Driver-Activated VIDeoscopic Surgery: An Innovation Journey from Idea to Industry-Ready.

Introduction: Innovation is not a straightforward path. While surgeons are intimately familiar with clinical problems and often devise clever solutions to address them, the journey from idea to a marketable product is opaque. We describe our experience developing a novel video navigation system to help streamline collaboration and enhance surgeon control of their video image in minimally invasive surgery. Materials and Methods: Our idea began with recognizing the primary clinical challenge: "one bad image for all" in laparoscopic surgery, when the least experienced member of the surgical team is often expected to hold the camera. Results: Through multiple iterations and pivots, including hardware-based solutions like head-mounted displays and individualized monitors, we arrived at a hardware-agnostic software algorithm to process laparoscopic video for real-time image navigation. As we explain why, how, and when to pivot, we provide brief overviews of protecting intellectual property and financing innovation. Finally, collaboration with professional societies, such as the International Pediatric Endosurgery Group, provides fertile testing grounds for new ideas. Conclusion: Our experience may help future surgeon-innovators go from their ideas to industry-ready.

Postnatal Myelomeningocele Repair in the United States: Rates and Disparities Before and After the Management of Myelomeningocele Study Trial.

BACKGROUND AND OBJECTIVES: Evolving technologies have influenced the practice of myelomeningocele repair (MMCr), including mandatory folic acid fortification, advances in prenatal diagnosis, and the 2011 Management of Myelomeningocele Study (MOMS) trial demonstrating benefits of fetal over postnatal MMCr in select individuals. Postnatal MMCr continues to be performed, especially for those with limitations in prenatal diagnosis, health care access, anatomy, or personal preference. A comprehensive, updated national perspective on the trajectory of postnatal MMCr volumes and patient disparities is absent. We characterize national trends in postnatal MMCr rates before and after the MOMS trial publication (2000-2010 vs 2011-2019) and examine whether historical disparities persist. METHODS: This retrospective, cross-sectional analysis queried Nationwide Inpatient Sample data for postnatal MMCr admissions. Annual and race/ethnicity-specific rates were calculated using national birth registry data. Time series analysis assessed for trends relative to the year 2011. Patient, admission, and outcome characteristics were compared between pre-MOMS and post-MOMS cohorts. RESULTS: Between 2000 and 2019, 12 426 postnatal MMCr operations were estimated nationwide. After 2011, there was a gradual, incremental decline in the annual rate of postnatal MMCr. Post-MOMS admissions were increasingly associated with Medicaid insurance and the lowest income quartiles, as well as increased risk indices, length of stay, and hospital charges. By 2019, race/ethnicity-adjusted rates seemed to converge. The mortality rate remained low in both eras, and there was a lower rate of same-admission shunting post-MOMS. CONCLUSION: National rates of postnatal MMCr gradually declined in the post-MOMS era. Medicaid and low-income patients comprise an increasing majority of MMCr patients post-MOMS, whereas historical race/ethnicity-specific disparities are improving. Now more than ever, we must address disparities in the care of MMC patients before and after birth.

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey.

INTRODUCTION: Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. METHODS: After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. RESULTS: We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1-5 EXIT consultations per year and 17/40 (42.5%) centers performed 1-5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. CONCLUSION: This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

BACKGROUND: Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. METHODS: The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. RESULTS: Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. CONCLUSION: Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Care Levels for Fetal Therapy Centers.

Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity, with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level I fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture but that would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level II center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level III therapy center should offer the full range of fetal interventions (including open fetal surgery) and be able manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.

Infected Urachal Cyst Masquerading as Acute Appendicitis on Point-of-care Ultrasound.

