Fetal Interventions Part I: Lung Lesions
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The average CVR (congenital pulmonary airway malformation volume ratio) for EXIT procedures with CCAM has been over 2.0, representing large lesions.
EXIT procedures for CCAM are reserved for cases with evidence of compression including diaphragmatic aversion, marked mediastinal shift, and often ascites.
It is very rare to need ECMO in CCAM patients.
Complex CCAM cases requiring EXIT and fetal surgery are referred to specialized centers while simple cases stay at referring institutions, skewing the percentage of interventions at high-volume centers.
There is no clear reduction in the ability to have subsequent pregnancy after fetal surgery, based on approximately four published studies.
After fetal surgery, patients are not allowed to labor in future pregnancies because the hysterotomy is equivalent to a classical cesarean section in the upper part of the uterus.
There has been no observed placenta accreta at the hysterotomy site following fetal surgery thus far.
EXIT procedure requires an anesthetic team experienced with uterine relaxation and maternal issues, and expertise with hysterotomy.
EXIT procedures can be learned and disseminated more widely than fetal surgery programs, with training through observation.
CHOP has performed close to 100 EXIT procedures in the past 10 years for conditions including cervical teratomas and airway obstructive problems.
Maternal expertise must be available at the hospital performing EXIT procedures, with protection of the mother being the first priority.
Approximately 4 or 5 centers in the US clearly have the qualifications and background to perform EXIT procedures correctly.
EXIT procedures require weeks of planning and involve 15 to 20 people in the team.
A minimum case volume of 3 to 5 EXIT procedures per year is needed to justify establishing a program; one case per year is insufficient.
Most bronchopulmonary sequestrations causing hydrops have associated pleural effusions and mediastinal shift, with hydrops due to mass effect rather than high-output cardiac failure.
Embolization or sclerotherapy procedures for fetal vascular lesions, particularly using alcohol as a sclerosant, carry potential hazards including neurologic effects that have not been adequately studied.
The main technical difference in fetal lobectomy compared to postnatal surgery is the delicacy and gelatinous, friable consistency of tissues, particularly at 20-23 weeks gestation.
Mishaps in fetal surgery have usually been related to traction injuries that tear tissues more easily than in postnatal open surgery.
The fetus is positioned before opening the uterus by converting it to the desired position within the amniotic fluid space.
During fetal thoracotomy, the fetus is stabilized by extracting the ipsilateral arm through the hysterotomy and is buoyed by amniotic fluid infusion, creating a seal at the hysterotomy site.
No successful complete pneumonectomy has been performed in fetal surgery; one attempted case for bronchial atresia resulted in fetal death.
Bilobectomies have been successfully performed in fetal surgery.
Small fragments of lung tissue left after fetal resection can grow dramatically postnatally if airway and vasculature are preserved.
Fetal surgery can still be performed in mothers who have had previous cesarean sections because the uterus heals incisions well.
Most cesarean sections are performed through the lower uterine segment, which does not interfere with the fetal surgery hysterotomy site.