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Ranza E, Le Gouez M, Guimier A, Dunlop NK, Beaudoin S, Malan V, Michot C, Baujat G, Rio M, Cormier-Daire V, Abadie V, Sarnacki S, Delacourt C, Lyonnet S, Attié-Bitach T, Pingault V, Rousseau V, Amiel J. Retrospective evaluation of clinical and molecular data of 148 cases of esophageal atresia. Am J Med Genet A 2023; 191:77-83. [PMID: 36271508 DOI: 10.1002/ajmg.a.62989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
Developmental abnormalities provide a unique opportunity to seek for the molecular mechanisms underlying human organogenesis. Esophageal development remains incompletely understood and elucidating causes for esophageal atresia (EA) in humans would contribute to achieve a better comprehension. Prenatal detection, syndromic classification, molecular diagnosis, and prognostic factors in EA are challenging. Some syndromes have been described to frequently include EA, such as CHARGE, EFTUD2-mandibulofacial dysostosis, Feingold syndrome, trisomy 18, and Fanconi anemia. However, no molecular diagnosis is made in most cases, including frequent associations, such as Vertebral-Anal-Cardiac-Tracheo-Esophageal-Renal-Limb defects (VACTERL). This study evaluates the clinical and genetic test results of 139 neonates and 9 fetuses followed-up at the Necker-Enfants Malades Hospital over a 10-years period. Overall, 52 cases were isolated EA (35%), and 96 were associated with other anomalies (65%). The latter group is divided into three subgroups: EA with a known genomic cause (9/148, 6%); EA with Vertebral-Anal-Cardiac-Tracheo-Esophageal-Renal-Limb defects (VACTERL) or VACTERL/Oculo-Auriculo-Vertebral Dysplasia (VACTERL/OAV) (22/148, 14%); EA with associated malformations including congenital heart defects, duodenal atresia, and diaphragmatic hernia without known associations or syndromes yet described (65/148, 44%). Altogether, the molecular diagnostic rate remains very low and may underlie frequent non-Mendelian genetic models.
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Affiliation(s)
- Emmanuelle Ranza
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Service de Médecine génétique, Hôpitaux Universitaires de Genève, Genève, Switzerland.,Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
| | - Morgane Le Gouez
- Service de Pédiatrie, Hôpital Necker-Enfants Malades (AP-HP), Paris, France
| | - Anne Guimier
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
| | - Naziha Khen Dunlop
- Service de Chirurgie Viscérale, Urologique et de Transplantation pédiatrique, Hôpital Universitaire Necker-Enfants Malades (AP-HP et Université de Paris), Paris, France
| | - Sylvie Beaudoin
- Service de Chirurgie Viscérale, Urologique et de Transplantation pédiatrique, Hôpital Universitaire Necker-Enfants Malades (AP-HP et Université de Paris), Paris, France
| | - Valérie Malan
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France
| | - Caroline Michot
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France
| | - Geneviève Baujat
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France
| | - Marlène Rio
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France
| | - Valérie Cormier-Daire
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
| | - Véronique Abadie
- Service de Pédiatrie, Hôpital Necker-Enfants Malades (AP-HP), Paris, France
| | - Sabine Sarnacki
- Service de Chirurgie Viscérale, Urologique et de Transplantation pédiatrique, Hôpital Universitaire Necker-Enfants Malades (AP-HP et Université de Paris), Paris, France
| | - Christophe Delacourt
- Service de Pneumologie Pédiatrique, Hôpital Necker-Enfants Malades (AP-HP), Paris, France
| | - Stanislas Lyonnet
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
| | - Tania Attié-Bitach
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
| | - Véronique Pingault
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
| | - Véronique Rousseau
- Service de Chirurgie Viscérale, Urologique et de Transplantation pédiatrique, Hôpital Universitaire Necker-Enfants Malades (AP-HP et Université de Paris), Paris, France
| | - Jeanne Amiel
- Service de médecine génomique des maladies rares, Hôpital Necker-Enfants Malades (AP-HP centre), Paris, France.,Institut Imagine, Inserm U1163, Université de Paris, Paris, France
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2
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Edwards NA, Shacham-Silverberg V, Weitz L, Kingma PS, Shen Y, Wells JM, Chung WK, Zorn AM. Developmental basis of trachea-esophageal birth defects. Dev Biol 2021; 477:85-97. [PMID: 34023332 DOI: 10.1016/j.ydbio.2021.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 02/07/2023]
Abstract
Trachea-esophageal defects (TEDs), including esophageal atresia (EA), tracheoesophageal fistula (TEF), and laryngeal-tracheoesophageal clefts (LTEC), are a spectrum of life-threatening congenital anomalies in which the trachea and esophagus do not form properly. Up until recently, the developmental basis of these conditions and how the trachea and esophagus arise from a common fetal foregut was poorly understood. However, with significant advances in human genetics, organoids, and animal models, and integrating single cell genomics with high resolution imaging, we are revealing the molecular and cellular mechanisms that orchestrate tracheoesophageal morphogenesis and how disruption in these processes leads to birth defects. Here we review the current understanding of the genetic and developmental basis of TEDs. We suggest future opportunities for integrating developmental mechanisms elucidated from animals and organoids with human genetics and clinical data to gain insight into the genotype-phenotype basis of these heterogeneous birth defects. Finally, we envision how this will enhance diagnosis, improve treatment, and perhaps one day, lead to new tissue replacement therapy.
