Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2015.12.001
Brazilian Journal of Anesthesiology
Scientific Article

Fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: retrospective study

Oclusão traqueal por fetoscopia em hérnia diafragmática congênita grave: estudo retrospectivo

Angélica de Fátima de Assunção Braga; Franklin Sarmento da Silva Braga; Solange Patricia Nascimento; Bruno Verri; Fabio C. Peralta; João Bennini Junior; Karina Jorge

http://dx.doi.org/10.1016/j.bjane.2015.12.001 Braz J Anesthesiol, vol.67, n4, p.331-336, 2017
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Abstract

Abstract Background and objectives: The temporary fetal tracheal occlusion performed by fetoscopy accelerates lung development and reduces neonatal mortality. The aim of this paper is to present an anesthetic experience in pregnant women, whose fetuses have diaphragmatic hernia, undergoing fetoscopic tracheal occlusion (FETO). Method: Retrospective, descriptive study, approved by the Institutional Ethics Committee. Data were obtained from medical and anesthetic records. Results: FETO was performed in 28 pregnant women. Demographic characteristics: age 29.8 ± 6.5; weight 68.64 ± 12.26; ASA I and II. Obstetric: IG 26.1 ± 1.10 weeks (in FETO); 32.86 ± 1.58 (reversal of occlusion); 34.96 ± 2.78 (delivery). Delivery: cesarean section, vaginal delivery. Fetal data: Weight (g) in the occlusion and delivery times, respectively (1045.82 ± 222.2 and 2294 ± 553); RPC in FETO and reversal of occlusion: 0.7 ± 0.15 and 1.32 ± 0.34, respectively. Preoperative maternal anesthesia included ranitidine and metoclopramide, nifedipine (VO) and indomethacin (rectal). Preanesthetic medication with midazolam IV. Anesthetic techniques: combination of 0.5% hyperbaric bupivacaine (5-10 mg) and sufentanil; continuous epidural predominantly with 0.5% bupivacaine associated with sufentanil, fentanyl, or morphine; general. In 8 cases, there was need to complement via catheter, with 5 submitted to PC and 3 to BC. Thirteen patients required intraoperative sedation; ephedrine was used in 15 patients. Fetal anesthesia: fentanyl 10-20 mg.kg-1 and pancuronium 0.1-0.2 mg.kg-1 (IM). Neonatal survival rate was 60.7%. Conclusion: FETO is a minimally invasive technique for severe congenital diaphragmatic hernia repair. Combined blockade associated with sedation and fetal anesthesia proved safe and effective for tracheal occlusion.

Keywords

Congenital diaphragmatic hernia, Prenatal diagnosis, Tracheal occlusion, Fetoscopy, Fetal surgery, Anesthesia

Resumo

Resumo Justificativa e objetivos: A oclusão traqueal fetal temporária feita por meio da fetoscopia acelera o desenvolvimento pulmonar e reduz a mortalidade neonatal. O objetivo deste trabalho é apresentar experiência anestésica em gestantes cujos fetos eram portadores de hérnia diafragmática e foram submetidos à oclusão traqueal por fetoscopia (FETO). Método: Estudo retrospectivo, descritivo, aprovado pelo Comitê de Ética da Instituição. Os dados foram obtidos das fichas anestésicas e dos prontuários. Resultados: A FETO foi feita em 28 gestantes. Características demográficos: idade 29,8 ± 6,5; peso 68,64 ± 12,26; ASA I e II. Obstétricas: IG 26,1 ± 1,10 semana (na FETO); 32,86 ± 1,58 (desoclusão); 34,96 ± 2,78 (parto). Via de parto: cesárea, parto vaginal. Dados fetais: peso (g) nos momentos da oclusão e nascimento, respectivamente (1.045,82 ± 222,2 e 2294 ± 553); RPC na FETO e desoclusão: 0,7 ± 0,15 e 1,32 ± 0,34, respectivamente. Anestesia materna: pré-operatório incluiu ranitidina e metoclopramida; nifedipina (VO) e indometacina (retal). Medicação pré-anestésica com midazolam EV. Técnicas anestésicas: bloqueio combinado com bupivacaína 0,5% hiperbárica 5-10 mg associada ao sufentanil; peridural contínua predominantemente com bupivacaína 0,5% associada a sufentanil, fentanil ou morfina; geral. Em oito casos houve necessidade de complementação pelo cateter, cinco nas submetidas a PC e três a BC. No intraoperatório 13 pacientes necessitaram de sedação; efedrina foi usada em 15 pacientes. Anestesia fetal: fentanil 10 a 20 mg.kg-1 e pancurônio 0,1-0,2 mg.kg-1 (IM). A taxa de sobrevida neonatal foi de 60,7%. Conclusão: A FETO constitui técnica minimamente invasiva para correção de hérnia diafragmática congênita grave. O bloqueio combinado associado à sedação e anestesia fetal se mostrou seguro e eficaz para a oclusão traqueal.

