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 The
Front Line
Fetal
surgery: applications to increase survival rates
by
Darrell L. Cass, MD
Assistant Professor of Surgery and Pediatrics
Baylor College of Medicine
As
a result of advances in prenatal ultrasound and ultrafast
MRI, many congenital structural anomalies (including abdominal
wall defects such as omphalocele and gastroschisis, diaphragmatic
hernia, fetal lung lesions, and myelomeningocele) are now diagnosed
before birth. In most instances these conditions are best evaluated
and treated after delivery at term. However, in rare circumstances
these malformations must be treated before birth if the fetus
is to have any hope of survival.
Fetal
surgery involves the application of well-established surgical
techniques (open, percutaneous or endoscopic) to treat the developing
fetus while the fetus remains in utero. Highly specialized surgical,
anesthetic and tocolytic approaches have been developed to open
the uterus safely with minimum blood loss and to treat associated
preterm labor. Presently, fetal surgery is only appropriate for
a limited number of life-threatening fetal surgical conditions
that include a lung mass with hydrops, a neck mass with tracheal
compression or hydrops, and sacrococcygeal teratoma with hydrops.
Studies are evaluating the benefit of fetal surgical interventions
for severe congenital diaphragmatic hernia, myelomeningocele,
and twin-twin transfusion syndrome.
Within
the last 10 months the Baylor College of Medicine Pediatric Surgical
Program at Texas Children’s Hospital, in collaboration with St.
Luke’s Episcopal Hospital, has successfully applied fetal surgical
techniques to manage severe tracheal compression from large cervical
tumors. In each case, an EXIT procedure (Ex-utero, Intrapartum
Treatment) was accomplished. Under deep general anesthesia
to relax the uterus and preserve placental blood flow, the uterus
was opened. The fetal head was delivered, and fetal laryngoscopy
and bronchoscopy was performed to permit endotracheal intubation
and control of the airway before separating the baby from placental
circulation.
We
are currently preparing to establish a Fetal Surgery Program at
Baylor College of Medicine. We expect that this program will involve
participation from many specialists including pediatric and fetal
surgery, obstetrics, anesthesiology, cardiology, radiology, neonatology,
neurosurgery, urology, cardiac surgery, neonatal and surgical
nursing, and biomedical ethics.
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