Balloon removal after fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia.

Jiménez JA, Eixarch E, Dekoninck P et al.

Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, Clínica Alemana, Universidad del Desarrollo Santiago, Chile.

American journal of obstetrics and gynecology. Mar 2017.

Isolated congenital diaphragmatic hernia (CDH) defect allows viscera to herniate into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. Antenatal measurement of lung size and liver herniation can predict survival after birth. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. This in utero treatment requires a second intevention to reestablish the airway, either before birth or at delivery.To describe our experience with in utero endotracheal balloon removal.This is a retrospective analysis of prospectively collected data on consecutive patients with congenital diaphragmatic hernia (CDH) treated in utero by fetal endoluminal tracheal occlusion (FETO) from three centers. Maternal and pregnancy-associated variables were retrieved. Balloon removal attempts were categorized as elective or emergency; and by technique (in utero: ultrasound guided puncture (USGP); fetoscopy; ex utero: on placental circulation or postnatal tracheoscopy).We performed 351 balloon insertions over a 144 months period. In nine cases removal was attempted outside FETO centers, being impossible in three leading to neonatal death. We attempted 302 in house balloon removals in 292 fetuses (217 elective (71.8%), 85 emergency (28.2%)) at 33.4±0.1 weeks (range: 28.9-37.1), with a mean interval to delivery of 16.6±0.8 days (0-85). Primary attempt was by fetoscopy in 196 (67.1%), by USP in 62 (21.2%), by tracheoscopy on placental circulation in 30 (10.3%) and postnatal tracheoscopy in 4 cases (1.4%), needing a secondary attempt in 10 (3.4%) cases. Each center had different preferences for primary technique selection. In elective removals, we found no differences in the interval to delivery between fetoscopic and USP removals. Difficulties during fetoscopic removals led to the development of a stylet to puncture the balloon leading to shorter operating time and easier reestablishment of airways.In these fetal treatment centers, the balloon could always be successfully removed. In 90% this was in utero, fetoscopy being preferred over USP. Ex utero removal was a fall back procedure. In utero removal, does not seem to precipitate immediate membrane rupture, labour or delivery though the design of the study does not allow for a formal conclusion. For fetoscopic removals, the introduction of a stylet facilitated retrieval. Successful removal may rely on a permanently prepared team with expertise in all possible techniques.


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