removal. While FETO is invasive, it has minimal maternal risks yet can cause preterm birth potentially offsetting its beneficial effects. Conclusion For left-sided severe and moderate CDH, the procedure is considered investigational and is currently being evaluated in a global randomized clinical trial (https://www.totaltrial.eu/). The procedure can be clinically offered to fetuses with severe right-sided CDH.
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Affiliation(s)
- Lennart Van der Veeken
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Francesca Maria Russo
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Luc De Catte
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Eduard Gratacos
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,3BCNatal - Barcelona Center for MaternaleFetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Alexandra Benachi
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,4Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine-Béclère, University Paris Sud, Clamart, France.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
| | - Yves Ville
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,5Fetal Medicine Unit, Obstetrics and Fetal Medicine Department, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Kypros Nicolaides
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,6Harris Birthright Centre, King's College Hospital, London, UK
| | - Christoph Berg
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,7Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany.,8Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - Glenn Gardener
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,9Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Nicola Persico
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,10Department of Obstetrics and Gynecology, "L. Mangiagalli," Fondazione IRCCS "Ca' Granda" - Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Bagolan
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,11Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165 Rome, Italy.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
| | - Greg Ryan
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,12Fetal Medicine Unit, Mt Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michael A Belfort
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,13Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas USA
| | - Jan Deprest
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
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25
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Mous DS, Kool HM, Wijnen R, Tibboel D, Rottier RJ. Pulmonary vascular development in congenital diaphragmatic hernia. Eur Respir Rev 2018; 27:27/147/170104. [DOI: 10.1183/16000617.0104-2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/09/2017] [Indexed: 02/03/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly characterised by a diaphragmatic defect, persistent pulmonary hypertension (PH) and lung hypoplasia. The relative contribution of these three elements can vary considerably in individual patients. Most affected children suffer primarily from the associated PH, for which the therapeutic modalities are limited and frequently not evidence based. The vascular defects associated with PH, which is characterised by increased muscularisation of arterioles and capillaries, start to develop early in gestation. Pulmonary vascular development is integrated with the development of the airway epithelium. Although our knowledge is still incomplete, the processes involved in the growth and expansion of the vasculature are beginning to be unravelled. It is clear that early disturbances of this process lead to major pulmonary growth abnormalities, resulting in serious clinical challenges and in many cases death in the newborn. Here we provide an overview of the current molecular pathways involved in pulmonary vascular development. Moreover, we describe the abnormalities associated with CDH and the potential therapeutic approaches for this severe abnormality.
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26
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Church JT, Perkins EM, Coughlin MA, McLeod JS, Boss K, Bentley JK, Hershenson MB, Rabah R, Bartlett RH, Mychaliska GB. Perfluorocarbons Prevent Lung Injury and Promote Development during Artificial Placenta Support in Extremely Premature Lambs. Neonatology 2018; 113:313-321. [PMID: 29478055 PMCID: PMC5980738 DOI: 10.1159/000486387] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extremely premature neonates suffer high morbidity and mortality. An artificial placenta (AP) using extracorporeal life support (ECLS) is a promising therapy. OBJECTIVES We hypothesized that intratracheal perfluorocarbon (PFC) instillation during AP support would reduce lung injury and promote lung development relative to intratracheal amniotic fluid or crystalloid. METHODS Lambs at an estimated gestational age (EGA) 116-121 days (term 145 days) were placed on venovenous ECLS with jugular drainage and umbilical vein reinfusion and intubated. Airways were managed by the instillation of amniotic fluid and tracheal occlusion (TO; n = 4), or lactated Ringer's (LR; n = 4) or perfluorodecalin (a PFC) without occlusion (n = 4). After 7 days, the animals were sacrificed. Early (EGA 116-121 days) and late (EGA 125-131 days) tissue control lambs were delivered and sacrificed. Lungs were formalin-inflated to 30 cm H2O and sectioned for histology. Injury was scored by an unbiased pathologist. Slides were immunostained for PDGFR-α and α-actin; development was quantified by the area fraction of double-positive tips. Surfactant protein-C (SP-C) concentration in bronchoalveolar lavage fluid was quantified using ELISA. RESULTS Total injury scores were lower in PFC lungs (1.8 ± 1.7) than in TO (6.5 ± 2.1; p = 0.01) and LR lungs (5.5 ± 2.4; p = 0.01). The area fraction of double-positive alveolar tips appeared higher in PFC lungs than in TO lungs (0.18 ± 0.007 vs. 0.008 ± 0.004; p = 0.07). SP-C concentration was higher in PFC lungs than in TO lungs (37.9 ± 7.6 vs. 20.0 ± 5.4 pg/mL; p = 0.005), and both early (12.4 ± 1.7 g/mL; p = 0.007) and late tissue control lungs (15.1 ± 5.0 pg/mL; p = 0.0008). CONCLUSION During AP support, intratracheal PFC prevents lung injury and promotes normal lung development better than crystalloid or amniotic fluid with TO.
