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Domínguez-Moreno M, Chimenea Á, García-Díaz L, Antiñolo G. Maternal and obstetric outcomes after Ex-Utero Intrapartum Treatment (EXIT): a single center experience. BMC Pregnancy Childbirth 2023; 23:831. [PMID: 38042795 PMCID: PMC10693058 DOI: 10.1186/s12884-023-06129-9] [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] [Received: 09/27/2023] [Accepted: 11/14/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The Ex-utero Intrapartum Treatment (EXIT) is a procedure developed to manage a range of fetal conditions, aiming to ensure the maintenance of neonatal airway and preserving the feto-placental circulation. Its goal is to enhance the neonatal ability to successfully transition and adapt to postnatal life, thereby reducing perinatal morbidity and mortality. However, EXIT has been associated with a high risk of maternal complications. This paper provides an overview of the indications and characteristics of the EXIT procedure, as well as the obstetric outcomes and maternal complications. METHODS A retrospective analysis was conducted on a cohort of patients undergoing EXIT at our center between January 2007 and December 2022. Maternal outcomes, including demographic information, data related to the surgical procedure, surgical complications, and postoperative complications were analyzed. To assess the severity of the surgical complications, a modified Clavien-Dindo classification was used. Comparative analysis was performed by randomly selecting a sample from elective cesarean deliveries performed at our center. RESULTS A total of 34 EXIT procedures were performed. According to the modified Clavien-Dindo classification, we observed no major complications, while minor maternal complications were present in 2.94% of cases. Compared to elective cesarean deliveries (n = 350), there were no significant differences in terms of maternal complications, highlighting the similarity observed in the mean decrease in postoperative hemoglobin (1.15 g/dL in EXIT vs. 1.2 g/dL in elective cesarean deliveries, p = 0.94). In EXIT group, there was a higher rate of polyhydramnios (26.47% vs 6.59%, p < 0.001), as well as the need for amnioreduction (14.71% vs 0%, p = 0.001) and preterm delivery (32.35% vs 6.02%, p = 0.001). There were no cases of endometritis, post-procedural fever, or abruptio placentae following EXIT. CONCLUSIONS EXIT can be considered a safe procedure when performed under adequate conditions, including appropriate uterine access and proper anesthetic management. In our series, EXIT procedure was not associated with a higher incidence of maternal complications when compared to elective cesarean delivery. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Marta Domínguez-Moreno
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - Ángel Chimenea
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain.
- Department of Surgery, University of Seville, Seville, Spain.
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain.
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain.
- Department of Surgery, University of Seville, Seville, Spain.
- Centre for Biomedical Network Research On Rare Diseases (CIBERER), Seville, Spain.
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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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Cruz-Martínez R, Gil-Pugliese S, Villalobos-Gómez R, Martínez-Rodríguez M, Márquez-Dávila A, López-Briones H, Chávez-González E, Méndez-González A, Pineda-Alemán H, Rebolledo-Fernández C, Barrios-Prieto E, Fajardo-Dueñas S. Fetal Laryngoscopy and Endoscopic Tracheal Intubation to Avoid ex utero Intrapartum Treatment in the Management of Fetuses with Suspected Airway Obstruction. Fetal Diagn Ther 2023; 50:472-479. [PMID: 37544292 DOI: 10.1159/000533348] [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: 04/12/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Large congenital neck tumors can cause neonatal death due to airway obstruction. The aim of this study was to report outcomes of the first cohort of fetuses with neck masses and suspected airway obstruction managed with fetal laryngoscopy (FL) and fetal endoscopic tracheal intubation (FETI) to secure fetal airways and avoid ex utero intrapartum treatment (EXIT) procedure. METHODS A prospective observational cohort of consecutive fetuses with neck masses that were candidates for an EXIT procedure due to suspicion of laryngeal and/or tracheal occlusion on ultrasonographic (US) or magnetic resonance imaging (MRI) examination were recruited for FL in a tertiary referral center in Queretaro, Mexico. FETI was performed if the obstruction was confirmed by FL. Maternal and perinatal outcomes were evaluated. RESULTS Between January 2012 and March 2023, 35 cases with neck masses were evaluated. Airway obstruction was suspected in 12/35 (34.3%), either by US in 10/35 (28.6%) or by fetal MRI in 2/35 (5.7%). In all cases, FL was successfully performed at the first attempt at a median gestational age (GA) of 36+5 (range, 33+5-39+6) weeks+days, with a median surgical time of 22.5 (12-35) min. In 4 cases, airway patency was confirmed during FL and an EXIT procedure was avoided. In 8/12 cases (66.7%), airway obstruction was confirmed during fetoscopy and FETI was successfully performed at a median GA of 36+3 (33+2-38+5) weeks+days, with a median surgical time of 25.0 (range, 12-45) min. No case required an EXIT procedure. All patients underwent conventional cesarean delivery with no maternal complications and all neonates were admitted to the neonatal intensive care unit with a correctly positioned endotracheal tube (ETT) immediately after delivery. Three neonatal deaths (37.5%) were reported due to postnatal unplanned extubation, failed ETT replacement, and tumoral bleeding. CONCLUSION In fetuses with neck masses and suspected airway obstruction, FL and FETI are feasible and could replace EXIT procedures with good maternal and perinatal outcomes.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
- Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara", Queretaro, Mexico
| | - Savino Gil-Pugliese
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Miguel Martínez-Rodríguez
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
- Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara", Queretaro, Mexico
| | - Alejandra Márquez-Dávila
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Hugo López-Briones
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Eréndira Chávez-González
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
- Department of Biomedical Sciences, University Center in Tonalá of the University of Guadalajara, Guadalajara, Mexico
| | - Antonio Méndez-González
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Hugo Pineda-Alemán
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
| | - Carlos Rebolledo-Fernández
- Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara", Queretaro, Mexico
| | - Ernesto Barrios-Prieto
- Fetal Medicine and Surgery Research Center, Fetal Medicine Mexico Institute, Guadalajara, Mexico
- Department of Maternal-Fetal Medicine, Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - Sergio Fajardo-Dueñas
- Department of Maternal-Fetal Medicine, Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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Joshi D, Stellon M, Antony K, Beninati M, Luks FI, Puricelli M, Lobeck IN. Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey. Fetal Diagn Ther 2023; 50:376-386. [PMID: 37339615 PMCID: PMC10614236 DOI: 10.1159/000531615] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. METHODS After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. RESULTS We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1-5 EXIT consultations per year and 17/40 (42.5%) centers performed 1-5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. CONCLUSION This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.
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Affiliation(s)
- Devashish Joshi
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA,
| | - Michael Stellon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathleen Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael Beninati
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Francois I Luks
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michael Puricelli
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Inna Neyman Lobeck
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Wang W, Pei L, Zhang Y, Chen W, Liu J, Jiang Y, Lv Y, Li Z, Jian S, Ma L, Huang Y. Neuraxial anesthesia in ex utero intrapartum therapy for parturients with fetal congenital diaphragm hernia: a prospective observational study. Int J Obstet Anesth 2022; 52:103599. [PMID: 36162368 DOI: 10.1016/j.ijoa.2022.103599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/05/2021] [Revised: 04/15/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is characterized by defects in the fetal diaphragm and thoracic herniation of the abdominal viscera. The ex utero intrapartum treatment (EXIT) procedure is used to establish the fetal airway while on placental support. These EXIT procedures are commonly performed under general anesthesia, which increases maternal bleeding and the risk of insufficient placental perfusion subsequently. This study investigated the feasibility of performing neuraxial anesthesia for the EXIT procedure for fetal congenital diaphragmatic hernia to improve outcomes. METHODS Parturients with fetal CDH who underwent an EXIT procedure between January 2019 and May 2021 in our institution were recruited. Variables evaluated included gestational age, surgical time, intra-operative blood loss, peri-operative hemoglobin, maternal complications, fetal lung-to-head ratio, time on placental bypass, and postnatal outcome. RESULTS Twenty-two cases were included. All procedures were performed under neuraxial anesthesia. The median gestational age at the time of the EXIT procedure was 37 weeks. The median estimated blood loss was 200 mL. There was no report of an adverse maternal event. The placental bypass time was 142.9 ± 72.6 s, and access to the airway was successfully established within the bypass time. Twenty-one neonates reached an Apgar score of 9 at 5 min. In the first two hours after birth, the average pH of neonatal peripheral arterial blood was 7.35 ± 0.07 (n=19), and lactate level 1.85 ± 0.71 mmol/L (n=19). CONCLUSIONS In the EXIT procedure to establish an airway for fetal CDH, neuraxial anesthesia proved a feasible technique for maternal anesthesia.
