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Feasibility and Outcomes of Fetoscopic Tracheal Occlusion for Severe Left Diaphragmatic Hernia

Belfort, Michael A. MD, PhD; Olutoye, Oluyinka O. MD, PhD; Cass, Darrell L. MD; Olutoye, Olutoyin A. MD, MSc; Cassady, Christopher I. MD; Mehollin-Ray, Amy R. MD; Shamshirsaz, Alireza A. MD; Cruz, Stephanie M. MD; Lee, Timothy C. MD; Mann, David G. MD; Espinoza, Jimmy MD; Welty, Stephen E. MD; Fernandes, Caraciolo J. MD; Ruano, Rodrigo MD, PhD

doi: 10.1097/AOG.0000000000001749
Contents: Original Research

OBJECTIVE: To evaluate feasibility and initial outcomes of fetoscopic tracheal occlusion for severe diaphragmatic hernia compared with a historical cohort who had not received fetal tracheal occlusion.

METHODS: Outcomes in a prospective observational cohort who underwent fetoscopic tracheal occlusion for severe fetal left diaphragmatic hernia without associated anomalies were compared with our historical nontreated cohort of matched fetuses of similar severity. Fetuses were classified using the same ultrasonography and magnetic resonance imaging methodology—prospectively in the fetoscopic tracheal occlusion group and retrospectively in the historical nontreated cohort. Obstetric and postnatal outcomes were evaluated and compared.

RESULTS: Between January 2004 and June 2015, 218 fetuses with diaphragmatic hernia were evaluated. Twenty (9%) fetuses had severe left diaphragmatic hernia (lung–head ratio 1.0 or less and liver herniation), of which 9 of 20 were managed without tracheal occlusion. Eleven were offered the procedure and in 10, it was successful. Mean (±standard deviation) gestational age was 27.9±1.1 weeks at attempted balloon placement, 34.1±1.1 weeks at removal, and 35.3±2.2 weeks at delivery. One patient required an ex utero intrapartum treatment procedure at delivery to remove the balloon. There were no maternal complications or fetal deaths. All neonates underwent postnatal repair with a patch. The 6-month, 1-year, and 2-year survival rates were significantly higher in our treated cohort than in our nontreated historical cohort (80% compared with 11%, risk difference 69%, 95% confidence interval [CI] 38–100%, P=.01; 70% compared with 11%, risk difference 59%, 95% CI 24–94%, P=.02; and 67% compared with 11%, risk difference 56%, 95% CI 19–93%, P=.04, respectively) with reduced need for extracorporeal membrane oxygenation (30% compared with 70%, risk difference 40%, 95% CI 10–79%, P=.05).

CONCLUSION: Fetoscopic tracheal occlusion is feasible and is associated with improved postnatal outcomes in severe left diaphragmatic hernia.

CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT00881660.

Fetoscopic tracheal occlusion is feasible and may improve lung growth and postnatal outcome in severe left diaphragmatic hernia.

Texas Children's Fetal Center and the Departments of Obstetrics and Gynecology, Surgery, Anesthesiology, and Radiology, and the Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.

Corresponding author: Michael A. Belfort, MD, PhD, Texas Children's Hospital - Pavilion for Women, 6651 Main Street, Suite 1040F, Houston, TX 77030; email: belfort@bcm.edu.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Society for Maternal-Fetal Medicine's 36th Annual Pregnancy Meeting, February 1–6, 2016, Atlanta, Georgia.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.