Fetal surgery: trials, tribulations, and turf

Current status of subspecialization in pediatric surgery: A focus on fetal surgery

BACKGROUND/PURPOSE

Fetal surgery is a growing field within pediatric surgery. We sought to understand practice patterns of pediatric surgeons who subspecialize in fetal surgery.

METHODS

A survey was sent to all active non-trainee surgeons within the American Pediatric Surgical Association. Respondents were stratified based on self-reported fetal affiliations.

RESULTS

Of 1015 surveys, we received 405 responses (40%). Fetal surgery practices were described by 77 self-designated fetal center members. Centers provide prenatal consultation (99%), diagnostic imaging (84%), care/delivery coordination (83%), and/or fetal surgery/procedures (52%). The majority (56%) of fetal programs are directed by surgery and maternal fetal medicine. Pediatric surgeons are represented on the fetal team in 96% of centers. Prenatal consultations are primarily seen by any pediatric surgeon in the group (53%), with the pediatric surgeon on call operating on/caring for the baby postnatally in the majority (64%), regardless of who performed the prenatal consultation. Only 29% of fetal center members performed a fetal operation in the last year. Yearly fetal case numbers vary widely per procedure, with the most common being complex twin procedures and needle-based sclerotherapy.

CONCLUSIONS

Fetal centers vary by services offered, team composition, and interventions performed, with few surgeons performing a wide range of fetal surgery.

LEVEL OF EVIDENCE

Level III.

The Future of Fetal Surgery

The field of fetal medicine has evolved significantly over the past several decades. Our ability to identify and treat the unborn patient has been shaped by advancements in imaging technology, genetic diagnosis, an improved understanding of fetal physiology, and the development and optimization of in utero surgical techniques. The future of the field will be shaped by medical innovators pushing for the continued refinement of minimally invasive surgical technique, the application of pioneering technologies such as robotic surgery and in utero stem cell and gene therapies, and the development of innovative ex utero fetal support systems.

"We want to do everything": how parents represent their experiences with maternal-fetal surgery online

OBJECTIVE

There is little available evidence on how patients make decisions regarding maternal-fetal surgery. We studied online patient narratives for insight on how pregnant women and their partners consider such decisions.

STUDY DESIGN

We used Google search strings and a purposive snowball method to locate patient blogs. We analyzed blog entries using qualitative methods to identify author details, medical information, and common themes.

RESULTS

We located 32 blogs of patients who describe maternal-fetal surgery consultation. Twenty-eight (88%) underwent fetal interventions. Most (91%) explicitly described consultation with maternal-fetal surgery teams; 83% of those depicted making decisions prior to formal consultation. Few expressed regret for decisions made (6%).

CONCLUSIONS AND RELEVANCE

Patients openly share experiences with maternal-fetal surgery online. Women portray their decisions as made outside of formal medical processes and overwhelmingly feel these decisions were "right". As the field of maternal-fetal surgery expands, prospective evaluation of patient decision-making is needed.

Prenatal coverage of experimental gastroschisis with a collagen scaffold to protect the bowel

BACKGROUND/PURPOSE

In fetuses with gastroschisis, toxic products in the amniotic fluid and constriction at the defect of the abdominal wall are considered causative of damage to the eviscerated bowel. The aim of this study was to cover the eviscerated bowel in gastroschisis with a collagen scaffold to protect the bowel and induce cell growth into the scaffold, which could lead to skin or abdominal wall formation replacing the scaffold.

METHODS

In 12 fetal lambs gastroschisis was surgically created at 79 days gestation. A dual-layer type I collagen scaffold was sutured into the skin of the abdominal wall around the defect covering the eviscerated bowel. Lambs were examined after caesarean section at 140 days' gestation.

RESULTS

Survival was 67%. In 7 of 8 surviving lambs the bowel was found to be covered after birth. One scaffold had ruptured. The bowel was found repositioned in the abdominal cavity in 5 lambs. In 2 lambs it was still partially outside. Only minor adherence of bowel loops and no fibrous peel formation were seen. Connective tissue and skin tissue replaced the scaffold.

CONCLUSIONS

Prenatal coverage of the bowel in experimental gastroschisis with a collagen scaffold is feasible in fetal lambs, significantly diminished damage to the bowel wall, and skin and connective tissue replaced the scaffold. This technique may be promising in the care of fetuses with this congenital anomaly.

Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists

OBJECTIVES

The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations.

METHODS

We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%).

RESULTS

FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001).

CONCLUSIONS

Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.

Fetal treatment center: history, infrastructure, and nursing perspective

It is important to recognize that it is only during our lifetime, the last decades of the 20th century, that the fetus has become a patient, with much of the credit due to the powerful imaging and sampling techniques now available. The secret life of the fetus has been revealed and with it the details of normal fetal growth and development and the opportunity to identify, detect, and treat fetal anomalies surgically. From a nursing perspective, this article provides a historical overview of fetal treatment, including the development and evolution of fetal surgery, a description of some milestones of this multifaceted, complex area, a delineation of the components and dynamics of collaborative team management of fetal therapy patients, and finally an introduction to introduce emerging trends that will affect the future of this rapidly evolving field.

Effects on the maternofetal unit of the rabbit model after substitution of the amniotic fluid with perfluorocarbons

OBJECTIVES

Exchanging amniotic fluid (AF) with perfluorocarbon (PFC) may serve as a medium for fetoscopic surgery. This study evaluates the distribution and physiologic effects of intraamniotic PFC as a medium for fetoscopy.

METHODS

Fetuses of 17 pregnant rabbits underwent either exchange of the AF with PFC, electrolyte solution (ES), or control. The quality of vision during fetoscopy was assessed in AF and PFC. After 6 h, we determined the distribution of PFC in the maternofetal unit.

RESULTS

Quality of vision during fetoscopy was better in PFC than with AF. There was no difference in fetal survival between the study groups. PFC was demonstrated on X-ray in the pharynx of 4 fetuses, and the esophagus in 1.

CONCLUSIONS

PFC provided an ideal medium for fetoscopy without fetal compromise.

Frontiers in fetal cardiovascular disease

This article reviews the state of the art in prenatal cardiovascular imaging, the elucidation of regional vascular flow patterns in the developing fetus and what can be learned from these flow patterns, the new clinical practice systems being that are being implemented to deal with the fetal patient and its family, and the prospects for fetal surgery.