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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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2
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Abstract
The ex-utero intrapartum treatment (EXIT) procedure was originally developed to reverse tracheal occlusion in fetuses with severe congenital diaphragmatic hernia that underwent fetal tracheal occlusion. The EXIT procedure has since been applied to a wide range of indications, but the primary indication remains securing a patent airway and providing respiratory support in fetuses with anticipated difficult airways. The authors review perinatal management of the anticipated difficult airway and their single-institution's experience with the EXIT procedure.
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Affiliation(s)
- M Silena Mosquera
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Sara Yuter
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA.
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3
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Chen Q, Ren Y, Zhou L, Chen C, Liu S. Design and Analysis of Joint Group Shuffled Scheduling Decoding Algorithm for Double LDPC Codes System. Entropy (Basel) 2023; 25:357. [PMID: 36832723 PMCID: PMC9954909 DOI: 10.3390/e25020357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
In this paper, a joint group shuffled scheduling decoding (JGSSD) algorithm for a joint source-channel coding (JSCC) scheme based on double low-density parity-check (D-LDPC) codes is presented. The proposed algorithm considers the D-LDPC coding structure as a whole and applies shuffled scheduling to each group; the grouping relies on the types or the length of the variable nodes (VNs). By comparison, the conventional shuffled scheduling decoding algorithm can be regarded as a special case of this proposed algorithm. A novel joint extrinsic information transfer (JEXIT) algorithm for the D-LDPC codes system with the JGSSD algorithm is proposed, by which the source and channel decoding are calculated with different grouping strategies to analyze the effects of the grouping strategy. Simulation results and comparisons verify the superiority of the JGSSD algorithm, which can adaptively trade off the decoding performance, complexity and latency.
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4
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Mufti N, Ebner M, Patel P, Aertsen M, Gaunt T, Humphries PD, Bredaki FE, Hewitt R, Butler C, Sokolska M, Kendall GS, Atkinson D, Vercauteren T, Ourselin S, Pandya PP, Deprest J, Melbourne A, David AL. Super-resolution Reconstruction MRI Application in Fetal Neck Masses and Congenital High Airway Obstruction Syndrome. OTO Open 2021; 5:2473974X211055372. [PMID: 34723053 PMCID: PMC8549475 DOI: 10.1177/2473974x211055372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Reliable airway patency diagnosis in fetal tracheolaryngeal obstruction is crucial to select and plan ex utero intrapartum treatment (EXIT) surgery. We compared the clinical utility of magnetic resonance imaging (MRI) super-resolution reconstruction (SRR) of the trachea, which can mitigate unpredictable fetal motion effects, with standard 2-dimensional (2D) MRI for airway patency diagnosis and assessment of fetal neck mass anatomy. Study Design A single-center case series of 7 consecutive singleton pregnancies with complex upper airway obstruction (2013-2019). Setting A tertiary fetal medicine unit performing EXIT surgery. Methods MRI SRR of the trachea was performed involving rigid motion correction of acquired 2D MRI slices combined with robust outlier detection to reconstruct an isotropic high-resolution volume. SRR, 2D MRI, and paired data were blindly assessed by 3 radiologists in 3 experimental rounds. Results Airway patency was correctly diagnosed in 4 of 7 cases (57%) with 2D MRI as compared with 2 of 7 cases (29%) with SRR alone or paired 2D MRI and SRR. Radiologists were more confident (P = .026) in airway patency diagnosis when using 2D MRI than SRR. Anatomic clarity was higher with SRR (P = .027) or paired data (P = .041) in comparison with 2D MRI alone. Radiologists detected further anatomic details by using paired images versus 2D MRI alone (P < .001). Cognitive load, as assessed by the NASA Task Load Index, was increased with paired or SRR data in comparison with 2D MRI. Conclusion The addition of SRR to 2D MRI does not increase fetal airway patency diagnostic accuracy but does provide improved anatomic information, which may benefit surgical planning of EXIT procedures.
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Affiliation(s)
- Nada Mufti
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Michael Ebner
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Premal Patel
- Radiology Department, Great Ormond Street Hospital for Children, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals Katholieke Universiteit, Leuven, Belgium
| | - Trevor Gaunt
- Radiology Department, Great Ormond Street Hospital for Children, London, UK.,Women's Health Division, University College London Hospitals, London, UK
| | - Paul D Humphries
- Radiology Department, Great Ormond Street Hospital for Children, London, UK
| | | | - Richard Hewitt
- Ear, Nose and Throat Department, Great Ormond Street Hospital for Children, London, UK
| | - Colin Butler
- Ear, Nose and Throat Department, Great Ormond Street Hospital for Children, London, UK
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Giles S Kendall
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Women's Health Division, University College London Hospitals, London, UK
| | - David Atkinson
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Pranav P Pandya
- Women's Health Division, University College London Hospitals, London, UK
| | - Jan Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Katholieke Universiteit, Leuven, Belgium
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Katholieke Universiteit, Leuven, Belgium
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Barrette LX, Morales CZ, Oliver ER, Gebb JS, Feygin T, Lioy J, Howell LJ, Hedrick HL, Jackson OA, Adzick NS, Javia LR. Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses. Int J Pediatr Otorhinolaryngol 2021; 149:110851. [PMID: 34311168 DOI: 10.1016/j.ijporl.2021.110851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. STUDY DESIGN A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. RESULTS Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. CONCLUSION This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.
