Fetal interventional procedures and surgeries: a practical approach

Perinatal outcome of twin-to-twin transfusion syndrome complicated with incidental septostomy after laser photocoagulation: A systematic review and meta-analysis

AIM

To evaluate perinatal outcomes of incidental septostomy (IS) after laser photocoagulation for twin-to-twin transfusion syndrome (TTTS), and to compare the outcomes with those who had intact intertwin membrane.

METHODS

Databases such as PubMed, Web of Science, Scopus, and Embase were systematically searched from inception up to August 2020. The random-effects model was used to pool the mean difference (MD) or odds-ratio (OR) with the corresponding 95% confidence intervals (CIs). Primary outcome was incidence of preterm delivery, and preterm premature rupture of membranes (PPROM), while secondary outcomes included gestational age (GA) at intervention, GA at delivery, neonatal survival, and incidence of pseudoamniotic band syndrome (PABS).

RESULTS

Four studies (1442 patients) met our inclusion criteria. Postoperative identification of IS was associated with earlier GA at delivery (MD = -2.52; 95% CI: -3.22, -1.82; p < 0.00), higher risk of PPROM < 32 weeks (OR = 2.82; 95% CI: 1.80, 4.40; p < 0.001), and preterm delivery < 32 weeks (OR = 4.01; 95% CI: 1.27, 12.63; p = 0.02). No differences were noted in pseudoamniotic band syndrome, at least one or dual neonatal survival rate between IS and non-IS groups.

CONCLUSIONS

Occurrence of IS after laser photocoagulation for TTTS is associated with earlier GA at delivery, increased risk for PPROM and preterm delivery <32 weeks' gestation. However, neonatal survival does not appear to be affected by this complication.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review

Objective

To cope with the changing health care services in the era of SARS-CoV-2 pandemic. We share the institutional framework for the management of anomalous fetuses requiring fetal intervention at Mayo Clinic, Rochester, Minnesota. To assess the success of our program during this time, we compare intraoperative outcomes of fetal interventions performed during the pandemic with the previous year.

Patients

We implemented our testing protocol on patients undergoing fetal intervention at our institution between March 1, and May 15, 2020, and we compared it with same period a year before. A total of 17 pregnant patients with anomalous fetuses who met criteria for fetal intervention were included: 8 from 2019 and 9 from 2020.

Methods

Our testing protocol was designed based on our institutional perinatal guidelines, surgical requirements from the infection prevention and control (IPAC) committee, and input from our fetal surgery team, with focus on urgency of procedure and maternal SARS-CoV-2 screening status. We compared the indications, types of procedures, maternal age, gestational age at procedure, type of anesthesia used, and duration of procedure for cases performed at our institution between March 1, 2020, and May 15, 2020, and for the same period in 2019.

Results

There were no statistically significant differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures (P values were all >.05) between the pre–SARS-CoV-2 pandemic in 2019 and the SARS-CoV-2 pandemic in 2020.

Conclusions

Adoption of new institutional protocols during SARS-CoV-2 pandemic, with appropriate screening and case selection, allows provision of necessary fetal intervention with maximal benefit to mother, fetus, and health care provider.

New Trends in Fetal Anesthesia

Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.