Journal of Pediatric Surgery Article Highlights: April 2022

Published: 2022-07-12

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Gerardo — host
Brittany Levy — host
Christina Theodoro — guest
Todd Ponsky — guest
Natalie Lopian — guest
Speaker 6

Chapters

0:03Introduction and Wilms Tumor Article — Hosts introduce the podcast and first article on Wilms tumor with intravascular extension from the SIOP study, discussing surgical management and outcomes based on completeness of tumor thrombus resection.
2:10Fetal Myelomeningocele Repair with Stem Cells — Discussion of UC Davis study using clinical-grade placental mesenchymal stromal cells on extracellular matrix for fetal myelomeningocele repair in ovine model, showing improved motor function outcomes.
4:37Fetal Surgery Subspecialization Survey — Review of survey examining fetal surgery practice patterns among APSA members, revealing training disparities and questions about standardization of fetal care centers.

Key claims

0:58The SIOP study examined children with Wilms tumor where tumor thrombus extended into the renal vein and provided outcomes for when complete resection was successful or unsuccessful — Brittany Levy
1:14Wilms tumor has been a great success story for pediatric surgery and pediatric oncology — Brittany Levy
1:54If half of Wilms tumor patients get complete tumor removal and half don't, and there is an outcome difference, then surgeons should still try hard to remove all of it — Brittany Levy
2:54The UC Davis study is a pivotal study in obtaining FDA approval for use of clinical grade stem cells in fetal myelomeningocele repair — Christina Theodoro
3:03The study represents being one step closer to first in human clinical trial for stem cell use in myelomeningocele repair — Brittany Levy
3:27In the ovine model, the extracellular matrix patch with placental stem cells is placed with cells facing the spinal cord in direct contact, then skin is closed and the fetus continues gestation until term — Christina Theodoro
3:54Lambs repaired with clinical grade placental stem cells have significantly improved motor function compared to lambs that did not receive stem cells — Christina Theodoro
4:08There is already shown benefit of repairing myelomeningocele in utero, and adding mesenchymal stromal cells provides even larger benefit in chance of ambulation — Todd Ponsky
4:58The fetal surgery survey was of non-trainee surgeons within the American Pediatric Surgical Association to gauge practice patterns in fetal surgery across the country — Rod Gerardo
5:13Only 4% of self-identified fetal surgery specialists reported receiving formal training in fetal surgery — Natalie Lopian
5:37Many survey respondents reported receiving fetal training during pediatric surgery fellowship, yet when asked differently, many responded they didn't have exposure to fetal surgery during fellowship — Brittany Levy
5:54Fetal surgery is a frontier for pediatric surgery and the survey provides a reality check on how to develop a treatment which remains rare and often experimental — Brittany Levy
6:38In an emerging field like fetal surgery, there are disparities in what is happening at different centers — Todd Ponsky
6:46There is value in having some centers with dedicated teams focusing on fetal care even if they don't do interventions — Todd Ponsky
7:04The survey results suggest people would not be interested in subspecialization for fetal surgery in America for a variety of reasons — Brittany Levy
7:26The study was not designed to link subspecialization of fetal surgery to outcomes and wasn't designed to provide a clear definition of a fetal surgery center — Natalie Lopian

Open questions

What constitutes a fetal care center on paper and what services should they provide?
Who should constitute the complement of the fetal surgery team?
Should fetal surgery exposure be a requirement during pediatric surgery fellowship training?
Will fetal surgery centers become the primary training ground for fetal surgeons as the field expands?
What are the outcomes associated with subspecialization in fetal surgery?
What is the clear definition of a fetal surgery center?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Fetal Surgery as a Subspecialty: Training Gaps in an Emerging Field

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why Fetal Surgery Exists as a Discipline

Fetal surgery emerged to address structural anomalies that, if left until birth, result in irreversible organ damage or death 5:54. Myelomeningocele — spinal cord exposed through an open neural tube defect — exemplifies the problem: ongoing amniotic fluid exposure throughout gestation causes progressive neurologic injury 5:54. In utero repair limits that exposure, improving motor outcomes compared to postnatal closure 5:54. The field remains small because the conditions amenable to fetal intervention are rare, the technical demands are extreme, and many interventions remain investigational 5:54.

