Skip to main content
Annals of Surgery logoLink to Annals of Surgery
. 1991 Apr;213(4):279–278. doi: 10.1097/00000658-199104000-00002

The fetus as a patient. Surgical considerations.

M R Harrison 1, N S Adzick 1
PMCID: PMC1358346  PMID: 2009009

Abstract

The diagnosis and treatment of human fetal defects has evolved rapidly over the past decade due to improved fetal imaging techniques and better understanding of fetal pathophysiology derived from animal models. The detection of a fetal anomaly may now lead to a change in the timing of delivery, a change in the mode of delivery, or prenatal treatment. Because most therapeutic maneuvers involve some risk to the fetus and mother, there must be a reasonable expectation that the procedure is feasible, safe, and effective before it can be attempted in humans. This requires reliable information about the pathophysiology and natural history of the disease process, the efficacy of fetal surgical intervention in ameliorating the disease, and the feasibility and safety of the proposed intervention. This paper focuses on the rationale and initial clinical experience with fetal surgery for a variety of life-threatening fetal anatomic defects.

Full text

PDF
281

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adzick N. S., Harrison M. R., Glick P. L., Anderson J., Villa R. L., Flake A. W., Laberge J. M. Fetal surgery in the primate. III. Maternal outcome after fetal surgery. J Pediatr Surg. 1986 Jun;21(6):477–480. doi: 10.1016/s0022-3468(86)80215-9. [DOI] [PubMed] [Google Scholar]
  2. Adzick N. S., Harrison M. R., Glick P. L., Beckstead J. H., Villa R. L., Scheuenstuhl H., Goodson W. H., 3rd Comparison of fetal, newborn, and adult wound healing by histologic, enzyme-histochemical, and hydroxyproline determinations. J Pediatr Surg. 1985 Aug;20(4):315–319. doi: 10.1016/s0022-3468(85)80210-4. [DOI] [PubMed] [Google Scholar]
  3. Adzick N. S., Harrison M. R., Glick P. L., Golbus M. S., Anderson R. L., Mahony B. S., Callen P. W., Hirsch J. H., Luthy D. A., Filly R. A. Fetal cystic adenomatoid malformation: prenatal diagnosis and natural history. J Pediatr Surg. 1985 Oct;20(5):483–488. doi: 10.1016/s0022-3468(85)80470-x. [DOI] [PubMed] [Google Scholar]
  4. Adzick N. S., Harrison M. R., Glick P. L., Nakayama D. K., Manning F. A., deLorimier A. A. Diaphragmatic hernia in the fetus: prenatal diagnosis and outcome in 94 cases. J Pediatr Surg. 1985 Aug;20(4):357–361. doi: 10.1016/s0022-3468(85)80219-0. [DOI] [PubMed] [Google Scholar]
  5. Adzick N. S., Harrison M. R., Glick P. L., Villa R. L., Finkbeiner W. Experimental pulmonary hypoplasia and oligohydramnios: relative contributions of lung fluid and fetal breathing movements. J Pediatr Surg. 1984 Dec;19(6):658–665. doi: 10.1016/s0022-3468(84)80349-8. [DOI] [PubMed] [Google Scholar]
  6. Adzick N. S., Outwater K. M., Harrison M. R., Davies P., Glick P. L., deLorimier A. A., Reid L. M. Correction of congenital diaphragmatic hernia in utero. IV. An early gestational fetal lamb model for pulmonary vascular morphometric analysis. J Pediatr Surg. 1985 Dec;20(6):673–680. doi: 10.1016/s0022-3468(85)80022-1. [DOI] [PubMed] [Google Scholar]
  7. Adzick N. S., Vacanti J. P., Lillehei C. W., O'Rourke P. P., Crone R. K., Wilson J. M. Fetal diaphragmatic hernia: ultrasound diagnosis and clinical outcome in 38 cases. J Pediatr Surg. 1989 Jul;24(7):654–658. doi: 10.1016/s0022-3468(89)80713-4. [DOI] [PubMed] [Google Scholar]