CASE PRESENTATION: A seven-year-old male presented to the pediatric emergency department with one day of abdominal pain. His physical exam was significant for rebound, guarding, and tenderness in the right lower quadrant, and his labs demonstrated a leukocytosis. Both a point-of-care ultrasound and radiology-performed ultrasound were concerning for acute appendicitis with a periappendiceal abscess, but on emergent laparoscopy the patient was found to have an infected urachal cyst. DISCUSSION: Infected urachal remnants are a rare but important cause of pediatric abdominal pain. In this case, inflammation surrounding the patient's midline urachal cyst triggered a serositis that involved the appendix and pulled the cyst to the right. This created a clinical and radiologic presentation similar to appendicitis. This atypical presentation of an already rare anomaly highlights the importance of maintaining a broad differential during the work-up of pediatric abdominal pain.

Successful Anesthesia Management of Postoperative Maternal Pulmonary Edema and Uterine Hyperactivity following Open Fetal Myelomeningocele Repair.

Effective tocolysis is essential after fetal myelomeningocele repair and is associated with the development of pulmonary edema. The increased uterine activity in the immediate postoperative period is commonly treated with magnesium sulfate. However, other tocolytic agents such as nitroglycerine, nifedipine, indomethacin, terbutaline, and atosiban (outside the US) have also been used to combat uterine contractility. The ideal tocolytic regimen which balances the risks and benefits of in-utero surgery has yet to be determined. In this case report, we describe a unique case of fetal myelomeningocele repair complicated by maternal pulmonary edema and increased uterine activity resistant to magnesium sulfate therapy.

Combination of volume-rendering 3D surface modeling and medical illustration to capture the living fetus.

OBJECTIVE: A good medical illustration renders essential aspects of a procedure or condition faithfully, yet idealizes it enough to make it widely applicable. Unfortunately, the live fetus is generally hidden from sight, and illustrating it relies either on autopsy material or manipulated newborn images. High-definition volume rendering of diagnostic imaging data can represent hidden conditions with an almost lifelike realism but is limited by the resolution and artifacts of the data capture. We have combined both approaches to enhance the accuracy and didactic value of illustrations of fetal conditions. METHODS: Three examples, of increasing complexity, are presented to demonstrate the creation of medical illustrations of the fetus based on semiautomatic computerized posthoc manipulation of diagnostic images. RESULTS: The end product utilizes the diagnostic accuracy of ultrasound and magnetic resonance imaging of the fetuses and the spatial manipulation of 3D models to create a lifelike, accurate and informative image of the fetal anomalies. CONCLUSION: Volume-rendering and 3D surface modeling can be combined with medical illustration to create realistic and informative images of the developing fetus, using a level of detail that is tailored to the intended audience.

Minimizing Individual Learning Curves in a Mature Endoscopic Fetal Surgery Program.

INTRODUCTION: Twin-to-twin transfusion syndrome affects monochorionic twin pregnancies and can result in fetal death. Endoscopic laser treatment remains a relatively infrequent procedure for this condition. This presents difficulties for maintaining proficiency and for training new personnel. OBJECTIVE: The dual mentoring program at our institution allows for continuous mentoring of new providers. We hypothesize that this approach stabilizes program proficiency despite the addition of new practitioners. METHODS: Query of the fetal treatment program database returned 146 cases of laser ablation between 2000 and 2019. Patient and pregnancy characteristics as well as operative time and outcomes were recorded. The learning curve-cumulative summation method and rolling averages were used to analyze outcomes. RESULTS: Overall survival was 69%, and survival of at least 1 twin was 89%. Mean operative time was 53.6 ± 20.9 min. Overall twin survival stabilized after the first 40 cases. Rolling averages for operative time decreased from 71 to 49 min for the most recent cases. These results were not affected by the introduction of new surgeons. CONCLUSIONS: Creative mentoring can maintain stable overall program outcomes despite changes in team composition. This training approach may be applicable to other rare procedures in fetal surgery.

Towards Placental Surface Vasculature Exploration in Virtual Reality.