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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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Shahi N, Phillips R, Meier M, Grover T, Galan H, Zaretsky M, Meyers M, Kelley P, Marwan AI. Outcomes of Airway Management in Micrognathia and Retrognathia Patients Born at Fetal versus Nonfetal Centers. Fetal Diagn Ther 2020; 47:933-938. [PMID: 33105131 DOI: 10.1159/000510856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/31/2019] [Accepted: 08/11/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES There is a paucity of evidence to guide the perinatal management of difficult airways in fetuses with micrognathia. We aimed to (1) develop a postnatal grading system based on the extent of airway intervention required at birth to assess the severity of micrognathic airways and (2) compare trends in airway management and outcomes by location of birth [nonfetal center (NFC), defined as a hospital with or without an NICU and no fetal team, versus fetal center (FC), defined as a hospital with an NICU and fetal team]. METHODS We retrospectively reviewed the prenatal and postnatal records of all neonates diagnosed with micrognathia from January 2010 to April 2018 at a quaternary children's hospital. We developed a novel grading scale, the Micrognathia Grading Scale (MGS), to grade the extent of airway intervention at birth from 0 (no airway intervention) to 4 (requirement of EXIT or advanced airway instrumentation for airway securement). RESULTS We identified 118 patients with micrognathia. Eighty-nine percent (105/118) were eligible for grading using the MGS. When the MGS was applied, the airway grades were as follows: grade 0 (30%), grade 1 (10%), grade 2 (9%), grade 3 (48%), and grade 4 (4%). A quarter of micrognathic patients with grade 0-2 airways had postnatal hospital readmissions for airway obstruction after birth, of which all were born at NFC. Over 40% of patients with grade 3-4 micrognathic airways required airway intervention within 24 h of birth. Overall, NFC patients had a readmission rate of (27%) for airway obstruction after birth compared to FC patients (17%). CONCLUSIONS Due to the high incidence of grade 3-4 airways on the MGS in micrognathic patients, fetuses with prenatal findings suggestive of micrognathia should be referred to a comprehensive fetal care center capable of handling complex neonatal airways. For grade 0-2 airways, infants frequently had postnatal complications necessitating airway intervention; early referral to a multidisciplinary team for both prenatal and postnatal airway management is recommended.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA,
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Theresa Grover
- Division of Neonatal-Perinatal Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Henry Galan
- Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Zaretsky
- Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mariana Meyers
- Division of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peggy Kelley
- Division of Otolaryngology, Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Children's Hospital Colorado, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
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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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Masahata K, Soh H, Tachibana K, Sasahara J, Hirose M, Yamanishi T, Ibuka S, Okuyama H, Usui N. Clinical outcomes of ex utero intrapartum treatment for fetal airway obstruction. Pediatr Surg Int 2019; 35:835-843. [PMID: 31165248 DOI: 10.1007/s00383-019-04494-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the indications and the clinical outcomes of the fetuses managed with ex utero intrapartum treatment (EXIT) procedures. METHODS We retrospectively reviewed the medical records of all fetuses who underwent EXIT procedures between 2003 and 2018. RESULTS EXIT procedures were performed in nine cases. The prenatal diagnosis of the neonates was congenital high airway obstruction syndrome in four cases, the neck masse in five cases. Although the airway management under the EXIT procedure was successful in eight cases, the airway management failed in one case. During the EXIT procedures, the airway was managed by endotracheal intubation in two cases, whereas six cases underwent tracheostomy. Six cases with fetal airway obstruction survived to discharge, whereas three cases died due to airway management failure or complications of the underlying disease. A case with a cervical teratoma underwent tumor resection the day after birth due to rapid enlargement of the neck mass. Long-term survival was achieved in five cases. CONCLUSIONS We concluded that the EXIT procedure was effective and could be performed safely in the airway management of fetuses with suspected airway obstruction. The treatment strategy for the neck masses should be planned before birth.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan.