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Affiliation(s)
- Louis-Xavier Barrette
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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6
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Parellada C, Pose MN, Vázquez Durand M, Rubies Y, Albas Maubett D, Saint Genez D, Vidaurreta S. [Epignathus, the importance of prenatal diagnosis and interdisciplinary work: A case report]. ARCH ARGENT PEDIATR 2021; 119:e499-e503. [PMID: 34569750 DOI: 10.5546/aap.2021.e499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/15/2021] [Indexed: 11/12/2022]
Abstract
Thanks to technological advances, it has been possible to carry out the prenatal diagnosis of different life-threatening congenital malformations. Among these, oral teratoma, or epignathus, is a rare form of congenital teratoma within those located in the head and neck. They are generally benign and comprise 4 % of neonatal teratomas. From the development of the EXIT technique (ex utero intrapartum treatment), which has been implemented since the 90's to support fetal circulation until the newborn's airway is secured, it is possible to plan a multidisciplinary management strategy that enables the correct approach of these pathologies. We present a case of giant epignathus in a 35-week gestation female patient, whose airway was secured using the EXIT technique, and follow up.
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Affiliation(s)
- Camila Parellada
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Mónica N Pose
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariana Vázquez Durand
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Yamile Rubies
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Delcys Albas Maubett
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Saint Genez
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Santiago Vidaurreta
- Sección Neonatología y Departamento de Pediatría, Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
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Tai HL, Mok TYD, Chao AS, Chu SM, Lien R. Staged Management of Congenital Chylothorax With Hydrops Fetalis: An Insight Into EXIT Related Procedures. Front Pediatr 2021; 9:633051. [PMID: 33681104 PMCID: PMC7925828 DOI: 10.3389/fped.2021.633051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Idiopathic congenital chylothorax is a rare but serious disease. Advancement in perinatal care and the renovated treatment modalities have brought about significant improvement in patient outcome. Objective: To describe the clinical course of severe forms of idiopathic congenital chylothorax, focusing on the development of recent treatment modalities and their impacts. Design: A retrospective cohort by review of medical records in the NICU of a perinatal referral center in Taiwan. Study period was from January 2006 to June 2017. Neonates with the diagnosis of idiopathic congenital chylothorax with non-immune hydrops fetalis were enrolled. Clinical relevant including demographic data, perinatal interventions, post-natal course, and treatment outcome were described and analyzed. Results: Twenty-eight neonatal patients were included. The median gestational age at birth was 34 (range 27-36) weeks and median birth weight was 2,369 (range 1,430-3,608) g. Prenatal intervention was performed in 39.3% of the patients. Besides, 11 out of the 28 neonates developed tension pneumothorax in the first 24 h and 4 (36.4%) of them died. Sepsis was documented in two patients (7.1%). Overall survival rate was 71.4%. There were five patients enrolled during the last 2 years of the study period. EXIT with intubation was performed in two and octreotide was given to four of these most recent neonates, and all of them survived. Conclusion: Recent advances in the management of these neonates, specifically EXIT with intubation and use of octreotide. Both of them improved patient survival in our cohort, but the evidence of impact has yet to be validated.
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Affiliation(s)
- Hung-Lin Tai
- Department of Pediatrics, Saint Paul's Hospital, Taoyuan City, Taiwan.,Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tze Yee Diane Mok
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Medical Center, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shih-Ming Chu
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Reyin Lien
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
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8
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Abstract
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.
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Affiliation(s)
- Kha M Tran
- University of Pennsylvania Perelman School of Medicine, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Debnath Chatterjee
- Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
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9
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Novoa RH, Quintana W, Castillo-Urquiaga W, Ventura W. EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature. J Pediatr Surg 2020; 55:1188-1195. [PMID: 32151401 DOI: 10.1016/j.jpedsurg.2020.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 11/24/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235). CONCLUSION EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE IV case series with no comparison group.
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Affiliation(s)
- Rommy H Novoa
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Willy Quintana
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Walter Ventura
- Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru; Fetal Medicine Unit, Clinica Delgado, Grupo AUNA, Lima, Peru.
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10
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Propst EJ, Wolter NE, Morency AM, Amin R, Blaser S, Moore AM, Windrim R, Ryan G. Fetoscopic Balloon Dilation and Cricotracheal Resection for Laryngeal Atresia in CHAOS. Laryngoscope 2020; 131:660-662. [PMID: 32574407 DOI: 10.1002/lary.28775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/28/2020] [Accepted: 05/08/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Evan J Propst
- Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Anne-Maude Morency
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Reshma Amin
- University of Toronto, Toronto, Ontario, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Blaser
- University of Toronto, Toronto, Ontario, Canada.,Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aideen M Moore
- University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rory Windrim
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Greg Ryan
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
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11
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Beckmann N, Luttrell J, Petty B, Rhodes C, Thompson J. Injection bronchoplasty with carboxymethlycellulose with cystoscopy needle for neonatal persistent bronchopleural fistulae. Int J Pediatr Otorhinolaryngol 2019; 127:109651. [PMID: 31470204 DOI: 10.1016/j.ijporl.2019.109651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We describe the novel use of injectable carboxymethylcellulose to close a persistent bronchopleural fistula (BPF) in a neonate who underwent an ex utero intrapartum treatment (EXIT) after aborted fetoscopy. METHODS In this case, a patient with laryngeal atresia underwent fetoscopy that was halted after concern for instruments within the mediastinum, and thus ultimately required an EXIT to establish an airway. Bilateral pneumothoraces and eventually multiple BPF were identified that continued to persist despite multiple attempts at removal of chest tubes over a four-week period. We look at the role of endoscopy and a substance often used in the larynx to help close a persistent BPF. RESULTS At initial bronchoscopy, no BPF was identified, but at subsequent evaluation due to persistent pneumothorax, we used increased positive end expiratory pressure to help reveal the fistula. Given the bronchial location of the fistula, traditional laryngeal instruments could not be used, requiring the use of urologic cystoscopy needles to assist in accessing these challenging locations. At postoperative day 2 from the injection, the chest tube was removed and did not require replacement. CONCLUSION There are many methods to help treat BPF. The endoscopic injection of carboxymethylcellulose adds a technique to the pediatric otolaryngologist's armamentarium.