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27
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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.
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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.
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28
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Amer K. Thoracoscopic approach to congenital diaphragmatic hernias in adults: Southampton approach and review of the literature. J Vis Surg 2017; 3:176. [PMID: 29302452 DOI: 10.21037/jovs.2017.10.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/10/2017] [Indexed: 12/21/2022]
Abstract
Congenital diaphragmatic hernias (CDH) are likely to present in early postnatal or infancy and are associated with significant morbidity and mortality due to associated pulmonary hypoplasia, pulmonary hypertension and heart failure. Symptomatic adult congenital Bochdalek hernia, on the other hand, is extremely rare with a prevalence of 0.17-6% of all diaphragmatic hernias. They present with recurrent abdominal pain and shortness of breath. Acute presentations could be life threatening especially if there is incarcerated or threatened bowel in the chest. Repair of symptomatic Bochdalek hernia is recommended in the adult population. We present two cases of right and left symptomatic Bochdalek hernias in adults, encountered over 15 years of practice in a tertiary referral centre in the UK. We discuss their presentation and surgical management and review the literature of similar cases treated by video-assisted thoracoscopic surgery (VATS). Thoracic surgeons are increasingly becoming involved in these cases, which used to be the domain of upper gastrointestinal surgeons. A synthetic patch may be required to close the defect, therefore; the thoracic surgeon must be familiar with such techniques. The recent expansion in video format publishing in the internet and social media has revolutionized the way knowledge and how-to-do-it expertise is distributed around the world. It has the advantage of reaching far more viewer than subscription paper-printed format journals and has a rising significance in encouraging thoracic surgeons to do things they were not used to do. Finally; Symptomatic Bochdalek hernia, and possibly Morgagni hernia in the adult population could be safely repaired by VATS with good and lasting results.
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Affiliation(s)
- Khalid Amer
- The Cardiovascular & Thoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
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29
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Abstract
In congenital diaphragmatic hernia (CDH), herniation of the abdominal organs into the fetal chest causes pulmonary hypoplasia and pulmonary hypertension, the main causes of neonatal mortality. As antenatal ultrasound screening improves, the risk of postnatal death can now be better predicted, allowing for the identification of fetuses that might most benefit from a prenatal intervention. Fetoscopic tracheal occlusion is being evaluated in a large international randomized controlled trial. We present the antenatal imaging approaches that can help identify fetuses that might benefit from antenatal therapy, and review the evolution of fetal surgery for CDH to date.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Calgary, 1403 29 Street NW, Calgary, Alberta.
| | - Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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30
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Munson D. The intersection of fetal palliative care and fetal surgery: Addressing mortality and quality of life. Semin Perinatol 2017; 41:101-105. [PMID: 28108023 DOI: 10.1053/j.semperi.2016.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Over the last few decades, the fields of fetal surgery and maternal-fetal medicine have developed interventions aimed at modifying severe diseases in utero. Innovations in fetal approaches to congenital diaphragmatic hernia and myelomeningocele have shown considerable promise in modifying the clinical course with fetal intervention. Patients who present to fetal centers to be evaluated for these interventions face challenging decisions that directly relate to questions of mortality and quality of life. This article explores how clinicians might apply the tools and principles of fetal palliative care to supporting a woman and her family who are considering fetal surgery.
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Affiliation(s)
- David Munson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; The Children׳s Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Main, Philadelphia, PA 19104.