We present a case study evaluating the potential for interactively identifying placental surface blood vessels using magnetic resonance imaging (MRI) scans in virtual reality (VR) environments. We visualized the MRI data using direct volume rendering in a high-fidelity CAVE-like VR system, allowing medical professionals to identify relevant placental vessels directly from volume visualizations in the VR system, without prior vessel segmentation. Participants were able to trace most of the observable vascular structure, and consistently identified blood vessels down to diameters of 1 mm, an important requirement in diagnosing vascular diseases. Qualitative feedback from our participants suggests that our VR visualization is easy to understand and allows intuitive data exploration, but complex user interactions remained a challenge. Using these observations, we discuss implications and requirements for spatial tracing user interaction methods in VR environments. We believe that VR MRI visualizations are the next step towards effective surgery planning for prenatal diseases.

An Open Fetal Myelomeningocele Repair With Incorporation of a Skin Allograft.

BACKGROUND: Myelomeningocele (MMC) is the most frequent congenital abnormality of the central nervous system that leads to significant physical disabilities. Historically, treatment involved postnatal repair with management of the hydrocephalus with ventricular shunting. Animal and early human studies demonstrated the feasibility of fetal closure. The benefit of in-utero closure was debated until the results of the prospective randomized multicenter Management of Myelomeningocele Study (MOMS trial) were published, demonstrating a decreased need for shunting, reversal of hindbrain herniation, and better neurologic function in the prenatal repair group compared to postnatal repair. Fetal MMC closure has become a standard of care option for prenatally diagnosed spina bifida. The size of the spinal defect may require modification of the classic surgical technique requiring patching. CASE: This report describes a case of open fetal myelomeningocele repair, which required incorporation of a skin allograft. CONCLUSION: Large myelomeningocele defects may be successfully repaired with utilization of a skin allograft.

Fetoscopy-Assisted Percutaneous Decompression of the Distal Trachea and Lungs Reverses Hydrops Fetalis and Fetal Distress in a Fetus with Laryngeal Atresia.

We present a case of prenatal hydrops secondary to congenital high airway obstruction syndrome (CHAOS) that was treated with fetoscopy-assisted needle decompression. A 22-year-old G3P2 woman presented after a 21-week ultrasound demonstrated CHAOS. The fetus developed hydrops at 25 weeks, characterized by abdominal ascites, pericardial effusion, and scalp edema. Fetal MRI showed complete obstruction of the glottis and subglottic airway, suggestive of laryngeal atresia. At 27 weeks, due to the progression of the hydrops, operative fetoscopy was proposed and performed. Fetal laryngoscopy confirmed fusion of the vocal cords and laryngeal atresia. The atretic segment was a solid cartilaginous block, preventing intubation. Using the fetoscope to stabilize the fetal head and neck, we performed ultrasound-guided percutaneous needle drainage of the cervical trachea through the anterior fetal neck. We removed 17 mL of viscous fluid from the lower trachea, resulting in immediate lung decompression. Two weeks later, ultrasound confirmed hydrops resolution. The patient was delivered and tracheostomy performed at 30 weeks via an ex utero intrapartum treatment (EXIT) procedure after progression of preterm labor. At 27 days of life, the infant was stable on minimal ventilator support. To our knowledge, this is the first successful report of an ultrasound-guided percutaneous tracheal decompression through the anterior neck of a fetus with CHAOS secondary to laryngeal atresia.

Proximity to the Diaphragm Predicts the Presence of Rhabdomyomatous Dysplasia in Congenital Pulmonary Airway Malformations.