The Core Clinical Problem

A survey of American Pediatric Surgical Association members who self-identified as fetal surgery specialists found that only 4% reported receiving formal training in fetal surgery 5:13. This creates a paradox: surgeons are performing highly specialized, often experimental procedures without standardized preparation 5:13. The survey revealed internal contradictions in how respondents described their own training — many reported receiving fetal surgery exposure during pediatric surgery fellowship when asked one way, but denied such exposure when the question was framed differently 5:37. This suggests both ambiguity in what constitutes "training" and variability in what fellows actually encounter 5:37.

How the Field Currently Operates

Fetal surgery practice in North America exists on a spectrum 5:54. Some centers perform open fetal interventions — hysterotomy, fetal exposure, repair, uterine closure — for conditions like myelomeningocele 5:54. Others focus on fetoscopic techniques or percutaneous procedures 5:54. Still others provide dedicated fetal care teams that counsel families, coordinate imaging, and manage high-risk pregnancies without performing interventions themselves 6:46. One discussant noted value in this last model: centers that build expertise in fetal diagnosis and perinatal planning even when they refer cases elsewhere for surgery 6:46.

The myelomeningocele repair technique discussed illustrates the technical complexity 3:27. After hysterotomy and fetal positioning, the surgeon re-exposes the spinal cord, identifies the defect, and places an extracellular matrix patch with placental mesenchymal stromal cells oriented so the cells contact the neural tissue directly 3:27. The fetal skin is then closed and the fetus returned to the uterus to continue gestation to term 3:27. A UC Davis study in an ovine model demonstrated that lambs repaired with clinical-grade placental stem cells showed significantly improved motor function compared to those repaired without stem cells 3:54. This builds on prior evidence that in utero repair itself improves outcomes; adding mesenchymal stromal cells appears to further increase the chance of ambulation 4:08. The work represents a pivotal step toward FDA approval for clinical-grade stem cell use in human fetal myelomeningocele repair 2:54 and moves the field closer to first-in-human trials 3:03.

The Wilms tumor discussion, though not fetal surgery, illustrates a related principle: when a subgroup of patients does poorly with standard treatment, targeted intervention may improve outcomes 0:58. A SIOP study examined children with Wilms tumor and intravascular extension into the renal vein, comparing outcomes when complete resection of the tumor thrombus was achieved versus when it was not 0:58. The implication: if complete resection produces better outcomes, surgeons should prioritize achieving it despite technical difficulty 1:54. The same logic applies in fetal surgery — if in utero intervention prevents irreversible injury, the technical challenge is justified 5:54.

Where Practice Remains Contested

The survey results highlight genuine uncertainty about how fetal surgery should develop as a subspecialty 5:13. One discussant interpreted the findings as suggesting limited interest in formal subspecialization within the United States, citing "a variety of reasons" 7:04. Another framed the disparities in training and practice patterns as expected in an emerging field 6:38. The study was not designed to link subspecialization to outcomes, nor did it establish a clear definition of what constitutes a fetal surgery center 7:26. Those questions remain open 7:26.

The training pathway is undefined 5:13. Should fetal surgery require a dedicated fellowship after pediatric surgery residency 5:13? Should all pediatric surgery fellows receive structured fetal surgery exposure 5:37? Should the field consolidate into a small number of high-volume centers, or should regional centers maintain fetal care teams even if they refer complex cases 6:46? The survey provides a reality check on these questions but does not resolve them 5:54.

When to Involve a Fetal Surgery Team

For a referring obstetrician or maternal-fetal medicine specialist, the threshold for consultation is any structural fetal anomaly that might benefit from in utero intervention or that requires coordinated perinatal planning 5:54. Myelomeningocele, congenital diaphragmatic hernia, sacrococcygeal teratoma, twin-twin transfusion syndrome, and certain thoracic or urologic malformations fall into this category 5:54. Timing matters — many interventions have gestational age windows 5:54. Even when intervention is not indicated, fetal surgery centers often provide value in coordinating delivery planning, neonatal surgery readiness, and family counseling 6:46. The discussion did not specify referral criteria or timing triggers, reflecting the field's lack of standardization 7:26.