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Marwan AI, Shabeka U, Dobrinskikh E. Suggested Mechanisms of Tracheal Occlusion Mediated Accelerated Fetal Lung Growth: A Case for Heterogeneous Topological Zones. Front Pediatr 2017; 5:295. [PMID: 29376042 PMCID: PMC5770375 DOI: 10.3389/fped.2017.00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022] Open
Abstract
In this article, we report an up-to-date summary on tracheal occlusion (TO) as an approach to drive accelerated lung growth and strive to review the different maternal- and fetal-derived local and systemic signals and mechanisms that may play a significant biological role in lung growth and formation of heterogeneous topological zones following TO. Pulmonary hypoplasia is a condition whereby branching morphogenesis and embryonic pulmonary vascular development are globally affected and is classically seen in congenital diaphragmatic hernia. TO is an innovative approach aimed at driving accelerated lung growth in the most severe forms of diaphragmatic hernia and has been shown to result in improved neonatal outcomes. Currently, most research on mechanisms of TO-induced lung growth is focused on mechanical forces and is viewed from the perspective of homogeneous changes within the lung. We suggest that the key principle in understanding changes in fetal lungs after TO is taking into account formation of unique variable topological zones. Following TO, fetal lungs might temporarily look like a dynamically changing topologic mosaic with varying proliferation rates, dissimilar scale of vasculogenesis, diverse patterns of lung tissue damage, variable metabolic landscape, and different structures. The reasons for this dynamic topological mosaic pattern may include distinct degree of increased hydrostatic pressure in different parts of the lung, dissimilar degree of tissue stress/damage and responses to this damage, and incomparable patterns of altered lung zones with variable response to systemic maternal and fetal factors, among others. The local interaction between these factors and their accompanying processes in addition to the potential role of other systemic factors might lead to formation of a common vector of biological response unique to each zone. The study of the interaction between various networks formed after TO (action of mechanical forces, activation of mucosal mast cells, production and secretion of damage-associated molecular pattern substances, low-grade local pulmonary inflammation, and cardiac contraction-induced periodic agitation of lung tissue, among others) will bring us closer to an appreciation of the biological phenomenon of topological heterogeneity within the fetal lungs.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Evgenia Dobrinskikh
- Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, United States
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Fetal Tracheal Occlusion for Severe Pulmonary Hypoplasia in Isolated Congenital Diaphragmatic Hernia. Ann Surg 2016; 264:929-933. [DOI: 10.1097/sla.0000000000001675] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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George UZ, Bokka KK, Warburton D, Lubkin SR. Quantifying stretch and secretion in the embryonic lung: Implications for morphogenesis. Mech Dev 2015; 138 Pt 3:356-63. [PMID: 26189687 DOI: 10.1016/j.mod.2015.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 12/21/2022]
Abstract
Branching in the embryonic lung is controlled by a variety of morphogens. Mechanics is also believed to play a significant role in lung branching. The relative roles and interactions of these two broad factors are challenging to determine. We considered three hypotheses for explaining why tracheal occlusion triples branching with no overall increase in size. Both hypotheses are based on tracheal occlusion blocking the exit of secretions. (H1) Increased lumen pressure stretches tissues; stretch receptors at shoulders of growing tips increase local rate of branching. (H2) Blocking exit of secretions blocks advective transport of morphogens, leading to (H2a) increased overall concentration of morphogens or (H2b) increased flux of morphogens at specific locations. We constructed and analyzed computational models of tissue stretch and solute transport in a 3D lung geometry. Observed tissue stresses and stretches were predominantly in locations unrelated to subsequent branch locations, suggesting that tissue stretch (H1) is not the mechanism of enhancement of branching. Morphogen concentration in the mesenchyme (H2a) increased with tracheal occlusion, consistent with previously reported results. Morphogen flux at the epithelial surface (H2b) completely changed its distribution pattern when the trachea was occluded, tripling the number of locations at which it was elevated. Our results are consistent with the hypothesis that tracheal occlusion blocks outflow of secretions, leading to a higher number of high-flux locations at branching tips, in turn leading to a large increase in number of branching locations.