INTRODUCTION: Rhabdomyomatous dysplasia (RD) is a pathologic finding in CPAMs that was incorrectly attributed to their malignant potential. The increasing recognition of extrathoracic (intradiaphragmatic and intraabdominal) congenital pulmonary airway malformations (CPAMs) offers a clue to the origin of RD. We hypothesize that the presence of RD is related to the CPAM's anatomic location. MATERIALS AND METHODS: Retrospective review was performed of all children who underwent resection of a CPAM during a 10-year period. The age at the time of operation, location of the CPAM, and pathologic findings were collected. Peridiaphragmatic location was defined as within the inferior pulmonary ligament, deep to the diaphragmatic portion of the parietal pleura ("intradiaphragmatic") or adjacent to the abdominal side of the diaphragm. Statistical analysis was performed using Fisher's exact test for 2 × 2 tables. RESULTS: Twenty-six patients with CPAM were identified. Preoperative imaging was performed by computed tomography (CT) scan (16/26), ultrasound (5/26), magnetic resonance imaging (MRI) (1/26), and chest radiograph (4/26). The median age at resection was 15 months. Of these, 16 were pure cystic adenomatoid malformations, 4 were extralobar sequestrations, 4 were intralobar sequestrations, and 2 were bronchogenic cysts. Nine lesions were peridiaphragmatic with four being intradiaphragmatic (44%). Eight of the nine resected peridiaphragmatic lesions contained histologic evidence of rhabdomyomatous changes (89%, confidence interval [CI] 52-99%). None of the other lesions contained RD (CI 0-19%, p < 0.001). CONCLUSION: RD was seen exclusively, and in virtually all peridiaphragmatic CPAMs. While the exact significance of RD remains unclear, it may represent incorporation of striated muscle tissue associated with the developing diaphragm.

Can time to healing in pediatric blunt splenic injury be predicted?

BACKGROUND: Current consensus guidelines do not recommend routine follow-up imaging for blunt splenic injury (BSI) in children. However, repeat imaging is recommended based on persistent symptoms. Wide variation of practice continues to exist among surgeons. By defining the natural evolution of BSI, we sought to identify patients at higher risk for delayed healing who could benefit from outpatient imaging. METHODS: A retrospective review of all children with BSI at a Level 1 Pediatric Trauma Center was completed. Grade of injury, hospital course, laboratory values and follow-up imaging results were obtained. Injured spleens were classified as 'healed', 'healing' (with echogenic scar), or 'non-healing' with persistence of parenchymal abnormalities. RESULTS: Between 2000 and 2014, 222 patients with BSI were identified. Seven patients (3%) underwent immediate splenectomy. Packed red blood cell transfusion was required in 13 (6%) of the 222 patients, and 3 (2%) of 145 with isolated splenic injuries. Seventy-one percent of patients underwent additional imaging 2-74 weeks post-injury. A receiver operating characteristics (ROC) curve was used to establish the relationship between sensitivity and specificity of capturing non-healing spleens over time. Optimal timing for post-injury imaging for grades I-II was 7-8 weeks; healing of higher-grade injuries could not accurately be predicted. CONCLUSIONS: If return to full physical activity, in particular contact sports, is contingent upon documented healing of the splenic parenchyma after blunt trauma in the pediatric population, follow-up imaging for low-grade injuries is best obtained around 7-8 weeks. No such recommendations can be made for high-grade splenic injuries, as the exact time to healing cannot be predicted based on initial data. LEVEL OF EVIDENCE: IV. Diagnostic test.

Expert surgical consensus for prenatal counseling using the Delphi method.

BACKGROUND: Pediatric surgeons frequently offer prenatal consultation for congenital pulmonary airway malformation (CPAM) and congenital diaphragmatic hernia (CDH); however, there is no evidence-based consensus to guide prenatal decision making and counseling for these conditions. Eliciting feedback from experts is integral to defining best practice regarding prenatal counseling and intervention. METHODS: A Delphi consensus process was undertaken using a panel of pediatric surgeons identified as experts in fetal therapy to address current limitations. Areas of discrepancy in the literature on CPAM and CDH were identified and used to generate a list of content and intervention questions. Experts were invited to participate in an online Delphi survey. Items that did not reach first-round consensus were broken down into additional questions, and consensus was achieved in the second round. RESULTS: Fifty-four surgeons (69%) responded to at least one of the two survey rounds. During round one, consensus was reached on 54 of 89 survey questions (61%), and 45 new questions were developed. During round two, consensus was reached on 53 of 60 survey questions (88%). CONCLUSIONS: We determined expert consensus to establish guidelines regarding perinatal management of CPAM and CDH. Our results can help educate pediatric surgeons participating in perinatal care of these patients. LEVEL OF EVIDENCE: V.