Palavras-chave

Hérnia diafragmática congênita, Diagnóstico pré-natal, Oclusão traqueal, Fetoscopia, Cirurgia fetal, Anestesia

References

Myers LB, Cohen D, Galinkin J. Anaesthesia for fetal surgery. Paediatr Anaesth. 2002;12:569-78.

Myers LB, Bulich LA, Hess P. Fetal endoscopic surgery: indications and anaesthetic management. Best Pract Res Clin Anaesthesiol. 2004;18:231-58.

Harrison MR. Fetal surgery. Am J Obstet Gynecol. 1996;174:1255-64.

Sala P, Prefumo F, Pastorino D. Fetal surgery: an overview. Obstet Gynecol Surv. 2014;69:218-28.

Ruano R, da Silva MM, Campos JÁ. Fetal pulmonary response after fetoscopic tracheal occlusion for severe isolated congenital diaphragmatic hernia. Obstet Gynecol. 2012;119:93-101.

Ruano R, Yoshisaki CT, da Silva MM. A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia. Ultrasound Obstet Gynecol. 2012;39:20-7.

Ruano R, Peiro JL, da Silva MM. Early fetoscopic tracheal occlusion for extremely severe pulmonary hypoplasia in isolated congenital diaphragmatic hernia: preliminary results. Ultrasound Obstet Gynecol. 2013;42:70-6.

Schwarz U, Galinkin JL. Anesthesia for fetal surgery. Semin Pediatr Surg. 2003;12:196-201.

Skarsgard ED, Meuli M, VanderWall KJ. Fetal endoscopic tracheal occlusion (Fetendo-PLUG) for congenital diaphragmatic hernia. J Pediatr Surg. 1996;31:1335-8.

Jani J, Nicolaides KH, Keller RL. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet Gynecol. 2007;30:67-71.

Peralta CF, Cavoretto P, Csapo B. Assessment of lung area in normal fetuses at 12-32 weeks. Ultrasound Obstet Gynecol. 2005;26:718-24.

Harrison MR, Adzick NS, Estes JM. A prospective study of the outcome for fetuses with diaphragmatic hernia. JAMA. 1994;271:382-4.

Longaker MT, Golbus MS, Filly RA. Maternal outcome after open fetal surgery. A review of the first 17 human cases. JAMA. 1991;265:737-41.

Deprest JA, Nicolaides K, Gratacos E. Fetal surgery for congenital diaphragmatic hernia is back from never gone. Fetal Diagn Ther. 2011;29:6-17.

Deprest J, Jani J, Lewi L. Fetoscopic surgery: encouraged by clinical experience and boosted by instrument innovation. Semin Fetal Neonatal Med. 2006;11:398-412.

