Fetoscopic temporary tracheal occlusion by means of detachable balloon for congenital diaphragmatic hernia

doi:10.1067/mob.2001.117344

American Journal of Obstetrics and Gynecology

Volume 185, Issue 3, September 2001, Pages 730-733

https://doi.org/10.1067/mob.2001.117344 Get rights and content

Abstract

Occlusion of the fetal trachea blocks the egress of fetal lung fluid and stimulates the growth of hypoplastic lungs in fetuses with diaphragmatic hernia. Accomplishing temporary and reversible occlusion of the fetal trachea has proven difficult without invasive fetal surgery. Using simultaneous real-time ultrasonography and fetal bronchoscopy through a single uterine port, we placed a detachable balloon in the trachea of 2 fetuses with severe diaphragmatic hernia. In both fetuses the fetal lung subsequently enlarged, allowing survival after birth. (Am J Obstet Gynecol 2001;185:730-3.)

Section snippets

Case 1

A 31-year-old gravida 3, para 0 woman carrying a fetus with a right-sided CDH, a normal karyotype, and no other detectable abnormalities came to the University of California, San Francisco Fetal Treatment Center at 26 weeks’ gestation for fetal ultrasonography, echocardiography, and magnetic resonance imaging (MRI), which demonstrated a severe right-sided CDH, a large amount of liver herniated into the right hemithorax, a low LHR of 0.52, signs of fetal hydrops (ascites and pleural fluid), and

Fetendo balloon technique

The Fetendo balloon technique is shown in Figure 1.

. Access to the fetus is through a single 5-mm uterine port. The fetus is positioned with the neck extended, and tracheoscopy is performed with a 4.5-mm (OD) Bettochi constant perfusion hysteroscope. A detachable balloon loaded on a catheter is passed through the working port of the fetoscope and into the fetal trachea. It is positioned with both endoscopic and ultrasonographic visualization during inflation. Gentle traction on the catheter

Prenatal course

In both cases the balloon was successfully placed in the fetal trachea with a single 5-mm uterine port. The intraoperative course was uneventful, and the procedure time was less than half of that required for the Fetendo clip procedure.¹¹ The postoperative course for mother and fetus was also uneventful, with a mean hospital stay of 7 days. In both cases the mothers were weaned from postoperative tocolytics, indomethacin, and magnesium sulfate and discharged on the oral calcium channel blocker

Comment

The clinical management for a prenatally diagnosed diaphragmatic hernia has evolved rapidly over the last decade and is based on a careful prognostic evaluation of the severity of the lesion. Fetuses with mild lesions have no herniation of the liver into the chest and reasonable lung volumes, as determined by LHR. Families can be reassured that these fetuses have an excellent prognosis with standard postnatal care after term delivery. On the other hand, fetuses with severe lesions have liver

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Cited by (102)

In Utero Therapy for Congenital Diaphragmatic Hernia
2022, Clinics in Perinatology
Citation Excerpt :
Fetal endoscopic tracheal occlusion (FETO) was developed as a minimally invasive method to obstruct the fetal airway, wherein a detachable silicone balloon was placed with the use of fetal bronchoscopy through a single 4- to 5-mm uterine port. Given encouraging initial results,39 the UCSF group conducted a randomized controlled trial comparing endoscopic tracheal occlusion to standard postnatal care in fetuses with severe CDH (LHR of <1.5 between 22 and 27 weeks, liver up).40 The trial was closed early after 24 patients had been enrolled, owing to the finding that tracheal occlusion did not improve survival or morbidity rates and was associated with higher rates of premature rupture of the membranes and preterm delivery.
Fetal intervention for congenital diaphragmatic hernia
2019, Seminars in Pediatric Surgery
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
An injectable, degradable hydrogel plug for tracheal occlusion in congenital diaphragmatic hernia (CDH)
2019, Materials Science and Engineering C
Congenital Diaphragmatic Hernia (CDH) is a birth defect characterized by failed closure of diaphragm, herniation of viscera in the thoracic cavity and impaired lung development. In most severe cases, fetoscopic endoluminal tracheal occlusion (FETO) is performed through a catheter-mounted balloon to contain pulmonary hypoplasia. To support the success rate of FETO and overcome some of the associated drawbacks, this work aimed at finding an injectable, degradable substitute for the balloon not requiring prenatal removal.
Two different types of gels were evaluated as tracheal plugs: calcium-alginate and hyaluronan/methylcellulose blends (HA-MC). The effect of composition on hydrogel properties was evaluated, to identify formulations meeting design requirements. Anatomical tracheal casts were fabricated and filled with a simulated lung fluid to assess injectability, cohesiveness, sealing pressure and persistence of plugs. In vitro cytotoxicity and adhesion of mouse fibroblasts on hydrogels were also investigated.
For both hydrogels, adjusting formulation enabled to obtain gelation time within the design range. Furthermore, when injected in the tracheal model, good cohesion and capability to adapt to the anatomical shape were also observed. Effective sealing up to 80 cm H₂0 was reached for selected compositions and was maintained for over 4 weeks in the in vitro model. Swelling and weight loss were also strongly influenced by composition and varied from few days to several weeks. Despite the absence of in vitro cytotoxicity, a favourably low cell-adhesion was observed for both hydrogels. However, due to their shear-thinning behaviour, HA-MC blends appeared as a particularly suitable candidate for single-surgery tracheal occlusion.
Minimally Invasive Fetal Surgery
2017, Clinics in Perinatology
Citation Excerpt :
Fetal endoscopic (Fetendo) tracheal clipping, first performed in a human fetus in 1997, involved a maternal laparotomy, followed by 4 trocars through the maternal uterus to access and clip the fetal trachea.80 Owing to complications of tracheal damage and vocal cord paralysis related to clipping, this technique evolved to the use of fetoscopic balloon tracheal occlusion, which avoids fetal neck dissection and requires only 1 uterine port (Fig. 6).81 Fetal endoscopic tracheal occlusion (FETO) is generally performed between 26 and 30 weeks of gestation.
The intrapartum strategy for thoracoscopic repair of congenital diaphragmatic hernia(CDH): Five cases report and literature review
2023, Research Square
Congenital diaphragmatic hernia: a single-centre experience at Kepler University Hospital Linz
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^☆: Reprint requests: Michael R. Harrison, MD, The Fetal Treatment Center, University of California, San Francisco, 513 Parnassus Avenue, HSW-1601, San Francisco, CA 94143-0570.

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Fetus-Placenta-NewbornFetoscopic temporary tracheal occlusion by means of detachable balloon for congenital diaphragmatic hernia☆

Abstract

Section snippets

Case 1

Fetendo balloon technique

Prenatal course

Comment

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Eur J Obstet Gynaecol Reprod Biol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Fetus-Placenta-Newborn
Fetoscopic temporary tracheal occlusion by means of detachable balloon for congenital diaphragmatic hernia☆