Understanding the Parent Perspective on Prenatal Consultation for Fetuses with Congenital Anomalies.

INTRODUCTION: An increasing number of congenital anomalies are diagnosed prenatally. Understanding the implications of these diagnoses on the life of their child is critical for parents, and the surgical consultation is often the primary venue for this education. Little is known about the parent perspective on prenatal consultation. METHODS: Parents undergoing prenatal consultation were identified and in-depth interviews were conducted to explore the following: understanding of the diagnosis, preparedness for postnatal course, and suggestions for improvement. Qualitative analysis was performed to generate themes. RESULTS: Twelve interviews with 16 family members were performed, encompassing a variety of prenatal diagnoses and outcomes. Near-ubiquitous emotions included fear, anxiety, and self-blame. Surgical consultation relieved anxiety for some, but the uncertain outcome increased anxiety in others. Most were satisfied with the information communicated during the encounter; however, those with worse outcomes wished they were better warned. Parents emphasized the importance of support systems and educational materials. CONCLUSIONS: Parents appreciate learning about all potential outcomes for the fetus, even though this generates anxiety. Surgeons should discuss the range of possible outcomes while acknowledging that uncertainty leads to anxiety. It is essential to incorporate the parent perspective when conducting prenatal consultation and training pediatric surgeons in this important practice.

Early Predictors of Abscess Development after Perforated Pediatric Appendicitis.

BACKGROUND: Approximately one-third of children with appendicitis present with advanced disease or perforation. Whereas this increases the risk for post-operative complications and re-admission, it is not yet possible to predict early on who will develop an abdominal abscess. We sought to identify specific risk factors for this complication, in an attempt to streamline post-operative care. PATIENTS AND METHODS: We reviewed the records of all cases of perforated appendicitis over a 12-month period at a tertiary children's hospital. All patients who developed an abscess despite treatment minimum of seven days of antibiotic therapy were identified. Patients who presented or were re-admitted with an abscess were excluded from analysis. Records were reviewed for demographics, laboratory results, progression of oral intake, and vital signs. RESULTS: Of 273 patients with appendicitis, we identified 59 cases of perforated appendicitis. Fifteen patients were excluded. Eight of the remaining 44 patients (18.2%) developed an abscess during their initial admission. Their mean length of stay was longer than that of patients without an abscess (13.4 ± 7.1 vs. 6.9 ± 1.9 d, p < 0.0001). Gender, leukocytosis, or diarrhea at presentation, maximum temperature on post-operative day 3, and maximum heart rate on post-operative day 3 were not statistically different. Diet progression was different between the two groups: none of the 21 patients who were tolerating a regular diet by post-operative day 3 developed an abscess, compared with 8 of the 23 patients who were not yet eating a regular diet on post-operative day 3 (p < 0.01). Late leukocytosis also correlated with the presence of an abscess: 7 of the 8 patients with an abscess had persistent leukocytosis at days 5 through 7, compared with 3 of 31 patients without abscess (p < 0.05). An ultrasound was obtained for these 3 patients and proved normal. CONCLUSIONS: Tolerating a regular diet three days after appendectomy for perforated appendicitis decreased the likelihood of a post-operative abscess. No other parameter was predictive of this complication early in the post-operative period. If confirmed in a larger prospective study, this finding may help decrease the length of stay for low-risk patients, and identify abscesses in high-risk patients in a timely fashion.

Clinicoplacental correlates of amniocyte vacuolization in association with gastroschisis.

