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Lopyan NM, Perrone EE, Gadepalli SK, Raval MV, Tsao K, Rich BS. Current status of subspecialization in pediatric surgery: A focus on fetal surgery. J Pediatr Surg 2022; 57:610-615. [PMID: 34134857 DOI: 10.1016/j.jpedsurg.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Natalie M Lopyan
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Erin E Perrone
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA; The North American Fetal Therapy Network (NAFTNet), USA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Mehul V Raval
- Department of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kuojen Tsao
- Department of Pediatric Surgery, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA; The North American Fetal Therapy Network (NAFTNet), USA
| | - Barrie S Rich
- Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
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Abstract
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.
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Affiliation(s)
- Eric Bergh
- Department of Obstetrics and Gynecology, The Fetal Center at Children's Memorial Hermann Hospital, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA.
| | - Cara Buskmiller
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA. https://twitter.com/CaraBuskmiller
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, The Fetal Center at Children's Memorial Hermann Hospital, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA
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Fry JT, Frader JE. "We want to do everything": how parents represent their experiences with maternal-fetal surgery online. J Perinatol 2018; 38:226-232. [PMID: 29317765 DOI: 10.1038/s41372-017-0040-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Joel E Frader
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Palliative Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Roelofs LAJ, Geutjes PJ, Hulsbergen-van de Kaa CA, Eggink AJ, van Kuppevelt TH, Daamen WF, Crevels AJ, van den Berg PP, Feitz WFJ, Wijnen RMH. Prenatal coverage of experimental gastroschisis with a collagen scaffold to protect the bowel. J Pediatr Surg 2013; 48:516-24. [PMID: 23480905 DOI: 10.1016/j.jpedsurg.2012.07.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 06/30/2012] [Accepted: 07/20/2012] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Luc A J Roelofs
- Department of Urology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Brown SD, Donelan K, Martins Y, Burmeister K, Buchmiller TL, Sayeed SA, Mitchell C, Ecker JL. Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists. Pediatrics 2012; 130:e1534-40. [PMID: 23129074 DOI: 10.1542/peds.2012-1352] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital, Boston, MA 02115, USA.
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Roelofs LAJ, Eggink AJ, Hulsbergen-van de Kaa CA, van den Berg PP, van Kuppevelt TH, van Moerkerk HTB, Crevels AJ, Lotgering FK, Feitz WFJ, Wijnen RMH. Fetal Abdominal Wall Repair with a Collagen Biomatrix in an Experimental Sheep Model for Gastroschisis. Tissue Eng Part A 2008; 14:2033-40. [DOI: 10.1089/ten.tea.2007.0191] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Luc A. J. Roelofs
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Alex J. Eggink
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Paul P. van den Berg
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Toin H. van Kuppevelt
- Department of Biochemistry, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - A. Jane Crevels
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Fred K. Lotgering
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Wout F. J. Feitz
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Rene M. H. Wijnen
- Department of Pediatric Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
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Roelofs LA, Eggink AJ, Hulsbergen-van de Kaa CA, Wijnen RM, van Kuppevelt TH, van Moerkerk HT, Crevels AJ, Hanssen A, Lotgering FK, van den Berg PP, Feitz WF. Fetal Bladder Wall Regeneration with a Collagen Biomatrix and Histological Evaluation of Bladder Exstrophy in a Fetal Sheep Model. Fetal Diagn Ther 2008; 24:7-14. [DOI: 10.1159/000132399] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 02/02/2007] [Indexed: 11/19/2022]
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Abstract
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.
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Affiliation(s)
- Jody A Farrell
- Fetal Treatment Center, San Francisco Medical Center and Children's Hospital, University of California, San Francisco 94143, USA.
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Muensterer OJ, Klis VJ, Till H, von Schweinitz D, Simbruner G. Effects on the maternofetal unit of the rabbit model after substitution of the amniotic fluid with perfluorocarbons. Fetal Diagn Ther 2005; 20:359-65. [PMID: 16113554 DOI: 10.1159/000086813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 05/11/2004] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Oliver J Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany.
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Abstract
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.
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Affiliation(s)
- Jack Rychik
- Fetal Heart Program, The Cardiac Center at The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Colombani PM. What's new in pediatric surgery. J Am Coll Surg 2003; 197:278-84. [PMID: 12892812 DOI: 10.1016/s1072-7515(03)00542-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paul M Colombani
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Current awareness in prenatal diagnosis. Prenat Diagn 2003; 23:522-8. [PMID: 12858868 DOI: 10.1002/pd.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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