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Affiliation(s)
- Nicole A Edwards
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Center for Stem Cell & Organoid Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vered Shacham-Silverberg
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Center for Stem Cell & Organoid Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Leelah Weitz
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA; Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Paul S Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Yufeng Shen
- Department of Systems Biology, Columbia University Medical Center, New York, NY, USA; Department of Biomedical Informatics, Columbia University Medical Center, New York, NY, USA
| | - James M Wells
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Center for Stem Cell & Organoid Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA; Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Aaron M Zorn
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Center for Stem Cell & Organoid Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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3
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van Lennep M, Singendonk MMJ, Dall'Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SWJ, Omari TI, Benninga MA, van Wijk MP. Oesophageal atresia. Nat Rev Dis Primers 2019; 5:26. [PMID: 31000707 DOI: 10.1038/s41572-019-0077-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.
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Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Fréderic Gottrand
- CHU Lille, University Lille, National Reference Center for Congenital Malformation of the Esophagus, Department of Pediatric Gastroenterology Hepatology and Nutrition, Lille, France
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne W J Terheggen-Lagro
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Pulmonology, Amsterdam, The Netherlands
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Center for Neuroscience, Flinders University, Adelaide, South Australia, Australia
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
| | - Michiel P van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Pediatric Gastroenterology, Amsterdam, The Netherlands
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4
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Identification of rare heterozygous missense mutations in FANCA in esophageal atresia patients using next-generation sequencing. Gene 2018; 661:182-188. [PMID: 29621589 DOI: 10.1016/j.gene.2018.03.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/12/2018] [Accepted: 03/29/2018] [Indexed: 11/23/2022]
Abstract
Esophageal atresia and tracheoesophageal fistula (EA/TEF) are relatively common malformations in newborns, but the etiology of EA/TEF remains unknown. Fanconi anemia (FA) complementation group A (FANCA) is a key component of the FA core complex and is essential for the activation of the DNA repair pathway. The middle region (amino acids 674-1208) of FANCA is required for its interaction with FAAP20. We performed targeted sequencing of this binding region of FANCA (exons 23-36) in 40 EA/TEF patients. We also investigated the effect of the p.A958V mutation on the protein-protein interaction between FANCA and FAAP20 using an in vitro binding assay and co-immunoprecipitation. Immunolocalization analysis was performed to investigate the subcellular localization of FANCA, and tissue sections and immunohistochemistry were used to explore the expression of FANCA. We identified four rare missense variants in the FANCA binding region. FANCA mutations were significantly overrepresented in EA/TEF patients compared with 4300 control subjects from the NHLBI-ESP project (Fisher's exact p = 2.17 × 10-5, odds ratio = 31.75). p.A958V, a novel de novo mutation in the FANCA gene, was identified in one patient with EA/TEF. We provide further evidence that the p.A958V mutation reduces the binding affinity of FANCA for FAAP20. Interestingly, the p.A958V mutation impaired the nuclear localization of the FANCA protein expressed in HeLa cells. We found that FANCA was more highly expressed in stratified squamous epithelium than in smooth muscle. In conclusion, mutations in the FANCA gene are associated with EA/TEF in humans.
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Kause F, Reutter H, Marsch F, Thiele H, Altmüller J, Ludwig M, Zhang R. Whole exome sequencing identifies a mutation in EYA1 and GLI3 in a patient with branchio‑otic syndrome and esophageal atresia: Coincidence or a digenic mode of inheritance? Mol Med Rep 2017; 17:3200-3205. [PMID: 29257230 DOI: 10.3892/mmr.2017.8196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/09/2017] [Indexed: 11/06/2022] Open
Abstract
Branchio‑otic (BO) syndrome is a clinically and genetically heterogeneous disorder that presents with variable branchial arch and otic anomalies. Dominant mutations in the human homologues of the Drosophila eyes absent (EYA1) gene, and the Drosophila sine oculis homeobox 1 and 5 (SIX1 and SIX5, respectively) genes have been causally associated with BO syndrome. Esophageal atresia (EA), with or without tracheo‑esophageal fistula (TEF), is the most common type of malformation of the upper digestive tract. To date, its causes are poorly understood. The present study investigated a family with three affected members who all presented with classic BO associated symptoms. Notably, the index patient also presented with the most common EA/TEF subtype type 3b. Whole exome sequencing (WES) was performed in the index patient, and prioritized genetic variants and their segregation in the family were analyzed by Sanger sequencing. WES demonstrated a known disease‑causing heterozygous EYA1 splice variant in the patient, as well as his sister and mother; all of whom were affected with BO syndrome. A further GLI family zinc finger 3 (GLI3) splice variant of unknown significance, inherited from the unaffected father, was also detected in the index patient. EYA1 and GLI3 are involved in the Sonic Hedgehog transcriptional network and GLI3 seems to be involved in human foregut malformations. Therefore, one may hypothesize a digenic inheritance model involving EYA1 and GLI3, where the effect of the GLI3 variant observed here only emerges in the background of the EYA1 defect.