  8. BUTLER N., CLAIREAUX A. E. Congenital diaphragmatic hernia as a cause of perinatal mortality. Lancet. 1962 Mar 31;1(7231):659–663. doi: 10.1016/s0140-6736(62)92878-7. [DOI] [PubMed] [Google Scholar]
  9. Benacerraf B. R., Frigoletto F. D., Jr, Wilson M. Successful midtrimester thoracentesis with analysis of the lymphocyte population in the pleural effusion. Am J Obstet Gynecol. 1986 Aug;155(2):398–399. doi: 10.1016/0002-9378(86)90841-0. [DOI] [PubMed] [Google Scholar]
  10. Bical O., Gallix P., Toussaint M., Hero M., Karam J., Sidi D., Neveux J. Y. Intrauterine creation and repair of pulmonary artery stenosis in the fetal lamb. Weight and ultrastructural changes of the ventricles. J Thorac Cardiovasc Surg. 1987 May;93(5):761–766. [PubMed] [Google Scholar]
  11. Carpenter R. J., Jr, Strasburger J. F., Garson A., Jr, Smith R. T., Deter R. L., Engelhardt H. T., Jr Fetal ventricular pacing for hydrops secondary to complete atrioventricular block. J Am Coll Cardiol. 1986 Dec;8(6):1434–1436. doi: 10.1016/s0735-1097(86)80319-9. [DOI] [PubMed] [Google Scholar]
  12. Clark S. L., Vitale D. J., Minton S. D., Stoddard R. A., Sabey P. L. Successful fetal therapy for cystic adenomatoid malformation associated with second-trimester hydrops. Am J Obstet Gynecol. 1987 Aug;157(2):294–295. doi: 10.1016/s0002-9378(87)80154-0. [DOI] [PubMed] [Google Scholar]
  13. Crombleholme T. M., Harrison M. R., Langer J. C., Longaker M. T., Anderson R. L., Slotnick N. S., Filly R. A., Callen P. W., Goldstein R. B., Golbus M. S. Early experience with open fetal surgery for congenital hydronephrosis. J Pediatr Surg. 1988 Dec;23(12):1114–1121. doi: 10.1016/s0022-3468(88)80325-7. [DOI] [PubMed] [Google Scholar]
  14. Del Rossi A. J., Strong M. D., Lemole G. M. Repair of caval lacerations during cardiac surgery. J Cardiovasc Surg (Torino) 1985 Jan-Feb;26(1):86–87. [PubMed] [Google Scholar]
  15. Docimo S. G., Luetic T., Crone R. K., Davies P., Reid L., Retik A. B., Mandell J. Pulmonary development in the fetal lamb with severe bladder outlet obstruction and oligohydramnios: a morphometric study. J Urol. 1989 Aug;142(2 Pt 2):657–668. doi: 10.1016/s0022-5347(17)38845-6. [DOI] [PubMed] [Google Scholar]
  16. Fishman N. H., Hof R. B., Rudolph A. M., Heymann M. A. Models of congenital heart disease in fetal lambs. Circulation. 1978 Aug;58(2):354–364. doi: 10.1161/01.cir.58.2.354. [DOI] [PubMed] [Google Scholar]
  17. Fitzgerald R. J. Congenital diaphragmatic hernia: a study of mortality factors. Ir J Med Sci. 1977 Sep;146(9):280–284. doi: 10.1007/BF03030975. [DOI] [PubMed] [Google Scholar]
  18. Flake A. W., Harrison M. R., Adzick N. S., Laberge J. M., Warsof S. L. Fetal sacrococcygeal teratoma. J Pediatr Surg. 1986 Jul;21(7):563–566. doi: 10.1016/s0022-3468(86)80404-3. [DOI] [PubMed] [Google Scholar]
  19. Flake A. W., Harrison M. R., Adzick N. S., Zanjani E. D. Transplantation of fetal hematopoietic stem cells in utero: the creation of hematopoietic chimeras. Science. 1986 Aug 15;233(4765):776–778. doi: 10.1126/science.2874611. [DOI] [PubMed] [Google Scholar]
  20. Glick P. L., Harrison M. R., Adzick N. S., Noall R. A., Villa R. L. Correction of congenital hydronephrosis in utero IV: in utero decompression prevents renal dysplasia. J Pediatr Surg. 1984 Dec;19(6):649–657. doi: 10.1016/s0022-3468(84)80348-6. [DOI] [PubMed] [Google Scholar]