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Affiliation(s)
- Nicholas Beckmann
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; LeBonheur Children's Hospital, Memphis, TN, USA.
| | - Jordan Luttrell
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brad Petty
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; LeBonheur Children's Hospital, Memphis, TN, USA
| | - Cecil Rhodes
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; LeBonheur Children's Hospital, Memphis, TN, USA
| | - Jerome Thompson
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; LeBonheur Children's Hospital, Memphis, TN, USA
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12
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Jiang S, Yang C, Bent J, Yang CJ, Gangar M, Nassar M, Suskin B, Dar P. Ex utero intrapartum treatment ( EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019; 127:109642. [PMID: 31479918 DOI: 10.1016/j.ijporl.2019.109642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/17/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.
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Affiliation(s)
- Sydney Jiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Catherina Yang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - John Bent
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Mona Gangar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Michel Nassar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Stamford Hospital, One Hospital Plaza, Whittingham Pavilion, Stamford, CT, 06902, USA
| | - Peer Dar
- Division of Fetal Medicine and OB-Gyn Ultrasound, Albert Einstein College of Medicine / Montefiore Medical Center, 1695 Eastchester Road Room L4, Bronx, NY, 10461, USA
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13
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Nicolas CT, Lynch-Salamon D, Bendel-Stenzel E, Tibesar R, Luks F, Eyerly-Webb S, Lillegard JB. Fetoscopy-Assisted Percutaneous Decompression of the Distal Trachea and Lungs Reverses Hydrops Fetalis and Fetal Distress in a Fetus with Laryngeal Atresia. Fetal Diagn Ther 2019; 46:75-80. [PMID: 31238308 DOI: 10.1159/000500455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
We present a case of prenatal hydrops secondary to congenital high airway obstruction syndrome (CHAOS) that was treated with fetoscopy-assisted needle decompression. A 22-year-old G3P2 woman presented after a 21-week ultrasound demonstrated CHAOS. The fetus developed hydrops at 25 weeks, characterized by abdominal ascites, pericardial effusion, and scalp edema. Fetal MRI showed complete obstruction of the glottis and subglottic airway, suggestive of laryngeal atresia. At 27 weeks, due to the progression of the hydrops, operative fetoscopy was proposed and performed. Fetal laryngoscopy confirmed fusion of the vocal cords and laryngeal atresia. The atretic segment was a solid cartilaginous block, preventing intubation. Using the fetoscope to stabilize the fetal head and neck, we performed ultrasound-guided percutaneous needle drainage of the cervical trachea through the anterior fetal neck. We removed 17 mL of viscous fluid from the lower trachea, resulting in immediate lung decompression. Two weeks later, ultrasound confirmed hydrops resolution. The patient was delivered and tracheostomy performed at 30 weeks via an ex utero intrapartum treatment (EXIT) procedure after progression of preterm labor. At 27 days of life, the infant was stable on minimal ventilator support. To our knowledge, this is the first successful report of an ultrasound-guided percutaneous tracheal decompression through the anterior neck of a fetus with CHAOS secondary to laryngeal atresia.
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Affiliation(s)
- Clara T Nicolas
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA
| | - David Lynch-Salamon
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Ellen Bendel-Stenzel
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Minnesota Neonatal Physicians, Minneapolis, Minnesota, USA
| | - Robert Tibesar
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Francois Luks
- Hasbro Children's Hospital and The Fetal Treatment Program of New England, Providence, Rhode Island, USA
| | - Stephanie Eyerly-Webb
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Joseph B Lillegard
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA, .,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA, .,Pediatric Surgical Associates, Minneapolis, Minnesota, USA,
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14
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Tay SY, Krishnasarma R, Mehta D, Mehollin-Ray A, Chandy B. Predictive Factors for Perinatal Outcomes of Infants Diagnosed With Micrognathia Antenatally. Ear Nose Throat J 2019; 100:NP16-NP20. [PMID: 31159574 DOI: 10.1177/0145561319855641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advances in fetal imaging have allowed us to identify abnormalities previously not appreciated. With this study, we hope to identify factors predicting a difficult airway at birth and review the perinatal outcomes of these patients. METHODS Sixteen patients with antenatally diagnosed micrognathia were reviewed from a tertiary care hospital database from 2011 to 2016. Jaw index (JI), amniotic fluid index (AFI), glossoptosis, gastric size, and oropharynx obliteration were assessed. The airway support required at birth, specialist team involvement, and outcomes were evaluated. RESULTS Nine (56.3%) of 16 patients had JI <5th percentile, 3 (33.3%) of 9 had difficult intubation, 2 (22.2%) of 9 needed an emergency tracheostomy, and 1 (11.1%) of 9 died. Seven patients had polyhydramnios, 2 (28.6%) of 7 had difficult intubation, 2 (28.6%) of 7 required tracheostomy, and 1 (14.3%) of 7 died. Twelve patients had either JI <5th percentile or abnormal AFI, 5 (41.7%) of 12 had difficult intubation, 2 (16.7%) of 12 required tracheostomy, and 1 (8.33%) of 12 died. For the group without otolaryngology consultation, 8 (50%) of 16, 1 (12.5%) of 8 had difficult intubation and 1 (12.5%) of 8 died because airway was not secured after 45 minutes of resuscitation. CONCLUSION Jaw index <5th percentile or abnormal AFI predicts a difficult airway. A multidisciplinary approach with otolaryngology involvement for airway intervention may be required at birth.
