Fetoscopic temporary tracheal occlusion for congenital diaphragmatic hernia: prelude to a randomized, controlled trial
Section snippets
Materials and methods
From January 1996 to April 1999, 19 fetuses underwent fetoscopic temporary tracheal occlusion (Fetendo clip) for congenital diaphragmatic hernia (CDH) at the University of California at San Francisco (UCSF) Fetal Treatment Center. We now update the previously reported experience with 8 left-sided CDHs3 with an additional 8 left-sided and 3 right-sided CDH patients.
Fetuses eligible for prenatal intervention met criteria including (1) diagnosis of CDH made before 25 weeks’ gestation, (2) a major
Operation
Although open hysterotomy was available as a back-up procedure if fetoscopic placement could not be accomplished for technical reasons (fetal position, visualization, bleeding), the last 16 cases (all new cases and the last 5 cases of the previous series) were accomplished without hysterotomy. Eleven of the 19 cases had the more favorable posterior placenta, whereas 8 had less-favorable anterior or fundal locations. Average operating time was 221 minutes ± 69 minutes. The first 8 cases averaged
Discussion
Two decades of extensive experimental investigation and agonizing and often frustrating clinical trials led to development of the prenatal strategy of temporary tracheal occlusion to enlarge the lungs of fetuses with the most severe form of CDH. Previous retrospective and prospective studies have found that without prenatal intervention, high-risk infants do poorly even with optimal postnatal care with mortality rates of 60% for LHRs less than 1.4 and nearly 100% for LHRs less than 1.0.1, 16
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Surgery
Cited by (113)
Fetal tracheal occlusion for congenital diaphragmatic hernia
2020, Seminars in PerinatologyCitation Excerpt :Eventually, vascular occlusion balloons were chosen due to several advantages: avoided secondary surgical procedures, provided total tracheal occlusion while allowing tracheal growth, required a simpler technical approach, and minimized dysmorphism of the trachea. Eventually, with the advent of percutaneous fetoscopic access to the fetus, this strategy could be accomplished without hysterotomy and thus minimizing maternal risk.28 Although fetal tracheal occlusion demonstrated increased lung volume, ongoing pulmonary distention had shown significant decrease in the production of type 2 pneumocytes and surfactant production29–31 with an increase in the risk of PH in CDH-affected neonates after birth.32
The Extremely Premature Infant (Micropremie) and Common Neonatal Emergencies
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2018, A Practice of Anesthesia for Infants and ChildrenBowel sounds in the chest: An uncommon presentation of adult hernia
2018, Respiratory Medicine Case ReportsLong-term morbidity of congenital diaphragmatic hernia: A plea for standardization
2017, Seminars in Pediatric SurgeryCitation Excerpt :Studies in animal models have revealed that changes to the tracheal architecture happens also at a microscopic level.129 Harrison et al.130 reported a small cohort of patients treated with prenatal TO who had stridor and vocal cord paralysis, two of whom also had tracheomalacia. Other authors did not find an association between the increase in airways’ width and short term131 or long-term tracheomegaly-related respiratory symptoms,126 and Cortes et al.24 found no difference in terms of 2 years outcome between CDH survivors who randomly underwent TO or not.
Fetal imaging and therapy for CDH—Current status
2017, Seminars in Pediatric Surgery