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Affiliation(s)
- Franziska Kause
- Institute of Human Genetics, University Hospital of Bonn, D‑53127 Bonn, Germany
| | - Heiko Reutter
- Institute of Human Genetics, University Hospital of Bonn, D‑53127 Bonn, Germany
| | - Florian Marsch
- Institute of Human Genetics, University Hospital of Bonn, D‑53127 Bonn, Germany
| | - Holger Thiele
- Cologne Center for Genomics, University of Cologne, D‑50931 Cologne, Germany
| | - Janine Altmüller
- Cologne Center for Genomics, University of Cologne, D‑50931 Cologne, Germany
| | - Michael Ludwig
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital of Bonn, D‑53127 Bonn, Germany
| | - Rong Zhang
- Institute of Human Genetics, University Hospital of Bonn, D‑53127 Bonn, Germany
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Beauregard-Lacroix E, Tardif J, Lemyre E, Kibar Z, Faure C, Campeau PM. Genetic Testing in a Cohort of Complex Esophageal Atresia. Mol Syndromol 2017; 8:236-243. [PMID: 28878607 DOI: 10.1159/000477429] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 12/12/2022] Open
Abstract
The objective of the present study is to describe a cohort of complex esophageal atresia and the yield of genetic tests performed for such patients. We selected 45 patients with complex esophageal atresia (EA), namely those having at least one associated anomaly. We reviewed their medical records to assess clinical features, other diagnoses, and genetic investigations. Most of the patients had a diagnosis of VACTERL association (56%) with no genetic variant identified. Interestingly, 5 patients in the cohort (11%) had a right pulmonary hypoplasia or agenesis. A majority of our cohort (73%) had genetic testing; 60% were karyotyped (abnormal in 4 of the 27 patients tested), 31% had aCGH (abnormal in 1 of the 14 patients tested), and 31% had diepoxybutane (DEB) testing for Fanconi anemia (abnormal in 2 of the 14 patients tested). One patient had exome sequencing studies, but no candidate gene was identified. Various anomalies were associated with EA, and overall a genetic variant could be identified in 7 of the 33 patients tested. Chromosomal studies such as aCGH and chromosomal breakage studies should be considered, and their yield varied between 7 and 14%. Other genetic investigations such as exome sequencing could possibly have even higher yields but will need to be assessed in a large cohort. Improved genetic diagnoses in EA may improve the management of these patients by directing specific surveillance and management schemes.
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Affiliation(s)
- Eliane Beauregard-Lacroix
- CHU Sainte-Justine Research Center, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Medical Genetics Service, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jessica Tardif
- CHU Sainte-Justine Research Center, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Medical Genetics Service, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Emmanuelle Lemyre
- CHU Sainte-Justine Research Center, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Medical Genetics Service, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Zoha Kibar
- CHU Sainte-Justine Research Center, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Department of Neurosciences, University of Montreal, Montreal, Quebec, Canada
| | - Christophe Faure
- Gastroenterology Service, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Philippe M Campeau
- CHU Sainte-Justine Research Center, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Medical Genetics Service, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
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7
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Abou Chaar MK, Meyers ML, Tucker BD, Galan HL, Liechty KW, Crombleholme TM, Marwan AI. Twin pregnancy complicated by esophageal atresia, duodenal atresia, gastric perforation, and hypoplastic left heart structures in one twin: a case report and review of the literature. J Med Case Rep 2017; 11:64. [PMID: 28314387 PMCID: PMC5357333 DOI: 10.1186/s13256-016-1195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022] Open
Abstract
Background The antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation. Case presentation We present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin. Conclusions Prenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, “the upper thoracic pouch sign”), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.
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Affiliation(s)
- Mohamad K Abou Chaar
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Mariana L Meyers
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Radiology, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Bethany D Tucker
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatrics, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Henry L Galan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Obstetrics and Gynecology - Maternal Fetal Medicine, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Timothy M Crombleholme
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Ahmed I Marwan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Surgery and Pediatrics, Colorado Fetal Care Center - Children's Hospital Colorado, 13123 East 16th Avenue, 328, Aurora, Colorado, 80045, USA.
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