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Affiliation(s)
- Uduak Z George
- North Carolina State University, Raleigh, NC 27695-8205, USA
| | - Kishore K Bokka
- North Carolina State University, Raleigh, NC 27695-8205, USA
| | - David Warburton
- Saban Research Institute, 4650 Sunset Boulevard, MS# 35, Los Angeles, CA 90027, USA
| | - Sharon R Lubkin
- North Carolina State University, Raleigh, NC 27695-8205, USA.
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Miyano T. History of the Pacific Association of Pediatric Surgeons (PAPS) 1984-1998. J Pediatr Surg 2014; 49:1707-11. [PMID: 25487465 DOI: 10.1016/j.jpedsurg.2014.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 09/05/2014] [Indexed: 11/29/2022]
Abstract
This is a history of the second 15 years of the Pacific Association of Pediatric Surgeons (PAPS) from 1984 to 1998.
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Affiliation(s)
- Takeshi Miyano
- Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo 117-8521, Japan.
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Chiu PPL. New Insights into Congenital Diaphragmatic Hernia - A Surgeon's Introduction to CDH Animal Models. Front Pediatr 2014; 2:36. [PMID: 24809040 PMCID: PMC4010792 DOI: 10.3389/fped.2014.00036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 04/16/2014] [Indexed: 12/11/2022] Open
Abstract
In recent decades, new research into the developmental defects and pathophysiological basis of congenital diaphragmatic hernia (CDH) has revealed opportunities for the development of innovative therapies. Importantly, the use of animal models to represent this anomaly in the laboratory has resulted in the discovery of many important genetic, epigenetic, and other molecular contributors to this condition. In this review, the most commonly used and newly devised animal models of CDH are presented to familiarize the reader with the latest innovations in the basic sciences.
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Affiliation(s)
- Priscilla Pui Lam Chiu
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto , Toronto, ON , Canada
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Ysasi AB, Belle JM, Gibney BC, Fedulov AV, Wagner W, AkiraTsuda, Konerding MA, Mentzer SJ. Effect of unilateral diaphragmatic paralysis on postpneumonectomy lung growth. Am J Physiol Lung Cell Mol Physiol 2013; 305:L439-45. [PMID: 23873841 PMCID: PMC3763038 DOI: 10.1152/ajplung.00134.2013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 07/15/2013] [Indexed: 11/22/2022] Open
Abstract
Respiratory muscle-associated stretch has been implicated in normal lung development (fetal breathing movements) and postpneumonectomy lung growth. To test the hypothesis that mechanical stretch from diaphragmatic contraction contributes to lung growth, we performed left phrenic nerve transections (PNT) in mice with and without ipsilateral pneumonectomy. PNT was demonstrated by asymmetric costal margin excursion and confirmed at autopsy. In mice with two lungs, PNT was associated with a decrease in ipsilateral lung volume (P<0.05) and lung weight (P<0.05). After pneumonectomy, PNT was not associated with a change in activity level, measureable hypoxemia, or altered minute ventilation; however, microCT scanning demonstrated altered displacement and underinflation of the cardiac lobe within the first week after pneumonectomy. Coincident with the altered structural realignment, lung impedance measurements, fitted to the constant-phase model, demonstrated elevated airway resistance (P<0.05), but normal peripheral tissue resistance (P>0.05). Most important, PNT appeared to abrogate compensatory lung growth after pneumonectomy; the weight of the lobes of the right lung was significantly less than pneumonectomy alone (P<0.001) and indistinguishable from nonsurgical controls (P>0.05). We conclude that the cyclic stretch associated with diaphragmatic muscle contraction is a controlling factor in postpneumonectomy compensatory lung growth.
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Affiliation(s)
- Alexandra B Ysasi
- Rm. 259, Brigham &Women's Hospital, 75 Francis St., Boston, MA 02115.