| | - Hideki Soh
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Jun Sasahara
- Department of Obstetrics, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masayuki Hirose
- Department of Otolaryngology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Tadashi Yamanishi
- Department of Oral and Maxillofacial Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Souji Ibuka
- Department of Pediatric Surgery, National Hospital Organization Fukuyama Medical Center, Hiroshima, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan
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10
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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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11
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Beckers K, Faes J, Deprest J, Delaere PR, Hens G, De Catte L, Naulaers G, Claus F, Hermans R, Vander Poorten VLM. Long-term outcome of pre- and perinatal management of congenital head and neck tumors and malformations. Int J Pediatr Otorhinolaryngol 2019; 121:164-172. [PMID: 30917301 DOI: 10.1016/j.ijporl.2019.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 01/03/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Congenital head and neck pathology may cause direct postnatal airway obstruction. Prenatal diagnosis facilitates safe delivery with pre- and perinatal airway assessment and management and Ex-Utero-Intrapartum-Treatment (EXIT) if necessary. Fetoscopic airway evaluation can optimize the selection of patients in need of an EXIT procedure. METHODS Description of 11 consecutive fetuses, born with a potential airway obstruction between 1999 and 2011 and treated at the University Hospitals Leuven, with a long-term follow-up until 2018. An algorithm including fetoscopic airway evaluation is presented. RESULTS In utero imaging revealed seven teratomas, one fourth branchial pouch cyst, one thymopharyngeal duct remnant, one lymphatic malformation and one laryngeal atresia. A multidisciplinary team could avoid EXIT in eight patients by ultrasonographic (n = 2) or fetoscopic (n = 6) documentation of accessible airways. Three patients needed an EXIT-to-airway-procedure. Neonatal surgery included tracheostomy during EXIT (n = 2) and resection of teratoma (n = 7) or branchiogenic pathology (n = 3). All patients do well at long-term (minimum 54 months) follow-up. CONCLUSIONS Combining prenatal imaging and perinatal fetoscopy, EXIT-procedure and neonatal surgery yields an optimal long-term outcome in these complex patients. Fetoscopy can dramatically reduce the number of EXIT-procedures.
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Affiliation(s)
- Karen Beckers
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Belgium and Department of Oncology, Section Head & Neck Oncology, KU Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium
| | - Julie Faes
- Department of Obstetrics & Gynaecology and Fetal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Deprest
- Department of Obstetrics & Gynaecology and Fetal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pierre R Delaere
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Belgium and Department of Oncology, Section Head & Neck Oncology, KU Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium
| | - Greet Hens
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Belgium and Department of Oncology, Section Head & Neck Oncology, KU Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium
| | - Luc De Catte
- Department of Obstetrics & Gynaecology and Fetal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Filip Claus
- Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Robert Hermans
- Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Vincent L M Vander Poorten
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Belgium and Department of Oncology, Section Head & Neck Oncology, KU Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium.
