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Joyeux L, Basurto D, Bleeser T, Van der Veeken L, Vergote S, Kunpalin Y, Trigo L, Corno E, De Bie FR, De Coppi P, Ourselin S, Van Calenbergh F, Hooper SB, Rex S, Deprest J. Fetoscopic insufflation of heated-humidified carbon dioxide during simulated spina bifida repair is safe under controlled anesthesia in the fetal lamb. Prenat Diagn 2022; 42:180-191. [PMID: 35032031 DOI: 10.1002/pd.6093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 12/22/2021] [Accepted: 01/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the safety of Partial-Amniotic-Insufflation-of-heated-humidified-CO2 (hPACI) during fetoscopic spina bifida repair (fSB-repair). METHOD A simulated fSB-repair through an exteriorized uterus under hPACI was performed in 100-day fetal lambs (term = 145 days) under a laboratory anesthesia protocol (n = 5; group 1) which is known to induce maternal-fetal acidosis and hypercapnia. Since these may not occur clinically, we applied a clinical anesthesia protocol (n = 5; group 2), keeping maternal parameters within physiological conditions, that is, controlled maternal arterial carbon dioxide (CO2) pressure (pCO2 = 30 mmHg), blood pressure (≥67 mmHg), and temperature (37.1-39.8°C). Our superiority study used fetal pH as the primary outcome. RESULTS Compared to group 1, controlled anesthesia normalized fetal pH (7.23 ± 0.02 vs. 7.36 ± 0.02, p < 0.001), pCO2 (70.0 ± 9.1 vs. 43.0 ± 1.0 mmHg, p = 0.011) and bicarbonate (27.8 ± 1.1 vs. 24.0 ± 0.9 mmol/L, p = 0.071) at baseline. It kept them within clinically acceptable limits (pH ≥ 7.23, pCO2 ≤ 70 mmHg, bicarbonate ≤ 30 mm/L) for ≥120 min of hPACI as opposed to ≤30 min in group one. Fetal pO2 and lactate were comparable between groups and generally within normal range. Fetal brain histology demonstrated fewer apoptotic cells and higher neuronal density in the prefrontal cortex in group two. There was no difference in fetal membrane inflammation, which was mild. CONCLUSION Fetoscopic insufflation of heated-humidified CO2 during simulated fSB-repair through an exteriorized uterus can be done safely under controlled anesthesia.
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Affiliation(s)
- Luc Joyeux
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - David Basurto
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Bleeser
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Lennart Van der Veeken
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Simen Vergote
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Yada Kunpalin
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, London, UK
| | - Lucas Trigo
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,BCNatal, Fetal Medicine Research Center, Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Enrico Corno
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Felix R De Bie
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paolo De Coppi
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium.,Specialist Neonatal and Pediatric Surgery Unit, Great Ormond Street Hospital, University College London Hospitals, NHS Trust, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, London, UK
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Abstract
INTRODUCTION Spina bifida is the most common non-lethal congenital birth defect of the central nervous system that causes chronic disability due to the combined effects of local nerve damage and the sequelae of non-communicating hydrocephalus. This abnormality can be identified early in gestation and the damage can be progressive over the course of pregnancy. Advances in fetal treatment have made minimally invasive prenatal surgery a realistic consideration for spina bifida in order to improve the outcome for children affected this condition. EVIDENCE ACQUISITION Prenatal surgery for spina bifida via open fetal surgery with hysterotomy decreases the rate of ventriculoperitoneal shunt placement and improves motor function compared to standard postnatal surgery. Maternal risks of open fetal surgery are primarily related to complications of the hysterotomy including thinning or rupture that begins in the index pregnancy but persists for every future pregnancy. Minimizing maternal risks is the largest impetus to explore and optimize a minimally invasive fetoscopic alternative. Techniques vary from using a complete percutaneous approach to open fetoscopy, which requires laparotomy but is minimally invasive to the uterus. This allows vaginal delivery at term and no scar complications are reported thus far. Fetal short-term neurosurgical outcomes compare favorably with improvement in hindbrain herniation >70% and decreased need for treatment for hydrocephalus between 40-45% after prenatal surgery performed either fetoscopically or through open fetal surgery. EVIDENCE SYNTHESIS Maternal obstetric outcomes are superior for fetoscopic spina bifida repair compared to open fetal surgery and avoids the ongoing risk in future pregnancy. Neonatal and infant benefits appear equivalent. The open fetoscopic approach minimizes the risk of ruptured membranes and subsequent preterm delivery as opposed to a completely percutaneous procedure. International collaboration is ongoing to share experience and assess long term treatment effects. CONCLUSIONS Continued refinement of a minimally invasive strategy for prenatal treatment of spina bifida is necessary to maximize benefits to the child and further minimize maternal risks and preterm birth.
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Affiliation(s)
- Jena L Miller
- Department of Gynecology and Obstetrics, The Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA -
| | - Mari L Groves
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, The Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA
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Peiró JL, Carreras E, Guillén G, Arévalo S, Sánchez-Durán MA, Higueras T, Castillo F, Marhuenda C, Lloret J, Martínez-Ibáñez V. Therapeutic Indications of Fetoscopy: A 5-Year Institutional Experience. J Laparoendosc Adv Surg Tech A 2009; 19:229-36. [DOI: 10.1089/lap.2007.0149] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jose L. Peiró
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Elena Carreras
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Gabriela Guillén
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Silvia Arévalo
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | | | - Teresa Higueras
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Felix Castillo
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Claudia Marhuenda
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
| | - Josep Lloret
- Fetal Surgery Program, Hospital Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
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