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Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013; 49:E420-7. [PMID: 23662685 DOI: 10.1111/jpc.12223] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- Perelman School of Medicine at the University of Pennsylvania, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Abstract
Although approximately 10% of all newborn infants receive some form of assistance after birth, only 1% of neonates require more advanced measures of life support. Because such situations cannot always be anticipated, paediatricians and neonatologists are frequently unavailable and resuscitation is delegated to the anaesthesiologist. The International Liaison Committee on Resuscitation, the European Resuscitation Council and the American Heart Association have recently updated the guidelines on neonatal resuscitation. The revised guidelines propose a simplified resuscitation algorithm that highlights the central role of respiratory support and promotes an increasing heart rate as the best indicator for effective ventilation. The most striking change in the new guidelines is the recommendation to start resuscitation in term infants with room air rather than 100% oxygen. Continuous pulse oximetry is recommended to monitor both heart rate and an appropriate increase in preductal oxygen saturation. Supplemental oxygen should only be used if, despite effective ventilation, the heart rate does not increase above 100 beats min(-1), or if oxygenation as indicated by pulse oximetry, remains unacceptably low. This review will focus on foetal physiology and pathophysiological aspects of neonatal adaptation and, thus, attempt to provide a solid basis for understanding the new resuscitation guidelines.
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Quintero RA, Kontopoulos EV, Quintero LF, Landy DC, Gonzalez R, Chmait RH. The observed vs. expected lung-to-head ratio does not correct for the effect of gestational age on the lung-to-head ratio. J Matern Fetal Neonatal Med 2012; 26:552-7. [DOI: 10.3109/14767058.2012.736000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shue EH, Harrison M, Hirose S. Maternal-fetal surgery: history and general considerations. Clin Perinatol 2012; 39:269-78. [PMID: 22682378 DOI: 10.1016/j.clp.2012.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reviews fetal intervention for congenital anomalies, which has evolved from a mere concept to a medical specialty over the past 3 decades. Advances in surgical techniques have paralleled developments in fetal imaging, fetal diagnosis, and the advent of maternal tocolysis to prevent preterm labor. Fetal intervention has become an important option for fetuses who would otherwise not survive gestation or who would endure significant morbidity and mortality after birth. However, there were many trials and tribulations as fetal surgery developed into a medical specialty.
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Affiliation(s)
- Eveline H Shue
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, 513 Parnassus Avenue, HSW-1601, San Francisco, CA 94143-0570, USA
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Shue EH, Miniati D, Lee H. Advances in prenatal diagnosis and treatment of congenital diaphragmatic hernia. Clin Perinatol 2012; 39:289-300. [PMID: 22682380 DOI: 10.1016/j.clp.2012.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a common birth anomaly. Absence or presence of liver herniation and determination of lung-to-head ratio are the most accurate predictors of prognosis for fetuses with CDH. Though open fetal CDH repair has been abandoned, fetal endoscopic balloon tracheal occlusion promotes lung growth in fetuses with severe CDH. Although significant improvements in lung function have not yet been shown in humans, reversible or dynamic tracheal occlusion is promising for select fetuses with severe CDH. This article reviews advances in prenatal diagnosis of CDH, the experimental basis for tracheal occlusion, and its translation into human clinical trials.
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Affiliation(s)
- Eveline H Shue
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center University of California, San Francisco, 513 Parnassus Avenue, HSW-1601, San Francisco, CA 94143-0570, USA
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Partridge EA, Flake AW. Maternal-fetal surgery for structural malformations. Best Pract Res Clin Obstet Gynaecol 2012; 26:669-82. [PMID: 22542765 DOI: 10.1016/j.bpobgyn.2012.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/02/2012] [Accepted: 03/12/2012] [Indexed: 12/22/2022]
Abstract
Although most prenatally diagnosed correctable anatomic abnormalities are best addressed by surgical interventions after birth, the outcomes of a small number of severe structural malformations with predicted fetal demise or devastating sequelae postnatally may be improved by correction before birth. Consideration of maternal-fetal surgical intervention is restricted to those anatomic malformations that interfere with normal organ development and which, if alleviated, may permit normal development to proceed. Advances in prenatal diagnosis and technical innovations in the surgical approach to the fetus have resulted in an increase in the successful clinical application of fetal intervention over the past 3 decades. The purpose of this review is to describe the current status of maternal-fetal surgery, with a focus on the congenital anomalies most commonly treated by intervention before birth, and to highlight the key areas for further research in this evolving surgical specialty.
