Comparison between Fetal Endoscopic Tracheal Occlusion Using a 1.0-mm Fetoscope and Prenatal Expectant Management in Severe Congenital Diaphragmatic Hernia

Abstract

Objectives: To evaluate if fetal endoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia (CDH) using a 1.0-mm fetoscope improves neonatal outcome. Method: Between January 2006 and December 2008, a controlled study was conducted at a single center in which FETO was proposed for fetuses with severe isolated CDH (lung-to-head ratio <1.0) and liver herniation to the thoracic cavity but no other detectable anomalies at diagnosis (<26 weeks). FETO was performed under maternal epidural and fetal intramuscular anesthesia, guided by ultrasonography and 1.0-mm fetoscope between 26 and 30 weeks. All cases submitted to FETO were delivered by ex utero intrapartum therapy procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was neonatal survival (up to 28 days after birth). Results: A total of 35 women met the inclusion criteria, and in 17 of them, fetal intervention was intended. However, in 1 case, it was not possible to insert the balloon inside the fetal trachea because of placental bleeding. FETO was therefore successfully performed in 16 fetuses with severe CDH. Eighteen cases received no prenatal intervention and served as the control group. Mean gestational age at diagnosis was similar in both groups (p > 0.05). Delivery occurred at 35.6 (range: 28–38) weeks in the FETO group and at 37.5 (range: 31–40) weeks (p = 0.18) among controls. Nine of 17 (52.9%) infants in the FETO group and 1 of 18 (5.6%) in the control group survived (p < 0.01). Severe pulmonary arterial hypertension was present in 8/17 (47.1%) infants from the FETO group and in 16/18 (88.9%) controls (p = 0.01). Conclusion: The present study shows that FETO using a 1.0-mm fetoscope is feasible and may improve neonatal outcome in severe CDH.

Predictors of neonatal morbidity in fetuses with severe isolated congenital diaphragmatic hernia undergoing fetoscopic tracheal occlusion

“…The FETO procedure has been described in detail 22,23,28 . Briefly it consists of the percutaneous fetoscopic insertion of a balloon into the fetal trachea, which in general is performed at approximately 26-28 (range, [23][24][25][26][27][28][29][30][31][32][33] weeks' gestation. The balloon is preferentially removed in utero at approximately 34 weeks by tracheoscopy or ultrasound-guided puncture.…”

Congenital diaphragmatic hernia

“…In utero anatomical repair improves lung development, but requires open fetal surgery and is not currently offered if there is liver herniation [33]. Alternatively, tracheal occlusion (TO) has been used to promote lung growth [34,35]. Antenatal TO prevents egress of lung fluid, which increases airway pressure, causing cell proliferation, increased alveolar airspace and maturation of pulmonary vasculature.…”

Evidence-Based Prenatal Management in Cases of Congenital Diaphragmatic Hernia

“…A higher survival rate (52.9% versus 5.6%; p<0.01) and a lower rate of pulmonary hypertension (47.1% versus 88.9%; p=0.01) were reported with the use of FETO. There was no statistically significant difference between the groups with respect to gestational age at delivery (35.6 weeks in the FETO group versus 37.5 weeks in the control group); however, it should be emphasized that the sample size was small (n = 35 women) (Ruano et al, 2011).…”