Ex vivo testing of a temperature- and pressure-controlled amnio-irrigator for fetoscopic surgery

[Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]

OBJECTIVES

To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used.

PATIENTS AND METHODS

This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil.

RESULTS

Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived.

CONCLUSIONS

The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

Invasive Antenatal Interventions in Complicated Multiple Pregnancies

Multiple pregnancies still pose challenging problems for modern medicine. Complications in monochorionic multiple pregnancies have sparked a revival of fetoscopy as a means surgery on the placenta and umbilical cord. As such, fetoscopic laser coagulation is currently the best first-line treatment for severe twin-to-twin transfusion syndrome. Also, fetoscopic or ultrasound-guided cord coagulation seems to be an effective technique for selective feticide in monochorionic twins, albeit with still considerably higher fetal loss rates compared with selective feticide by potassium chloride injection in dichorionic twins.

Successful patching of iatrogenic rupture of the fetal membranes

Rupture of the fetal membranes is a common, but potentially serious complication of invasive fetal procedures. Quintero described a technique to seal the fetal membrane defect by means of a bloodpatch, usually called 'amniopatch' in this application. The successful use in two consecutive patients with ruptured membranes after a fetoscopic intervention at respectively 17 and 22 weeks' gestational age is described, together with a literature review of published experience.

Monochorionic diamniotic twins: complications and management options

PURPOSE OF REVIEW

Monochorionic compared with dichorionic twins have disproportionately high fetal loss rates, perinatal mortality and morbidity. This is because of the unpredictable vascular anastomoses and the often asymmetrical distribution of the single placenta between both twins.

RECENT FINDINGS

The pathophysiology of twin-to-twin transfusion syndrome is usually explained on an angioarchitectural basis, although certain hemodynamic and hormonal factors also may be involved. The results of the large randomized trials on amnioreduction, fetoscopic laser coagulation and septostomy are still awaited. An update is given on hardware and instruments required for fetoscopic laser. Subsequently, the problem of the monochorionic twin set with severe early discordant growth is addressed. Several etiological mechanisms have been proposed, but little is known of its natural history. Also, umbilical artery Doppler waveforms may not have the same predictive value as in singletons. Prophylactic laser coagulation of the vascular anastomoses to protect against the adverse effects of single intrauterine demise, has so far not been shown to confer any benefit in outcome. Finally, pathophysiology and management of discordant structural and chromosomal anomalies in monochorionic twins are discussed. Laser and monopolar coagulation, which can be introduced through a needle, may be used for selective feticide in early pregnancy or low hemodynamic conditions. Bipolar coagulation seems more effective at later gestational ages and normal hemodynamic conditions.

SUMMARY

Our insight into the complications associated with monochorionic twins has increased in recent years. It is hoped that this will lead to better surveillance and ultimately an improved outcome for these high-risk pregnancies.

Incidence, complications, and management of Meckel's diverticulum

OBJECTIVES

To elucidate the incidence of Meckel's diverticulum; to determine the correlation between the histologic type of the diverticulum's mucosa and its clinical presentation; and to review our experience with Meckel's diverticulum.

DESIGN

Case-control study.

SETTING

University hospital in Ioannina, Greece.

PATIENTS

A total of 2074 patients undergoing an appendectomy were examined intraoperatively for Meckel's diverticulum (subgroup A1). In addition, Meckel's diverticulum was found incidentally in 15 patients who were undergoing intra-abdominal surgery (subgroup A2). An operation for a complicated Meckel diverticulum was performed in an additional 15 patients (group B).

RESULTS

Thirty-three (1.59%) Meckel diverticulae were found incidentally among 2074 patients in subgroup A1. A positive correlation between Meckel's diverticulum and male sex was found (P < .004), but no difference was found in sex distribution between patients in group B and subgroup A1 (P < .6744). The histologic type of the mucosa (gastric) had significant positive correlation with the clinical presentation of the diverticulum (complicated) (P < .001).

CONCLUSION

Resection of the unexpected Meckel diverticulum can be performed safely with a low complication rate, regardless of the patient's age.