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Affiliation(s)
- Emily A Partridge
- Center for Fetal Diagnosis and Treatment and The Children's Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Abstract
Background Fetal surgery, also referred to as in utero, prenatal or intrauterine surgery, consists of treatment of congenital malformations during the fetal period. The idea of treating malformations diagnosed in the course of intrauterine life dates back to 1963, when Lilly performed the first blood transfusion in a fetus. Since then it has been introduced as a treatment option in a series of lethal malformations. Efforts are being made to treat nonlethal malformations by means of fetal surgery. Material/Methods A comprehensive search of the literature using MEDLINE and PubMed between 1925 and February 2009 was performed. Search terms for MEDLINE and PubMed were: fetal surgery, foetal surgery, in utero surgery, prenatal surgery, and in utero treatment. In addition, information was obtained at Web sites of the International Medicine and Surgery Society and the University of California Fetal Treatment Centre. Results Authors’ attention focused on the survey of indications to intrauterine operations. We outline potential directions of its development, quoting the groundwork of the most experienced researchers and clinicians. Moreover, owing to the authors’ interest in plastic surgery, some remarks on the role of intrauterine medicine and surgery in this branch of medicine are made. Conclusions In utero surgery may be regarded as an efficient tool of preventive medicine. It offers some advantages that no other branch of medicine may offer. However, its implementation is more troublesome than in the past, therefore only selected cases may benefit from its advantages. Nevertheless, current tendencies are to include, after thorough evaluation of benefit-risk ratio, some new indications for fetal surgery.
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Affiliation(s)
- Piotr Wójcicki
- Department of Plastic Surgery, Wrocław Medical University, Polanica-Zdroj, Poland
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Abstract
Congenital Diaphragmatic Hernia (CDH) is defined by the presence of an orifice in the diaphragm, more often left and posterolateral that permits the herniation of abdominal contents into the thorax. The lungs are hypoplastic and have abnormal vessels that cause respiratory insufficiency and persistent pulmonary hypertension with high mortality. About one third of cases have cardiovascular malformations and lesser proportions have skeletal, neural, genitourinary, gastrointestinal or other defects. CDH can be a component of Pallister-Killian, Fryns, Ghersoni-Baruch, WAGR, Denys-Drash, Brachman-De Lange, Donnai-Barrow or Wolf-Hirschhorn syndromes. Some chromosomal anomalies involve CDH as well. The incidence is < 5 in 10,000 live-births. The etiology is unknown although clinical, genetic and experimental evidence points to disturbances in the retinoid-signaling pathway during organogenesis. Antenatal diagnosis is often made and this allows prenatal management (open correction of the hernia in the past and reversible fetoscopic tracheal obstruction nowadays) that may be indicated in cases with severe lung hypoplasia and grim prognosis. Treatment after birth requires all the refinements of critical care including extracorporeal membrane oxygenation prior to surgical correction. The best hospital series report 80% survival but it remains around 50% in population-based studies. Chronic respiratory tract disease, neurodevelopmental problems, neurosensorial hearing loss and gastroesophageal reflux are common problems in survivors. Much more research on several aspects of this severe condition is warranted.
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Kline-Fath BM. Current advances in prenatal imaging of congenital diaphragmatic [corrected] hernia. Pediatr Radiol 2012; 42 Suppl 1:S74-90. [PMID: 21739292 DOI: 10.1007/s00247-011-2183-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/22/2011] [Accepted: 03/31/2011] [Indexed: 11/29/2022]
Abstract
Congenital diaphragmatic hernia, despite advances in therapy, remains a complex condition with significant morbidity and mortality. The etiology of the disorder is still incompletely understood, though the pulmonary hypoplasia and pulmonary hypertension that develop secondarily must be overcome to improve survival. Prenatal US and fetal MRI have helped in the development of a greater understanding of this disease. Also with these modalities, measurement techniques have been developed in an attempt to provide prognosticators for the development of pulmonary hypoplasia and pulmonary hypertension. There is a broad range of approaches for performing these measurements, and variability among imaging centers is noted. Despite inconsistent approaches, these techniques have become the foundation for counseling and prenatal and postnatal therapy. It is hoped that with further research with prenatal US and fetal MRI and the development of innovative medical and surgical therapies that the morbidity and mortality of children with congenital diaphragmatic hernias can be significantly reduced.