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12
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Hochwald O, Gil Z, Gordin A, Winer Z, Avrahami R, Abargel E, Khoury A, Lehavi A, Abecassis P, Eldor L, Ben-Izhak O, Borenstein-Levin L, Stienberg R, Kugelman A. Three-step management of a newborn with a giant, highly vascularized, cervical teratoma: a case report. J Med Case Rep 2019; 13:73. [PMID: 30851737 PMCID: PMC6409158 DOI: 10.1186/s13256-019-1976-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 06/25/2018] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background A giant congenital cervical teratoma is often highly vascularized; thus, in addition to a life-threatening airway occlusion at birth it comprises a high risk for significant and lethal blood loss during resection. In the case presented, an endovascular embolization of the carotid artery that supplied a giant congenital cervical teratoma was done as part of a three-stage treatment soon after birth and contributed to an overall good outcome. Embolization in cases of cervical teratomas was not described previously. Case presentation We present a case of a preterm newborn from a Sephardic jewish origin with a giant, highly vascularized, congenital cervical teratoma that was managed successfully in three stages: (1) delivery by an ex utero intrapartum treatment procedure after extensive preoperative planning and followed by tracheostomy, (2) endovascular embolization of the carotid artery that supplied the tumor in order to decrease blood loss during resection, and (3) complete surgical resection. The parents were involved in all the ethical and medical decisions, starting just after the cervical mass was diagnosed prenatally. Conclusion The management of giant congenital cervical teratoma is often challenging from both a medical and ethical prospective. Meticulous perinatal planning and parents’ involvement is crucial. Endovascular embolization of the tumor feeding vessels can significantly improve the resection outcome and overall prognosis.
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Affiliation(s)
- Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel.
| | - Ziv Gil
- Department of Otolaryngology Head and Neck Surgery, Rambam Health Campus, Haifa, Israel
| | - Arie Gordin
- Department of Otolaryngology Head and Neck Surgery, Rambam Health Campus, Haifa, Israel.,The Pediatric ENT service, Rambam Health Campus, Haifa, Israel
| | - Zeev Winer
- The Obstetrics & Gynecology Division, Rambam Health Campus, Haifa, Israel
| | - Ron Avrahami
- The Obstetrics & Gynecology Division, Rambam Health Campus, Haifa, Israel
| | - Eitan Abargel
- Invasive Neuroradiology Unit, Rambam Health Campus, Haifa, Israel
| | - Asaad Khoury
- Department of Pediatric Cardiology & Congenital Heart Disease in Adults, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Amit Lehavi
- The Department of Anesthesiology, Rambam Health Campus, Haifa, Israel
| | | | - Liron Eldor
- The Department of Plastic Surgery, Rambam Health Campus, Haifa, Israel
| | - Ofer Ben-Izhak
- The Department of Pathology, Rambam Health Campus, Haifa, Israel
| | - Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Ran Stienberg
- The Department of Pediatric Surgery, Rambam Health Campus, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
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13
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Chen XY, Yang JX, Zhang HY, Xiong XF, Abdullahi KM, Wu XJ, Feng JX. Ex utero intrapartum treatment for giant congenital omphalocele. World J Pediatr 2018; 14:399-403. [PMID: 29508360 DOI: 10.1007/s12519-018-0129-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/20/2016] [Revised: 08/07/2017] [Accepted: 08/20/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND To determine whether ex utero intrapartum treatment (EXIT) is an appropriate approach for managing fetuses antenatally diagnosed with giant congenital omphaloceles. METHODS We retrospectively reviewed patients with omphaloceles who underwent either an EXIT procedure or a traditional repair surgery. Basic and clinical parameters including gender, gestational age, birth weight, maternal blood loss, operative times and operative complications were analyzed. During the 6-12-month follow-ups, postoperative complications including bowel obstruction, abdominal infections, postoperative abdominal distension were monitored, and survival rate was analyzed. RESULTS A total of seven patients underwent the EXIT procedure and 11 patients underwent the traditional postnatal surgery. We found no differences in maternal age, gestational age at diagnosis, gestational age at delivery and birth weight between the two groups. In the EXIT group, the average operation time for mother was 68.3 ± 17.5 minutes and the average maternal blood loss was 233.0 ± 57.7 mL. The operation time in the EXIT group (22.0 ± 4.5 minutes) was shorter than that in the traditional group (35 ± 8.7 minutes), but the length of hospital stay in the EXIT group (20.5 ± 3.1 days) was longer than that in the traditional group (15.7 ± 2.5 days, P < 0.05). During the follow-up, one patient in the EXIT group had an intestinal obstruction, one developed abdominal compartment syndrome and one died in the traditional group. CONCLUSIONS In our experience, EXIT is a safe and effective procedure for the treatment of giant congenital omphaloceles. However, more experience is needed before this procedure can be widely recommended.