INTRODUCTION/OBJECTIVES: Gastroschisis has been associated with a characteristic type of amniocyte vacuolization. In this study, we determined the frequency and clinicoplacental correlates of this apparently unique alteration of the amniotic epithelium. METHODS: We performed a retrospective clinicopathologic analysis of 74 consecutive cases of isolated gastroschisis. Placental membrane sections were reviewed for presence and extent of amniocyte vacuolization, and immunostained for adipophilin, a lipid droplet-associated protein. Controls included placentas from pregnancies complicated by omphalocele, meconium exposure or chorioamnionitis. RESULTS: A distinct type of diffuse, fine and homogeneous amniocyte vacuolization was present in 15/74 (20%), absent in 41/74 (55%), and equivocal in 18/74 (24%) gastroschisis cases. Similar amniocyte vacuolization was seen in only 1/30 meconium-stained controls, and in none of the other non-gastroschisis controls. Adipophilin immunostaining enhanced the visualization of the cytoplasmic vacuoles and confirmed their lipid nature. Compared to gastroschisis cases without such vacuolization, cases with typical, extensive amniocyte vacuolization had a tendency to lower birth weight percentile (26% versus 40%; P < 0.08), a significantly lower fetal:placental weight ratio (4.72 versus 5.51; P < 0.01), and a significantly higher frequency of associated meconium exposure (14/15 versus 15/41, P < 0.001) and/or chorioamnionitis (8/15 versus 6/41; P < 0.01). The length of hospital stay was equivalent for infants with or without amniocyte vacuolization. CONCLUSION: Diffuse, fine and homogeneous lipid droplet accumulation in amniocytes is highly characteristic of gastroschisis, but only seen in about 20% of cases. The functional implications of excessive lipid accumulation, and the exact mechanisms underlying the strong association between amniocyte lipid accumulation and chorioamnionitis/meconium exposure in a subset of gastroschisis cases remain undetermined.

Florid Intussusceptive-like Microvascular Dysangiogenesis in a Preterm Lung.

The cellular mechanisms underlying the microvascular dysangiogenesis of bronchopulmonary dysplasia (chronic lung disease of the newborn) remain largely undetermined. We report unusual pulmonary vascular findings in a 27-week-gestation male newborn who died on the second day of life from intractable respiratory failure, following a pregnancy complicated by prolonged membrane rupture and persistent severe oligohydramnios. As expected, postmortem examination revealed pulmonary hypoplasia (lung/body weight ratio: 2.23%; 10th percentile for 27 weeks: 2.59%). In addition, lung microscopy revealed complex networks of non-sprouting, tortuous, and bulbously dilated capillaries, randomly distributed in widened airspace septa. Anti-smooth muscle actin immunohistochemistry demonstrated immunoreactive central densities within capillary lumina, suggestive of intravascular pillar formation. The plexus-forming, non-sprouting type of angiogenesis and apparent transluminal pillar formation are consistent with intussusceptive ("longitudinal splitting") angiogenesis. In concordance with previous observations made in human fetal lung xenografts, these findings support the notion that human postcanalicular lungs have the capacity to switch from sprouting to non-sprouting, intussusceptive-like angiogenesis, possibly representing an adaptive response activated by hemodynamic flow alterations and/or hypoxia. The possible relationship between the intussusceptive-like vascular changes observed in this case and the microvascular dysangiogenesis characteristic of bronchopulmonary dysplasia remains to be determined.

Fetal Treatment 2017: The Evolution of Fetal Therapy Centers - A Joint Opinion from the International Fetal Medicine and Surgical Society (IFMSS) and the North American Fetal Therapy Network (NAFTNet).

More than 3 decades ago, a small group of physicians and other practitioners active in what they called "fetal treatment" authored an opinion piece outlining the current status and future challenges anticipated in the field. Many advances in maternal, neonatal, and perinatal care and diagnostic and therapeutic modalities have been made in the intervening years, yet a thoughtful reassessment of the basic tenets put forth in 1982 has not been published. The present effort will aim to provide a framework for contemporary redefinition of the field of fetal treatment, with a brief discussion of the necessary minimum expertise and systems base for the provision of different types of interventions for both the mother and fetus. Our goal will be to present an opinion that encourages the advancement of thoughtful practice, ensuring that current and future patients have realistic access to centers with a range of fetal therapies with appropriate expertise, experience, and subspecialty and institutional support while remaining focused on excellence in care, collaborative scientific discovery, and maternal autonomy and safety.