  21. Glick P. L., Harrison M. R., Golbus M. S., Adzick N. S., Filly R. A., Callen P. W., Mahony B. S., Anderson R. L., deLorimier A. A. Management of the fetus with congenital hydronephrosis II: Prognostic criteria and selection for treatment. J Pediatr Surg. 1985 Aug;20(4):376–387. doi: 10.1016/s0022-3468(85)80223-2. [DOI] [PubMed] [Google Scholar]
  22. Glick P. L., Harrison M. R., Noall R. A., Villa R. L. Correction of congenital hydronephrosis in utero III. Early mid-trimester ureteral obstruction produces renal dysplasia. J Pediatr Surg. 1983 Dec;18(6):681–687. doi: 10.1016/s0022-3468(83)80003-7. [DOI] [PubMed] [Google Scholar]
  23. Golladay E. S., Mollitt D. L. Surgically correctable fetal hydrops. J Pediatr Surg. 1984 Feb;19(1):59–62. doi: 10.1016/s0022-3468(84)80017-2. [DOI] [PubMed] [Google Scholar]
  24. Harrison M. R., Adzick N. S., Jennings R. W., Duncan B. W., Rosen M. A., Filly R. A., Goldberg J. D., deLorimier A. A., Golbus M. S. Antenatal intervention for congenital cystic adenomatoid malformation. Lancet. 1990 Oct 20;336(8721):965–967. doi: 10.1016/0140-6736(90)92420-m. [DOI] [PubMed] [Google Scholar]
  25. Harrison M. R., Adzick N. S., Longaker M. T., Goldberg J. D., Rosen M. A., Filly R. A., Evans M. I., Golbus M. S. Successful repair in utero of a fetal diaphragmatic hernia after removal of herniated viscera from the left thorax. N Engl J Med. 1990 May 31;322(22):1582–1584. doi: 10.1056/NEJM199005313222207. [DOI] [PubMed] [Google Scholar]
  26. Harrison M. R., Anderson J., Rosen M. A., Ross N. A., Hendrickx A. G. Fetal surgery in the primate I. Anesthetic, surgical, and tocolytic management to maximize fetal-neonatal survival. J Pediatr Surg. 1982 Apr;17(2):115–122. doi: 10.1016/s0022-3468(82)80193-0. [DOI] [PubMed] [Google Scholar]
  27. Harrison M. R., Bjordal R. I., Langmark F., Knutrud O. Congenital diaphragmatic hernia: the hidden mortality. J Pediatr Surg. 1978 Jun;13(3):227–230. doi: 10.1016/s0022-3468(78)80391-1. [DOI] [PubMed] [Google Scholar]
  28. Harrison M. R., Bressack M. A., Churg A. M., de Lorimier A. A. Correction of congenital diaphragmatic hernia in utero. II. Simulated correction permits fetal lung growth with survival at birth. Surgery. 1980 Aug;88(2):260–268. [PubMed] [Google Scholar]
  29. Harrison M. R., Filly R. A., Golbus M. S., Berkowitz R. L., Callen P. W., Canty T. G., Catz C., Clewell W. H., Depp R., Edwards M. S. Fetal treatment 1982. N Engl J Med. 1982 Dec 23;307(26):1651–1652. doi: 10.1056/NEJM198212233072623. [DOI] [PubMed] [Google Scholar]
  30. Harrison M. R., Filly R. A., Parer J. T., Faer M. J., Jacobson J. B., de Lorimier A. A. Management of the fetus with a urinary tract malformation. JAMA. 1981 Aug 7;246(6):635–639. [PubMed] [Google Scholar]
  31. Harrison M. R., Golbus M. S., Filly R. A., Callen P. W., Katz M., de Lorimier A. A., Rosen M., Jonsen A. R. Fetal surgery for congenital hydronephrosis. N Engl J Med. 1982 Mar 11;306(10):591–593. doi: 10.1056/NEJM198203113061006. [DOI] [PubMed] [Google Scholar]
  32. Harrison M. R., Golbus M. S., Filly R. A. Management of the fetus with a correctable congenital defect. JAMA. 1981 Aug 14;246(7):774–777. [PubMed] [Google Scholar]
  33. Harrison M. R., Golbus M. S., Filly R. A., Nakayama D. K., Callen P. W., de Lorimier A. A., Hricak H. Management of the fetus with congenital hydronephrosis. J Pediatr Surg. 1982 Dec;17(6):728–742. doi: 10.1016/s0022-3468(82)80437-5. [DOI] [PubMed] [Google Scholar]