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Affiliation(s)
- Xu-Yong Chen
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Ji-Xin Yang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Hong-Yi Zhang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Xiao-Feng Xiong
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Khalid Mohamoud Abdullahi
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Xiao-Juan Wu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Jie-Xiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
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14
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Hung TH, Huang TX, Hsieh TT. Ex utero intrapartum treatment for extremely low birth-weight neonates requiring resuscitation at birth. Taiwan J Obstet Gynecol 2017; 56:561-563. [PMID: 28805620 DOI: 10.1016/j.tjog.2017.07.001] [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] [Accepted: 07/14/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Difficulties often encountered during intubation in extremely low birth-weight (ELBW) neonates requiring resuscitation at birth because of the smaller airway and the pressure from the limited number of attempts before hemodynamic instability occurs. CASE REPORT We evaluated two pregnant women at 26 weeks of gestation with premature rupture of membranes and evidence of chorioamnionitis and applied the concept of ex utero intrapartum treatment, which involved delaying cord clamping (DCC) after establishing a secured airway with adequate ventilation during cesarean delivery. The resuscitative procedure was smooth and all three neonates had favorable outcomes at one month of age. CONCLUSION When cesarean delivery is indicated in ELBW infants and intubation after birth is anticipated, DCC after establishing a secured airway may help maintain neonatal cardiovascular stability and allow physicians to resolve the technical difficulties of intubation.
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Affiliation(s)
- Tai-Ho Hung
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ting-Xuan Huang
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - T'sang-T'ang Hsieh
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
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15
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Shieh HF, Wilson JM, Sheils CA, Smithers CJ, Kharasch VS, Becker RE, Studley M, Morash D, Buchmiller TL. Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change morbidity outcomes for high-risk congenital diaphragmatic hernia survivors? J Pediatr Surg 2017; 52:22-25. [PMID: 27836357 DOI: 10.1016/j.jpedsurg.2016.10.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 09/27/2016] [Accepted: 10/20/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE In high-risk congenital diaphragmatic hernia (CDH), significant barotrauma or death can occur before extracorporeal membrane oxygenation (ECMO) can be initiated. We previously examined ex utero intrapartum treatment (EXIT)-to-ECMO in our most severe CDH patients, but demonstrated no survival advantage. We now report morbidity outcomes in survivors of this high-risk cohort to determine whether EXIT-to-ECMO conferred any benefit. METHODS All CDH survivors with <15% predicted lung volume (PPLV) from September 1999 to December 2010 were included. We recorded prenatal imaging, defect size, and pulmonary, nutritional, cardiac, and neurodevelopmental outcomes. RESULTS Seventeen survivors (8 EXIT-to-ECMO, 9 non-EXIT) had an average PPLV of 11.7%. Eight of 9 non-EXIT received ECMO within 2days. There were no significant defect size differences between groups, mostly left-sided (13/17) and type D (12/17). Average follow-up was 6.7years (0-13years). There were no statistically significant differences in outcomes, including supplemental oxygen, diuretics, gastrostomy, weight-for-age Z scores, fundoplication, pulmonary hypertension, stroke or intracranial hemorrhage rate, CDH recurrence, and reoperation. No survivor in our cohort was neurologically devastated. All had mild motor and/or speech delay, which improved in most. CONCLUSIONS In this pilot series of severe CDH survivors, EXIT-to-ECMO confers neither significant survival nor long-term morbidity benefit. LEVEL OF EVIDENCE Level III treatment study.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay M Wilson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Catherine A Sheils