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Affiliation(s)
- Sok Yan Tay
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Rekha Krishnasarma
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Amy Mehollin-Ray
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Binoy Chandy
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
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15
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Gaffuri M, Torretta S, Iofrida E, Cantarella G, Borzani IM, Ciralli F, Calderini E, Leva E, Iurlaro E, Mosca F, Pignataro L. Multidisciplinary management of congenital giant head and neck masses: Our experience and review of the literature. J Pediatr Surg 2019; 54:733-739. [PMID: 30955589 DOI: 10.1016/j.jpedsurg.2018.09.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Large fetal head and neck (HN) masses can be life-threatening at birth and postnatally owing to airway obstruction. The two most frequent congenital masses that may obstruct the airway are lymphatic malformation (LM) and teratoma. The aim of this paper was to evaluate the results of our experience in the management of giant congenital HN masses and to conduct a literature review. METHODS The study involved a consecutive series of 13 newborns (7 females) affected by giant HN masses. Prenatal diagnosis was achieved by means of ultrasound (US) and fetal magnetic resonance imaging (MRI). Delivery was performed by means of EXIT procedure in case of radiological evidence of airway obstruction. In the postnatal period all feasible therapeutic options (surgery, sclerotherapy, medical therapy) were discussed and adopted by a multidisciplinary team. Twelve patients underwent surgery and one received Rapamycin for one month, with consequent surgical resection owing to increasing size of the mass. RESULTS The histopathological diagnosis was LM in 11 cases and teratoma in 2 cases. Airway obstruction was solved in 11 cases; 2 LM patients required a tracheotomy because of persistent airway obstruction. Major complications were flap necrosis (one patient) and facial nerve palsy (2 cases). Recurrence occurred in 5 patients. CONCLUSIONS The management of congenital HN masses is always challenging and necessarily requires an interdisciplinary approach. Current therapeutic options include surgery, sclerotherapy, medical therapy or a combination of them. When they are large enough to obstruct the airway, a patient-centered approach should guide timing and modality of treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michele Gaffuri
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
| | - Sara Torretta
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Elisabetta Iofrida
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giovanna Cantarella
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Maria Borzani
- Radiology Unit Pediatric Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabrizio Ciralli
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Neonatal Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Calderini
- Pediatric Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Enrico Iurlaro
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Neonatal Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Pignataro
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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16
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Shires CB, Giurintano JP, McLevy-Bazzanella J, Thompson J. Anterior skull base duplication requiring delivery via EXIT procedure: A case report. Int J Pediatr Otorhinolaryngol 2018; 115:24-26. [PMID: 30368386 DOI: 10.1016/j.ijporl.2018.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022]
Abstract
Duplication of the anterior skull base structures is an extremely rare malformation of failed midline blastogenesis. We present the case of a child with an obstructive oral cavity mass diagnosed on prenatal imaging. The child was successfully delivered by EXIT procedure, a tracheotomy was performed, and postnatal imaging demonstrated an array of craniofacial malformations, including complete duplication of the maxilla, pituitary glands, aqueducts of Sylvius, and basilar arteries. The child underwent excision of the duplicate maxilla, resulting in a wide cleft palate that will be repaired at a future date.
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Affiliation(s)
- Courtney B Shires
- University of Tennessee Health Science Center, Department of Otolaryngology - Head and Neck Surgery, 910 Madison Avenue Suite 430, Memphis, TN, 38163, USA.
| | - Jonathan P Giurintano
- University of Tennessee Health Science Center, Department of Otolaryngology - Head and Neck Surgery, 910 Madison Avenue Suite 430, Memphis, TN, 38163, USA.
| | - Jennifer McLevy-Bazzanella
- University of Tennessee Health Science Center, Department of Otolaryngology - Head and Neck Surgery, 910 Madison Avenue Suite 430, Memphis, TN, 38163, USA.
| | - Jerome Thompson
- University of Tennessee Health Science Center, Department of Otolaryngology - Head and Neck Surgery, 910 Madison Avenue Suite 430, Memphis, TN, 38163, USA.