  34. Harrison M. R., Jester J. A., Ross N. A. Correction of congenital diaphragmatic hernia in utero. I. The model: intrathoracic balloon produces fatal pulmonary hypoplasia. Surgery. 1980 Jul;88(1):174–182. [PubMed] [Google Scholar]
  35. Harrison M. R., Langer J. C., Adzick N. S., Golbus M. S., Filly R. A., Anderson R. L., Rosen M. A., Callen P. W., Goldstein R. B., deLorimier A. A. Correction of congenital diaphragmatic hernia in utero, V. Initial clinical experience. J Pediatr Surg. 1990 Jan;25(1):47–57. doi: 10.1016/s0022-3468(05)80163-0. [DOI] [PubMed] [Google Scholar]
  36. Harrison M. R., Nakayama D. K., Noall R., de Lorimier A. A. Correction of congenital hydronephrosis in utero II. Decompression reverses the effects of obstruction on the fetal lung and urinary tract. J Pediatr Surg. 1982 Dec;17(6):965–974. doi: 10.1016/s0022-3468(82)80476-4. [DOI] [PubMed] [Google Scholar]
  37. Harrison M. R., Ross N. A., de Lorimier A. A. Correction of congenital diaphragmatic hernia in utero. III. Development of a successful surgical technique using abdominoplasty to avoid compromise of umbilical blood flow. J Pediatr Surg. 1981 Dec;16(6):934–942. doi: 10.1016/s0022-3468(81)80849-4. [DOI] [PubMed] [Google Scholar]
  38. Harrison M. R., Ross N., Noall R., de Lorimier A. A. Correction of congenital hydronephrosis in utero. I. The model: fetal urethral obstruction produces hydronephrosis and pulmonary hypoplasia in fetal lambs. J Pediatr Surg. 1983 Jun;18(3):247–256. doi: 10.1016/s0022-3468(83)80094-3. [DOI] [PubMed] [Google Scholar]
  39. Inselman L. S., Mellins R. B. Growth and development of the lung. J Pediatr. 1981 Jan;98(1):1–15. doi: 10.1016/s0022-3476(81)80524-0. [DOI] [PubMed] [Google Scholar]
  40. Kleinman C. S., Hobbins J. C., Jaffe C. C., Lynch D. C., Talner N. S. Echocardiographic studies of the human fetus: prenatal diagnosis of congenital heart disease and cardiac dysrhythmias. Pediatrics. 1980 Jun;65(6):1059–1067. [PubMed] [Google Scholar]
  41. Krummel T. M., Nelson J. M., Diegelmann R. F., Lindblad W. J., Salzberg A. M., Greenfield L. J., Cohen I. K. Fetal response to injury in the rabbit. J Pediatr Surg. 1987 Jul;22(7):640–644. doi: 10.1016/s0022-3468(87)80117-3. [DOI] [PubMed] [Google Scholar]
  42. Langer J. C., Harrison M. R., Schmidt K. G., Silverman N. H., Anderson R. L., Goldberg J. D., Filly R. A., Crombleholme T. M., Longaker M. T., Golbus M. S. Fetal hydrops and death from sacrococcygeal teratoma: rationale for fetal surgery. Am J Obstet Gynecol. 1989 May;160(5 Pt 1):1145–1150. doi: 10.1016/0002-9378(89)90177-4. [DOI] [PubMed] [Google Scholar]
  43. Longaker M. T., Chiu E. S., Harrison M. R., Crombleholme T. M., Langer J. C., Duncan B. W., Adzick N. S., Verrier E. D., Stern R. Studies in fetal wound healing. IV. Hyaluronic acid-stimulating activity distinguishes fetal wound fluid from adult wound fluid. Ann Surg. 1989 Nov;210(5):667–672. doi: 10.1097/00000658-198911000-00016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Longaker M. T., Laberge J. M., Dansereau J., Langer J. C., Crombleholme T. M., Callen P. W., Golbus M. S., Harrison M. R. Primary fetal hydrothorax: natural history and management. J Pediatr Surg. 1989 Jun;24(6):573–576. doi: 10.1016/s0022-3468(89)80509-3. [DOI] [PubMed] [Google Scholar]