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Virginia S Kharasch
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ronald E Becker
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mollie Studley
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Donna Morash
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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16
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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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17
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Kakogawa J, Nako T, Igarashi S, Nakamura S, Tanaka M. Prenatal diagnosis of pyriform sinus fistula: case report and literature review. Clin Case Rep 2014; 3:106-9. [PMID: 25767708 PMCID: PMC4352364 DOI: 10.1002/ccr3.166] [Citation(s) in RCA: 7] [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: 06/04/2014] [Revised: 07/30/2014] [Accepted: 09/15/2014] [Indexed: 12/11/2022] Open
Abstract
We describe a case of prenatal diagnosis of a pharyngeal cyst as a pyriform sinus fistula on the findings of ultrasonography and magnetic resonance imaging.
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Affiliation(s)
- Jun Kakogawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine Kanagawa, Japan
| | - Takafumi Nako
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine Kanagawa, Japan
| | - Suguru Igarashi
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine Kanagawa, Japan
| | - Shin Nakamura
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine Kanagawa, Japan
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine Kanagawa, Japan
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18
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Laje P, Howell LJ, Johnson MP, Hedrick HL, Flake AW, Adzick NS. Perinatal management of congenital oropharyngeal tumors: the ex utero intrapartum treatment (EXIT) approach. J Pediatr Surg 2013; 48:2005-10. [PMID: 24094948 DOI: 10.1016/j.jpedsurg.2013.02.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [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: 12/05/2012] [Revised: 02/01/2013] [Accepted: 02/01/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To present our experience in the perinatal management of fetuses with large oropharyngeal tumors by ex utero intrapartum treatment (EXIT). METHODS We performed a retrospective chart review of all patients with congenital oropharyngeal tumor who underwent an EXIT procedure between May 2006 and June 2012. RESULTS Four patients were included in the series, three females and one male. The diagnoses were epignathus (n=2) and congenital epulis (n=2). Three EXITs were done at term and one at late preterm due to premature rupture of membranes. Median maternal time under anesthesia was 185 min (range: 166-281) and median maternal operative time was 99 min (range: 85-153). Median maternal blood loss was 550 ml (range: 350-2000); one mother required a blood transfusion. Mean maternal hospital stay was 4 days. Median hysterotomy-to-cord clamp time was 24 min (range: 18-66). Mean fetal birth weight was 2.7 kg (range: 2.4-3). The airway was successfully accessed and secured under placental circulation in all cases. In the two patients with congenital epulis the tumors were resected at the base of their pedicles and the airway accessed via direct laryngoscopy before the umbilical cord was clamped. One patient with epignathus underwent a retrograde tracheal intubation under placental circulation and had the tumor resected thereafter. The second patient with epignathus had a tracheostomy done under placental circulation and then had tumor debulking immediately after the EXIT. The maternal morbidity was minimal and there were no mortalities. CONCLUSIONS We conclude that the EXIT procedure is the ideal delivery strategy for fetuses with prenatally diagnosed oropharyngeal tumors and potential airway obstruction at birth. Patients with prenatally diagnosed oropharyngeal tumors should be promptly referred to a fetal treatment center with a dedicated multidisciplinary team and EXIT capabilities.
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Affiliation(s)
- Pablo Laje
- Department of Surgery, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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