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17
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Yu YR, Espinoza J, Mehta DK, Keswani SG, Lee TC. Perinatal diagnosis and management of oropharyngeal fetus in fetu: A case report. J Clin Ultrasound 2018; 46:286-291. [PMID: 28949025 DOI: 10.1002/jcu.22528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/24/2017] [Accepted: 07/17/2017] [Indexed: 06/07/2023]
Abstract
Fetus in fetu is an extremely rare congenital anomaly. We describe the perinatal diagnosis and management of a fetus with oropharyngeal and cervical fetus in fetu. High-resolution ultrasonography with 3-dimensional rendering can identify increased risks of airway obstruction in utero. Early identification allows a multidisciplinary team to be assembled for a scheduled ex utero intrapartum treatment procedure.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, Texas 77030
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, Suite F420, Houston, Texas 77030
| | - Deepak K Mehta
- Division of Otolaryngology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 540, Houston, Texas 77030
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, Texas 77030
| | - Timothy C Lee
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, Texas 77030
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18
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Dharmarajan H, Rouillard-Bazinet N, Chandy BM. Mature and immature pediatric head and neck teratomas: A 15-year review at a large tertiary center. Int J Pediatr Otorhinolaryngol 2018; 105:43-47. [PMID: 29447817 DOI: 10.1016/j.ijporl.2017.11.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pediatric head and neck teratomas account for less than 4% of congenital teratomas. The distinct presentations and outcomes of mature and immature head and neck teratomas have not been well established. OBJECTIVES To review the management and outcomes of pediatric head and neck teratomas. To distinguish differences between mature and immature tumors with respect to the age at presentation and surgery, tumor size and location, alpha fetoprotein (AFP) levels, airway management, and recurrence. METHODS A 15-year retrospective chart review of patients treated for head and neck teratomas at Texas Children's Hospital was performed. A total of 20 patients were included. Wilcoxon rank and Fisher's exact tests were used for statistical analysis. RESULTS Immature teratomas were associated with both higher AFP levels (80800 ng/ml, p = 0.02) and maximum tumor dimensions (14.4 cm, p = 0.0034) than mature teratomas (24400 ng/ml and 6.44 cm). Patients with immature tumors were younger at the time of surgical resection (19.8 days, p = 0.025) compared to those with mature tumors (348 days). 89% of immature teratomas involved anterior neck localization compared to 27% for mature teratomas (p = 0.0098); 88% of the immature teratomas required an EXIT (Ex Utero Intrapartum Treatment) procedure compared with 40% of the mature teratomas (p = 0.0656). Recurrence was noted in only two cases: an immature teratoma 51 months after incomplete resection and a mature teratoma 33 months after complete resection. Long-term consequences of surgical resection included cleft palate (38.9%), dysphagia (33.3%), facial nerve paresis/paralysis (16.7%) and tracheotomy (16.7%). CONCLUSION Immature teratomas had higher AFP levels, tumor dimensions, frequency of anterior neck localization, and requirement of EXIT than mature teratomas. Given that there was no significant difference between the recurrence rates of immature and mature teratomas, follow-up vigilance should be maintained equally regardless of tumor maturity.
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Affiliation(s)
- Harish Dharmarajan
- Baylor College of Medicine, Department of Otolaryngology - Head and Neck Surgery, One Baylor Plaza Suite NA-102, Houston, TX, USA.
| | - Noémie Rouillard-Bazinet
- Centre Hospitalier Universitaire Ste-Justine, Departement of Pediatric Otolaryngology, Université de Montréal, Montreal, Qc, Canada.
| | - Binoy M Chandy
- Baylor College of Medicine, Department of Otolaryngology - Head and Neck Surgery, One Baylor Plaza Suite NA-102, Houston, TX, USA; Texas Children's Hospital, Department of Pediatric Otolaryngology, 6701 Fannin St, Suite 540, Houston, TX 77030, USA.
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19
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Brodsky JR, Irace AL, Didas A, Watters K, Estroff JA, Barnewolt CE, Perez-Atayde A, Rahbar R. Teratoma of the neonatal head and neck: A 41-year experience. Int J Pediatr Otorhinolaryngol 2017; 97:66-71. [PMID: 28483254 DOI: 10.1016/j.ijporl.2017.02.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/11/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To review our institution's experience with the presentation, evaluation, and management of teratoma of the head and neck in the neonatal population. DESIGN Retrospective case series (November 1970 through September 2011). SETTING Tertiary care children's hospital. PATIENTS 14 patients (12 boys and 2 girls). INTERVENTION Detailed review of presentation, diagnostic approaches, surgical management, and outcomes. MAIN OUTCOME MEASURES Anatomic sites, use of pre and post-natal imaging, use of EXIT (ex utero intrapartum treatment) procedure, presenting symptoms, surgical approaches, additional therapeutic modalities, and outcomes are reviewed. RESULTS Seven patients were diagnosed prenatally, while the remaining 7 patients were diagnosed at birth or shortly thereafter. The tumor emanated from the neck in 9 patients, the nasopharynx/oropharynx in 3 patients, the external nose in 1 patient and the face in 1 patient. Nine patients had associated upper airway obstruction. Four underwent an EXIT procedure, with 3 requiring intubation and 1 requiring tracheostomy. All patients underwent surgical resection. One patient demonstrated recurrence at follow-up. CONCLUSIONS Teratoma of the head and neck, though rare, is an important part of the differential diagnosis of neck masses in children, particularly in the perinatal period. The ability to make this diagnosis prenatally with high-resolution fetal ultrasound and MRI (magnetic resonance imaging) permits planning for airway and tumor management prior to delivery. An EXIT procedure should be considered when airway compromise by tumor compression is suspected. Early surgical excision is the treatment of choice and recurrence is rare when a complete resection is achieved.
