Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia in Australia and New Zealand: are we willing, able, both or neither?

AIM: An estimated 140 pregnancies are diagnosed with congenital diaphragmatic hernia (CDH) in Australia and New Zealand each year, with these fetuses having a less than even chance of 1-year survival. Fetoscopic endoluminal tracheal occlusion (FETO) is a relatively new technique that offers a prenatal interventional strategy for selective cases of CDH. This is not routinely offered in Australia or New Zealand. The aim of this systematic review is to critically appraise controlled clinical trials investigating the role of FETO in moderate and severe isolated CDH and explore whether this treatment is justified within our region. METHODS: A systematic literature search of multiple electronic databases was undertaken, with restrictions to human subjects and controlled clinical trials. RESULTS: Nine relevant studies were identified. No current evidence was found in favour of FETO for moderate severity CDH. For severe CDH, the most recent evidence demonstrates significantly improved survival following FETO performed using contemporary percutaneous minimally invasive techniques. Optimum timing for balloon insertion, removal and occlusion duration remains conjectural. Substantial variation in survival rates observed among control groups highlights the impact of post-natal care in prenatally diagnosed CDH. CONCLUSION: Until recently, evidence to support a role for FETO in prenatal CDH management was weak. Recently reported and ongoing controlled trials give cause for optimism, with improved FETO safety and increased survival reported for severe CDH cases. Should Australasia embrace FETO for selected CDH cases, a co-ordinated, evidence-informed service should be established under the guidance of experienced international partnerships.

Serum metal levels after minimally invasive repair of pectus excavatum.

BACKGROUND: Metal implants may wear and corrode, resulting in systemic dissemination of metallic debris that is measurable in serum. Concern exists regarding adverse health effects related to implant-derived debris. Minimally invasive repair of pectus excavatum (MIRPE) is a popular technique in which a stainless steel substernal bar is implanted to achieve deformity correction. Serum metal levels have not previously been investigated after MIRPE. METHODS: Serum chromium, molybdenum, and nickel levels were measured in this cross-sectional study of 11 children implanted with pectus bars after MIRPE. Samples were analyzed using high-resolution inductively coupled plasma mass spectrometry. RESULTS: Median serum chromium and nickel values were elevated 3.3-fold (P = .0003) and 2.3-fold (P = .25), respectively, compared with age-matched controls. Serum chromium and nickel levels were abnormally elevated in 6 (55%) of 11 and 5 (45%) of 11, respectively. In patients whom postexplantation metal levels were measured, previously elevated levels were lowered. Serum chromium levels in children after MIRPE are comparable with adult cohorts with hip arthroplasty implants measured 1-year postoperatively. No acute metal toxicity was observed. CONCLUSIONS: Abnormally elevated levels of serum metal levels are measurable in children implanted with pectus bars. These findings warrant further investigation to assess the biocompatibility of this surgical implant in children.

Fournier's gangrene in a child with congenital genitourinary anomalies.

Fournier's gangrene is a rare urologic emergency in childhood that requires prompt diagnosis to deliver definitive and supportive care. Host susceptibility risk factors differ between adult and pediatric age groups with affected children usually otherwise systemically healthy. We present a case of Fournier's gangrene in a 2-year-old, from a genitourinary source of sepsis secondary to previously unreported genitourinary anatomical anomalies of congenital buried penis and hypospadias. Illustrative applied anatomy identifies the pathogenesis of this case, aiding recognition and understanding of this rapidly progressive and destructive pathology.

Preoperative use of ultrasonography to localize an ingested foreign body.

We report a 9-year-old boy who had swallowed a small dressmaker's pin during an art & craft class. Confirmation of ingestion of the pin and its passage through the gut was achieved with abdominal radiography. When the pin had not passed after 8 days, and with increasing concern about the likelihood of perforation, US was used to locate its exact position to allow surgical removal. This case report illustrates the unique use of US to reveal the intraappendiceal location of an ingested foreign body, facilitating its surgical removal.