The ex utero intrapartum treatment procedure: looking back at the EXIT

Presented at the 34th Annual Meeting of the American Pediatric Surgical Association, Fort Lauderdale, Florida, May 25–28, 2003.
https://doi.org/10.1016/j.jpedsurg.2003.11.011Get rights and content

Abstract

Purpose

The ex utero intrapartum treatment (EXIT) procedure was developed originally for management of airway obstruction after fetal surgery, and indications have continued to expand for a variety of fetal anomalies. The authors review their single-institution experience with EXIT.

Methods

Retrospective review of all patients who underwent an EXIT procedure from 1993 to 2003 (n = 52) was performed. Variables evaluated include indication for EXIT, gender, gestational age at EXIT, birth weight, maternal blood loss, operative complications, operative time, and survival rate. Technique, personnel, and anesthesic management were reviewed.

Results

Long-term follow-up was available for all patients. Fifty-one of 52 patients were born alive; currently, 27 of 52 patients (52%) are alive. All deaths have been in patients with congenital diaphragmatic hernia. Forty-five patients underwent EXIT for reversal of tracheal occlusion for congenital diaphragmatic hernia. Of these patients, 30 underwent tracheal clip removal. Two patients had repair of tracheal injury from clipping at EXIT. Fifteen patients underwent bronchoscopy and tracheal balloon removal. Five patients underwent EXIT procedure for neck masses. Tracheostomy was performed in 3 of these patients. One patient was intubated successfully, and 1 patient underwent resection of the neck mass while on placental support. Two patients underwent EXIT procedure and tracheostomy for congenital high-airway obstruction syndrome. Average gestational age at delivery was 31.95 ± 2.55 weeks. Average birth weight was 1,895 ± 653 g. Average maternal blood loss was 970 ± 510 mL. Average operating time on placental support was 45 ± 25 minutes with a maximum of 150 minutes.

Conclusions

EXIT procedures can be performed with minimal maternal morbidity and with good outcomes. It is an excellent strategy for establishing an airway in a controlled manner, avoiding “crash” intubation or tracheostomy. Longer procedures on placental support allowing for definitive management of neck masses and airway obstruction have been realized. EXIT procedures have evolved from an adjunct to fetal surgery to a potentially life-saving procedure in fetuses with airway compromise at birth.

Section snippets

Description of procedure

The key to the successful outcome of EXIT procedures is orchestration of multiple personnel from varied disciplines, including pediatric surgery, obstetrics, radiology, neonatology, anesthesia, and nursing. Anesthetic considerations are critical. Preoperatively, indomethacin is prophylactically administered to the mother as a tocolytic. Most patients also undergo placement of a lumbar epidural catheter for intraoperative and postoperative pain relief. Induction of anesthesia is performed in the

Results

Indications for EXIT procedure have included reversal of tracheal occlusion for CDH, neck mass, and CHAOS. To date, 52 EXIT procedures have been performed at UCSF. Forty-five of these were performed for reversal of tracheal occlusion. Thirty patients underwent tracheal clip removal. Two patients required repair of tracheal injury from clipping at EXIT. Fifteen patients underwent bronchoscopy and tracheal balloon removal. The preponderance of EXIT procedures for CDH was caused by the fact that

Reversal of tracheal occlusion

The EXIT procedure was designed originally to allow removal of tracheal clips that were placed in utero to treat fetuses with severe CDH. In these patients, placental circulation allowed time for removal of clips, fetal bronchoscopy, endotracheal intubation, and surfactant administration.7 Currently, tracheal occlusion is performed via fetoscopy using an intratracheal detachable balloon. At EXIT, fetal bronchoscopy is performed, the balloon is pierced and suctioned out through the bronchoscope,

References (17)

There are more references available in the full text version of this article.

Cited by (0)

View full text
Copyright © 2004 Elsevier Inc. All rights reserved.