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20
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Perkowski EF, Zulauf KE, Weerakoon D, Hayden JD, Ioerger TR, Oreper D, Gomez SM, Sacchettini JC, Braunstein M. The EXIT Strategy: an Approach for Identifying Bacterial Proteins Exported during Host Infection. mBio 2017; 8:e00333-17. [PMID: 28442606 DOI: 10.1128/mBio.00333-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Exported proteins of bacterial pathogens function both in essential physiological processes and in virulence. Past efforts to identify exported proteins were limited by the use of bacteria growing under laboratory (in vitro) conditions. Thus, exported proteins that are exported only or preferentially in the context of infection may be overlooked. To solve this problem, we developed a genome-wide method, named EXIT (exported in vivotechnology), to identify proteins that are exported by bacteria during infection and applied it to Mycobacterium tuberculosis during murine infection. Our studies validate the power of EXIT to identify proteins exported during infection on an unprecedented scale (593 proteins) and to reveal in vivo induced exported proteins (i.e., proteins exported significantly more during in vivo infection than in vitro). Our EXIT data also provide an unmatched resource for mapping the topology of M. tuberculosis membrane proteins. As a new approach for identifying exported proteins, EXIT has potential applicability to other pathogens and experimental conditions. There is long-standing interest in identifying exported proteins of bacteria as they play critical roles in physiology and virulence and are commonly immunogenic antigens and targets of antibiotics. While significant effort has been made to identify the bacterial proteins that are exported beyond the cytoplasm to the membrane, cell wall, or host environment, current methods to identify exported proteins are limited by their use of bacteria growing under laboratory (in vitro) conditions. Because in vitro conditions do not mimic the complexity of the host environment, critical exported proteins that are preferentially exported in the context of infection may be overlooked. We developed a novel method to identify proteins that are exported by bacteria during host infection and applied it to identify Mycobacterium tuberculosis proteins exported in a mouse model of tuberculosis.
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21
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Gupta K, Venkatesan B, Manoharan KS, Rajalakshmi V, Menon M. CHAOS: Prenatal imaging findings with post mortem contrast radiographic correlation. J Radiol Case Rep 2016; 10:39-49. [PMID: 27761192 PMCID: PMC5065282 DOI: 10.3941/jrcr.v10i8.2692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Congenital high airway obstruction syndrome is a rare fetal anomaly with characteristic constellation of prenatal findings on ultrasound and MRI. The typical triad of imaging features are enlarged and echogenic lungs, flattening or inversion of diaphragm and fetal hydrops. Early prenatal recognition of congenital high airway obstruction syndrome by ultrasound and/or MRI is mandatory for the appropriate perinatal management. We report a case of a male fetus with typical imaging findings of congenital high airway obstruction syndrome on ultrasound and MRI at 19 weeks of gestation. The role of contrast radiographs of fetal airways, including retrograde laryngogram, in confirming the postnatal diagnosis of this fetal condition is demonstrated. The prenatal imaging findings were correlated with contrast radiographs of upper airways, sonography of aborted fetus and fetal autopsy findings.
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Affiliation(s)
- Kanika Gupta
- Department of Radiodiagnosis, ESI Medical College and PGIMSR, K K Nagar, Chennai-600078. Tamil Nadu, India
| | - Bhuvaneswari Venkatesan
- Department of Radiodiagnosis, ESI Medical College and PGIMSR, K K Nagar, Chennai-600078. Tamil Nadu, India
| | - Kiruba Shankar Manoharan
- Department of E.N.T, ESI Medical College and PGIMSR, K K Nagar, Chennai-600078. Tamil Nadu, India
| | - Vaithianathan Rajalakshmi
- Department of Pathology, ESI Medical College and PGIMSR, K K Nagar, Chennai-600078. Tamil Nadu, India
| | - Maya Menon
- Department of Obstetrics and Gynecology, ESI Medical College and PGIMSR, K K Nagar, Chennai-600078. Tamil Nadu, India
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Sharma R, Dey AK, Alam S, Mittal K, Thakkar H. A Series of Congenital High Airway Obstruction Syndrome - Classic Imaging Findings. J Clin Diagn Res 2016; 10:TD07-9. [PMID: 27134966 DOI: 10.7860/jcdr/2016/15243.7463] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 11/17/2015] [Indexed: 11/24/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) is a very rare entity with very poor prognosis in which upper airway is intrinsically obstructed, the most common reason being laryngeal atresia. In summary prenatal early diagnosis of patients with CHAOS is necessary so that perinatal management can be undertaken successfully or elective termination of pregnancy can be undertaken. The fetoscopic approach may be a life saving modality in a subset of CHAOS patients. Involving a multidisciplinary team comprising of paediatricians, radiologists, obstetricians and anaesthesiologists increases the efficiency of management.
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Affiliation(s)
- Rajaram Sharma
- Student, Deparment of Radiology, Seth GS Medical College and KEM Hospital , Mumbai, Maharashtra, India
| | - Amit Kumar Dey
- Student, Deparment of Obstetrics and Gynaecology, Seth GS Medical College and KEM Hospital , Mumbai, Maharashtra, India
| | - Shah Alam
- Student, Deparment of Radiology, Seth GS Medical College and KEM Hospital , Mumbai, Maharashtra, India
| | - Kartik Mittal
- Student, Deparment of Radiology, Seth GS Medical College and KEM Hospital , Mumbai, Maharashtra, India
| | - Hemangini Thakkar
- Additional Professor, Deparment of Radiology, Seth GS Medical College and KEM Hospital , Mumbai, Maharashtra, India
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23
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Abstract
Fetal magnetic resonance imaging (MRI) is currently offered in a limited number of centers but is predominantly used for suspected fetal central nervous system abnormalities. This article concentrates on the role of the different imaging sequences and their value to clinical practice. It also discusses the future of fetal MRI.