  45. Mahony B. S., Filly R. A., Callen P. W., Hricak H., Golbus M. S., Harrison M. R. Fetal renal dysplasia: sonographic evaluation. Radiology. 1984 Jul;152(1):143–146. doi: 10.1148/radiology.152.1.6729104. [DOI] [PubMed] [Google Scholar]
  46. NICOLAY K. S., GAINEY H. L. PSEUDOTOXEMIC STATE ASSOCIATED WITH SEVERE RH ISOIMMUNIZATION. Am J Obstet Gynecol. 1964 May 1;89:41–45. doi: 10.1016/s0002-9378(16)35039-6. [DOI] [PubMed] [Google Scholar]
  47. Nakayama D. K., Glick P. L., Harrison M. R., Villa R. L., Noall R. Experimental pulmonary hypoplasia due to oligohydramnios and its reversal by relieving thoracic compression. J Pediatr Surg. 1983 Aug;18(4):347–353. doi: 10.1016/s0022-3468(83)80179-1. [DOI] [PubMed] [Google Scholar]
  48. Nakayama D. K., Harrison M. R., Chinn D. H., Callen P. W., Filly R. A., Golbus M. S., De Lorimier A. A. Prenatal diagnosis and natural history of the fetus with a congenital diaphragmatic hernia: initial clinical experience. J Pediatr Surg. 1985 Apr;20(2):118–124. doi: 10.1016/s0022-3468(85)80282-7. [DOI] [PubMed] [Google Scholar]
  49. Nakayama D. K., Harrison M. R., Seron-Ferre M., Villa R. L. Fetal surgery in the primate II. Uterine electromyographic response to operative procedures and pharmacologic agents. J Pediatr Surg. 1984 Aug;19(4):333–339. doi: 10.1016/s0022-3468(84)80248-1. [DOI] [PubMed] [Google Scholar]
  50. O'Rourke P. P., Vacanti J. P., Crone R. K., Fellows K., Lillehei C., Hougen T. J. Use of the postductal PaO2 as a predictor of pulmonary vascular hypoplasia in infants with congenital diaphragmatic hernia. J Pediatr Surg. 1988 Oct;23(10):904–907. doi: 10.1016/s0022-3468(88)80381-6. [DOI] [PubMed] [Google Scholar]
  51. Puri P., Gorman F. Lethal nonpulmonary anomalies associated with congenital diaphragmatic hernia: implications for early intrauterine surgery. J Pediatr Surg. 1984 Feb;19(1):29–32. doi: 10.1016/s0022-3468(84)80010-x. [DOI] [PubMed] [Google Scholar]
  52. Reid L. 1976 Edward B.D. Neuhauser lecture: the lung: growth and remodeling in health and disease. AJR Am J Roentgenol. 1977 Nov;129(5):777–788. doi: 10.2214/ajr.129.5.777. [DOI] [PubMed] [Google Scholar]
  53. Rodeck C. H., Fisk N. M., Fraser D. I., Nicolini U. Long-term in utero drainage of fetal hydrothorax. N Engl J Med. 1988 Oct 27;319(17):1135–1138. doi: 10.1056/NEJM198810273191706. [DOI] [PubMed] [Google Scholar]
  54. Saltzman D. H., Adzick N. S., Benacerraf B. R. Fetal cystic adenomatoid malformation of the lung: apparent improvement in utero. Obstet Gynecol. 1988 Jun;71(6 Pt 2):1000–1002. [PubMed] [Google Scholar]
  55. Soper R. T., Pringle K. C., Scofield J. C. Creation and repair of diaphragmatic hernia in the fetal lamb: techniques and survival. J Pediatr Surg. 1984 Feb;19(1):33–40. doi: 10.1016/s0022-3468(84)80011-1. [DOI] [PubMed] [Google Scholar]
  56. Taylor P. V., Scott J. S., Gerlis L. M., Esscher E., Scott O. Maternal antibodies against fetal cardiac antigens in congenital complete heart block. N Engl J Med. 1986 Sep 11;315(11):667–672. doi: 10.1056/NEJM198609113151103. [DOI] [PubMed] [Google Scholar]
  57. Wigglesworth J. S., Desai R., Guerrini P. Fetal lung hypoplasia: biochemical and structural variations and their possible significance. Arch Dis Child. 1981 Aug;56(8):606–615. doi: 10.1136/adc.56.8.606. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES