Encouraging Early Clinical Experience with Deliberately Delayed Temporary Fetoscopic Tracheal Occlusion for the Prenatal Treatment of Life-Threatening Right and Left Congenital Diaphragmatic Hernias

Abstract

Objective: In order to assess the effect of deliberately delayed percutaneous fetoscopic tracheal occlusion on survival of fetuses with life-threatening congenital diaphragmatic hernia. Methods: Eight fetuses with life-threatening congenital diaphragmatic hernia underwent fetoscopic tracheal balloon occlusion between 29 + 0 and 32 + 4 weeks of gestation. Delayed occlusion was chosen in order to minimize potentially negative pulmonary effects from premature delivery as a result of fetal surgery. In addition, we wanted to become able to provide all available postnatal intensive care treatment means in these patients. Results: Six of the 8 fetuses survived to discharge from hospital. Conclusion: Delayed fetoscopic tracheal balloon occlusion may be rewarded with lung growth sufficient to allow survival of fetuses with life-threatening congenital diaphragmatic hernia.

Temporary Fetoscopic Tracheal Balloon Occlusion Enhanced by Hyperoncotic Lung Distension: Is There a Role in the Treatment of Fetal Pulmonary Hypoplasia from Early Preterm Premature Rupture of Membranes?

“…The degree of lung distension noted within 24 h following fetal tracheal occlusion enhanced by hyperoncotic distension by far surpassed that observed in our experience following fetoscopic tracheal balloon occlusion for severe diaphragmatic hernia [11] . We speculate that one reason for this impressive distension lies in the fact that, in contrast to a fetus with severe diaphragmatic hernia, a fetus who suffers ePPROM has normally developed lungs until the event occurs.…”

“…Based on our encouraging experience with very shortterm fetoscopic tracheal balloon occlusion in fetuses with diaphragmatic hernia [11] , depending on the clinical course of mother and fetus, we had planned to maintain a tracheal occlusion period of between 7 and 10 days. Unfortunately, due to a defective valve, the balloon dislodged from the trachea following only between 4 and 5 days of fetoscopic tracheal balloon occlusion.…”

“…This translated into a lung volume increase from 10 to 18 ml. Monitored by maternal transabdominal ultrasound, following amnioinfusion of about 600 ml, an 11-french catheter sheath (external diameter 5 mm) was percutaneously inserted into the amniotic cavity close to the fetal head [11] . Via the sheath, a 2-mm 0-degree rod-lens fetoscope housed in a custom-made endoscope sheath (Karl Storz Company, Tuttlingen, Germany) was advanced into the fetal mouth and carefully manipulated into the fetal trachea.…”

Fetal Surgery for Congenital Diaphragmatic Hernia Is Back from Never Gone

“…We are aware of other experience [114,115] , and also US-based programmes at UCSF [116] (NIH trial identifier: NCT00768703), St. Lukes at Denver, Colo. (NCT00881660) and the Hasbro Hospital in Providence, R.I. (NCT00966823). In this issue of Fetal Diagnosis and Therapy , two larger case series from Brazil are also published.…”

Minimally invasive fetoscopic interventions: an overview in 2010

“…Based on the UCSF and the Eurofetus experience and the ever growing body of experimental studies on fetal tracheal occlusion, our group introduced the strategy of deliberately delayed fetoscopic tracheal balloon occlusion [67]. The first goal of this strategy was to prevent entirely iatrogenic preterm delivery of immature fetuses with diaphragmatic hernia by postponing the intervention to beyond 30 weeks of gestation.…”