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Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology, Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Quintero RA, Quintero LF, Chmait R, Gómez Castro L, Korst LM, Fridman M, Kontopoulos EV. The quantitative lung index (QLI): a gestational age-independent sonographic predictor of fetal lung growth. Am J Obstet Gynecol 2011; 205:544.e1-8. [PMID: 21944224 DOI: 10.1016/j.ajog.2011.07.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 07/08/2011] [Accepted: 07/16/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We sought to develop a gestational age-independent sonographic parameter to characterize lung growth. STUDY DESIGN Reported descriptors of lung growth, including lung-to-head circumference (HC) ratio (LHR) and observed/expected LHR, were examined. A new index, the quantitative lung index (QLI) was derived using published data on HC and the area of the base of the right lung. RESULTS Neither the LHR nor the observed/expected LHR proved to be gestational age independent. Right lung growth can be expressed using the following formula: QLI = lung area/(HC/10)^2. The 50th percentile of the QLI remained constant at approximately 1.0 for the gestational age between 16-32 weeks. A small lung (<1st percentile) was defined as a QLI <0.6. CONCLUSION Fetal right lung growth can be adequately described using the QLI, independent of gestational age. Further studies are needed to assess the clinical accuracy of the QLI in characterizing fetal right lung growth.
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Benachi A, Saada J, Martinovic J, de Lagausie P, Storme L, Jani J. Hernie congénitale du diaphragme : prise en charge anténatale. Rev Mal Respir 2011; 28:800-8. [DOI: 10.1016/j.rmr.2010.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/30/2010] [Indexed: 10/18/2022]
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Deprest JA, Flake AW, Gratacos E, Ville Y, Hecher K, Nicolaides K, Johnson MP, Luks FI, Adzick NS, Harrison MR. The making of fetal surgery. Prenat Diagn 2010; 30:653-67. [PMID: 20572114 DOI: 10.1002/pd.2571] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospitals KU Leuven, Leuven, Belgium.
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Cloutier M, Tremblay M, Piedboeuf B. ROCK2 is involved in accelerated fetal lung development induced by in vivo lung distension. Pediatr Pulmonol 2010; 45:966-76. [PMID: 20648664 DOI: 10.1002/ppul.21266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Lung development is strongly influenced by its state of distension. For instance, increasing distension induced by fetal tracheal occlusion (TO) stimulates lung development. In contrast, oligohydramnios (OH) reduces lung distending forces and results in lung hypoplasia. We hypothesize that Rho/Rho-associated kinase (ROCK) pathway plays an important role as mechanosensor in vivo acting either directly or indirectly in the translation of increased distension into acceleration of lung growth. TO was done in fetal mice sacrificed either 3 or 24 hr later; in a subset of dam, fasudil, a specific ROCK inhibitor, or vehicle was injected intra-peritoneally. OH was done by puncture of the amniotic sac. ROCK2 protein levels were assessed by Western blot and immunohistochemistry (IHC); lung development was assessed by measuring the generation of distal respiratory airway. Significant differences were found in ROCK2 protein levels between TO and Sham-TO at 3 and 24 hr, but not for ROCK1. Indeed, IHC revealed that ROCK2 staining was sparse and restricted to a few mesenchymal cells in Sham-TO, whereas it was strong in acini of TO lungs. OH lungs expressed lower levels of ROCK2 in the acini when compared to untouched controls. In fasudil-treated animals, the degree of lung development following TO was significantly lower than in the group injected with vehicle. At the dose regimen used, fasudil did not affect normal lung development, as observed in the untouched animals. In summary, ROCK2 protein levels was affected by the degree of lung expansion and blunting ROCK activity abolished the response to increased lung distension, suggesting that ROCK is a key regulator in TO-induced accelerated lung development.
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Affiliation(s)
- Marc Cloutier
- Unité de Recherche en Pédiatrie, Centre de Recherche du Centre Hospitalier de l'Université Laval, Québec, QC, Canada
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