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Affiliation(s)
- Elspeth Whitby
- Academic Unit of Reproductive and Developmental Medicine, Sheffield, UK.
| | - Peter Wright
- Medical Imaging and Medical Physics, Radiology, Royal Hallamshire Hospital, Sheffield, UK
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24
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Cansaran S, Cerrah Celayir A, Moralıoğlu S, Ayvacı H, Tuğrul S, Ovalı F, Çetiner H. The EXIT for Prenatally Diagnosed Cervical Cystic Teratoma: A Case Report. J Neonatal Surg 2015; 4:18. [PMID: 26034712 PMCID: PMC4447471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/06/2015] [Indexed: 12/03/2022] Open
Abstract
The Ex-utero intrapartum treatment (EXIT) is a procedure performed during caesarean section while on fetal-placental circulation. We present a prenatally diagnosed cervical cystic mass causing tracheal compression which was managed successfully with the EXIT procedure.
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Affiliation(s)
- Sabri Cansaran
- Department of Paediatric Surgery, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
| | - Ayşenur Cerrah Celayir
- Department of Paediatric Surgery, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
| | - Serdar Moralıoğlu
- Department of Paediatric Surgery, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
,
Correspondence: Serdar Moralıoğlu, M.D. Zeynep Kamil Mah. Op. Dr.Burhanettin Üstünel Cad. No:4/3, 34668 Üsküdar, İstanbul, TURKEY. E-mail:
| | - Habibe Ayvacı
- Department of Perinatology, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
| | - Semih Tuğrul
- Department of Perinatology, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
| | - Fahri Ovalı
- Department of Neonatology, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
| | - Handan Çetiner
- Department of Pathology, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul
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25
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George R, Shah R, Bulas D, Kline S, Alexander S, Reilly BK. The delivered promise of prenatal imaging and a challenge to the utility of sildenafil for severe lymphatic malformations. Int J Pediatr Otorhinolaryngol 2015; 79:89-93. [PMID: 25547959 DOI: 10.1016/j.ijporl.2014.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/21/2014] [Accepted: 12/02/2014] [Indexed: 11/27/2022]
Abstract
We report the case of an infant with severe lymphatic malformation necessitating ex-utero intrapartum treatment (EXIT) procedure and examine recent advances in high resolution ultrasonography and magnetic resonance imaging, which allow for improved prenatal diagnosis of lesions that cause critical airway obstruction in the neonate. Treatments for lymphatic malformations including surgical resection, sclerotherapy, coblation, and sildenafil are discussed. Our patient did not have any reduction in the size of the lymphatic malformation from sildenafil as suggested in another series.
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Affiliation(s)
- Ryan George
- Walter Reed National Military Medical Center, Bethesda, MD 20889, United States.
| | - Rahul Shah
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Dorothy Bulas
- Division of Diagnostic Imaging and Radiology, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, United States.
| | - Shannon Kline
- Division of Anesthesia, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Sean Alexander
- Division of Anesthesia, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Brian K Reilly
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010, United States.
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26
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Laje P, Peranteau WH, Hedrick HL, Flake AW, Johnson MP, Moldenhauer JS, Adzick NS. Ex utero intrapartum treatment ( EXIT) in the management of cervical lymphatic malformation. J Pediatr Surg 2015; 50:311-4. [PMID: 25638626 DOI: 10.1016/j.jpedsurg.2014.11.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to review the outcomes and technical details of EXIT procedures performed in fetuses with large cervical lymphatic malformations. METHODS A retrospective chart review of fetuses with a prenatal diagnosis of cervical lymphatic malformation evaluated at our center between 1995 and 2013 was performed. RESULTS We evaluated a total of 112 fetuses with a prenatal diagnosis of cervical lymphatic malformation. Thirteen of the 112 fetuses (11%) were delivered by an EXIT procedure. Criteria to deliver by EXIT were: 1) deviation/compression/obstruction of the airway, and 2) involvement of the floor of the mouth. Two fetuses developed hydrops. Five fetuses developed polyhydramnios. Eleven EXITs were performed electively at term (n=7; 37-38 weeks) or late pre-term (n=4; 34-36/6 weeks), whereas two patients underwent emergency EXIT at 33 and 38 weeks, respectively. The airway was accessed successfully in 12 of 13 cases. Laryngoscopy only was sufficient in 7, rigid bronchoscopy was required in 4, and 1 required a tracheostomy. In one case with a massive lymphatic malformation of the face, neck, and airway, a tracheostomy was not attempted, and the fetus expired. Four patients had invasion of the larynx by the lymphatic malformation. Five patients required a tracheostomy later. Median time from fetal exposure to intubation was 8 (2-29) min. Median total EXIT time was 105.5 (67-142) min. Median maternal blood loss was 800 (300-1000) ml. Median maternal hospital stay was 4 (3-6) days. CONCLUSION The EXIT procedure allows controlled airway access in fetuses with cervical lymphatic malformations and evidence of airway impairment on prenatal images.
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Affiliation(s)
- Pablo Laje
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - William H Peranteau
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA.
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27
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Marques MV, Carneiro J, Adriano M, Lança F. Anesthesia for ex utero intrapartum treatment: renewed insight on a rare procedure. Braz J Anesthesiol 2015; 65:525-8. [PMID: 26614153 DOI: 10.1016/j.bjane.2013.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/04/2013] [Indexed: 01/03/2023] Open
Abstract
The ex utero intrapartum treatment is a rare surgical procedure performed in cases of expected postpartum fetal airway obstruction. The technique lies on a safe establishment of a patent airway during labor in anticipation of a critical respiratory event, without interrupting maternal-fetal circulation. Anesthetic management is substantially different from that regarding standard cesarean delivery and its main goals include uterine relaxation, fetal anesthesia and preservation of placental blood flow. We present the case of an ex utero intrapartum treatment procedure performed on a fetus with a large cervical lymphangioma and prenatal evidence of airway compromise. Modifications to the classic ex utero intrapartum treatment management strategies were successfully adopted and will be discussed in the following report.
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28
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Rugolotto S, Giacomello L, El-Dalati G, Sacchetto L, Antonello L, De Luca G, Raffaelli R. Unplanned ultrasound-guided puncture of a tracheal balloon in a premature infant with congenital diaphragmatic hernia. J Neonatal Perinatal Med 2014; 7:311-313. [PMID: 25468617 DOI: 10.3233/npm-14814025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Temporary tracheal balloons have been shown to improve lung growth in fetuses with severe congenital diaphragmatic hernia. Fetoscopic Endoluminal Tracheal Occlusion (FETO) is performed at 26-28 weeks gestation, and then is removed in utero at 34 weeks gestation at highly specialized centers. In case of preterm labor at a hospital without a specialized team, a number of techniques have been used to remove the balloon, sometimes with death of the newborn. We have successfully performed an ultrasound-guided approach to puncture and remove the tracheal balloon in a premature infant in an emergency setting at birth. After that she was treated for congenital diaphragmatic hernia at our Newborn Intensive Care Unit.
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Affiliation(s)
- S Rugolotto
- Neonatal Intensive Care Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - L Giacomello
- Section of Pediatric Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - G El-Dalati
- Section of Radiology, Department of Pathology and Diagnosis, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - L Sacchetto
- Section of Otorhinolaryngology, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - L Antonello
- Section of Anaesthesiology, Department of Emergency and Intensive Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - G De Luca
- Neonatal Intensive Care Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - R Raffaelli
- Section of Obstetrics and Gynaecology, Department of Mother and Child, University of Verona, Verona, Italy
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29
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Pivetti V, Cavigioli F, Lista G, Napolitano M, Rustico M, Paganelli A, Ferrazzi E. Cesarean section plus delayed cord clamping approach in the perinatal management of congenital high airway obstruction syndrome (CHAOS): a case report. J Neonatal Perinatal Med 2014; 7:237-239. [PMID: 25318627 DOI: 10.3233/npm-14814006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In this case, we describe a newborn with prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS), successfully managed with a cesarean section with delayed cord clamping 180 seconds. In case of prenatal diagnosis of CHAOS, prompt airway intervention at delivery allows survival of this otherwise fatal condition. Ex utero intrapartum treatment (EXIT) is considered the elective procedure to secure the fetal airway before the baby is completely separated from the maternal circulation. In cases where the EXIT procedure is not possible for maternal reasons (Ballantyne's syndrome), delayed cord clamping may serve as an alternative method to manage CHAOS.
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Affiliation(s)
- V Pivetti
- Neonatal Intensive Care Unit, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, Milan, Italy
| | - F Cavigioli
- Neonatal Intensive Care Unit, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, Milan, Italy
| | - G Lista
- Neonatal Intensive Care Unit, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, Milan, Italy
| | - M Napolitano
- Department of Radiology and Neuroradiology, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, Milan, Italy
| | - M Rustico
- Departments of Obstetric and Gynecology, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, University of Milan, Milan, Italy
| | - A Paganelli
- Departments of Obstetric and Gynecology, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, University of Milan, Milan, Italy
| | - E Ferrazzi
- Departments of Obstetric and Gynecology, "V.Buzzi" Hospital, ICP, Via Castelvetro 32, University of Milan, Milan, Italy
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30
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Issue of assisting suicide dominates meeting in England. Concern Dying 1980; 6:1-2. [PMID: 11649492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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31
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32
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Schar M. Assisted suicide in Switzerland. When is it permitted? Hawaii Med J 1997; 56:63, 67-8. [PMID: 9108716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M Schar
- Swiss Society for Humane Dying, Zurich
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33
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Humphry D. Compassionate crimes. Euthan Rev 1987; 2:141-59. [PMID: 16121438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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34
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35
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Abstract
Discussion about euthanasia is often confused because of a failure to distinguish between deliberate death acceleration and letting nature take its course. There is a need to reiterate the traditional principles upon which the care of the dying should be based, including the need for the doctor to practise medicine in the knowledge that eventually all his patients will die. It follows that a doctor does not have a duty to preserve life at all costs. The care of the patient with far-advanced cancer has improved considerably in many areas as a result of the establishment of hospices and domiciliary support teams. Treating the patient as a person is the key to a successful doctor-patient relationship. An analytical approach is necessary to control pain and other symptoms. Care of the relatives is also fundamental. Voluntary euthanasia and 'assisted suicide' represent an extreme solution to a situation which demands a far more comprehensive and compassionate approach. The need is not for a change in the law but for a change of emphasis in medical education.
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36
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Williams RM. This way out. Omni 1981; 3:44-47, 90-91. [PMID: 11649355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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