Flageole H, Evrard VA, Vandenberghe K. Tracheoscopic endotracheal occlusion in the ovine model: technique and pulmonary effects. J Pediatr Surg. 1997;32:1328-31.

Papadakis K, Luks FI, Deprest JA. Single-port tracheoscopic surgery in the fetal lamb. J Pediatr Surg. 1998;33:918-20.

Deprest JA, Evrard VA, Van Ballaer PP. Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model. Eur J Obstet Gynecol Reprod Biol. 1998;81:165-9.

Flageole H, Evrard VA, Piedboeuf B. The plug-unplug sequence: an important step to achieve type II pneumocyte maturation in the fetal lamb model. J Pediatr Surg. 1998;33:299-303.

Deprest JA, Evrard VA, Verbeken EK. Tracheal side effects of endoscopic balloon tracheal occlusion in the fetal lamb model. Eur J Obstet Gynecol Reprod Biol. 2000;92:119-26.

Roubliova XI, Verbeken EK, Wu J. Effect of tracheal occlusion on peripheric pulmonary vessel muscularization in a fetal rabbit model for congenital diaphragmatic hernia. Am J Obstet Gynecol. 2004;191:830-6.

Deprest J, Gratacos E, Nicolaides KH. Fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia: evolution of a technique and preliminary results. Ultrasound Obstet Gynecol. 2004;24:121-6.

Jani JC, Nicolaides KH, Gratacós E. Severe diaphragmatic hernia treated by fetal endoscopic tracheal occlusion. Ultrasound Obstet Gynecol. 2009;34:304-10.

Manrique S, Munar F, Andreu E. Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results. Rev Esp Anestesiol Reanim. 2008;55:407-13.

Peralta CF, Sbragia L, Bennini JR. Fetoscopic endotracheal occlusion for severe isolated diaphragmatic hernia: initial experience from a single clinic in Brazil. Fetal Diagn Ther. 2011;29:71-7.

Jani JC, Nicolaides KH, Gratacós E. Fetal lung-to-head ratio in the prediction of survival in severe left-sided diaphragmatic hernia treated by fetal endoscopic tracheal occlusion (FETO). Am J Obstet Gynecol. 2006;195:1646-50.

Jani J, Gratacós E, Greenough A. Percutaneous fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia. Clin Obstet Gynecol. 2005;48:910-22.

Deprest J, Jani J, Gratacos E. Fetal intervention for congenital diaphragmatic hernia: the European experience. Semin Perinatol. 2005;29:94-103.

Peralta CF, Sbragia L, Bennini JR. Tracheal occlusion for fetuses with severe isolated left-sided diaphragmatic hernia: a nonrandomized controlled experimental study. Rev Bras Ginecol Obstet. 2011;33:381-7.

Rosen MA. Anesthesia for fetal surgery. Obstetric anesthesia. Principles and practice. 1999:110-21.

Cauldwell CB. Anesthesia for fetal surgery. Anesthesiol Clin N Am. 2002;20:211-26.

Gaiser RR, Kurth CD. Anesthetic considerations for fetal surgery. Semin Perinatol. 1999;23:507-14.

Rychik J, Tian ZY, Cohen DE. Hymodynamic changes during human fetal surgery. Circulation. 1998;98:1481.

Van de Velde M, Van Schoubroeck D, Lewi LE. Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam. Anesth Analg. 2005;101:251-8.

Leo S, Sng BL, Lim Y. A randomized comparison of low doses of hyperbaric bupivacaine in combined spinal-epidural anesthesia for cesarean delivery. Anesth Analg. 2009;109:1600-5.

Riley ET. Spinal anaesthesia for Caesarean delivery: keep the pressure up and don’t spare the vasoconstrictors. Br J Anaesth. 2004;92:459-61.

Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-9.

Fan SZ, Susetio L, Tsai MC. Neuromuscular blockade of the fetus with pancuronium or pipecuronium for intra-uterine procedures. Anaesthesia. 1994;49:284-6.

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