Takeaways from this story

Only 4% of self-identified fetal surgery specialists received formal training, revealing a training gap in this emerging subspecialty.
Placental stem cells on extracellular matrix improved motor function in fetal myelomeningocele repair in ovine models, advancing toward human trials.
Fetal surgery centers provide value even without performing interventions, through coordinated perinatal planning and family counseling.
The field lacks consensus on subspecialization structure, training requirements, and what defines a fetal surgery center.

Advancing Pediatric Surgery Through Wilms Tumor Resection, Stem Cell Therapy, and Subspecialty Development

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

This discussion traces three parallel advances in pediatric surgery — each illustrating how the field refines itself by identifying gaps in success, testing biological interventions, and confronting the structural realities of emerging subspecialties.

Complete resection matters when outcomes diverge

Wilms tumor represents one of pediatric oncology's success stories 1:14, but success creates its own teaching problem: how do you improve when most patients already do well? The answer lies in subgroup analysis. The SIOP study examined children with tumor thrombus extending into the renal vein and compared outcomes when complete resection was achieved versus when it was not 0:58. The logic is straightforward — if half the patients get complete removal and half don't, and there's an outcome difference, then surgeons should continue prioritizing complete resection despite technical difficulty 1:54. This is not about chasing perfection for its own sake; it's about establishing whether the extra operative effort translates to survival benefit. When it does, the technical challenge becomes justified.

Stem cell augmentation builds on proven fetal repair

The UC Davis ovine study demonstrates how to advance an already beneficial intervention 2:54. Fetal myelomeningocele repair has established benefit; the question is whether adding mesenchymal stromal cells improves outcomes further 4:08. The technique is precise: expose the fetal back, re-expose the spinal cord, identify the defect, place an extracellular matrix patch with placental stem cells facing the spinal cord in direct contact, close the skin, and return the fetus to the uterus for continued gestation 3:27. Lambs repaired with clinical-grade placental stem cells showed significantly improved motor function compared to those without stem cells 3:54. This represents incremental science done correctly — take an intervention with known benefit, add a biologically plausible enhancement, and measure whether the enhancement delivers. The study positions the field one step closer to first-in-human clinical trials 3:03, which is the appropriate next move after demonstrating efficacy in a large animal model.

Training infrastructure lags behind clinical ambition

The fetal surgery workforce survey reveals a structural problem common to emerging subspecialties. Among self-identified fetal surgery specialists within the American Pediatric Surgical Association, only 4% reported receiving formal training in fetal surgery 5:13. Survey responses showed internal contradiction: many respondents reported receiving fetal training during pediatric surgery fellowship, yet when asked differently, many said they had no fellowship exposure to fetal surgery 5:37. This is not a trivial inconsistency — it suggests that what counts as "training" in an emerging field is poorly defined and possibly inadequate. The survey provides a reality check on how to develop a treatment that remains rare and often experimental 5:54. In emerging fields, disparities in practice patterns are expected 6:38, and there is value in having dedicated fetal care teams even at centers that don't perform interventions 6:46. However, the survey results suggest limited interest in formal subspecialization for fetal surgery in America 7:04. The study was not designed to link subspecialization to outcomes or to define what constitutes a fetal surgery center 7:26, which means the field still lacks the data infrastructure to answer whether centralization improves results.

The pattern across all three studies

What ties these articles together is the recognition that progress requires identifying where current success is incomplete. For Wilms tumor, it's the subgroup with vascular extension. For myelomeningocele, it's the gap between good outcomes and better ones. For fetal surgery training, it's the mismatch between clinical ambition and educational infrastructure. Each study asks a version of the same question: given what we already do well, what specific intervention or structural change will move outcomes forward? The answers are different, but the discipline of asking is the same.

Takeaways from this story

Complete resection of Wilms tumor thrombus is justified when outcome data show survival benefit over incomplete resection.
Placental stem cells on extracellular matrix patches significantly improved motor function in fetal myelomeningocele repair in lambs.
Only 4% of self-identified fetal surgery specialists received formal training, revealing a gap between clinical practice and educational infrastructure.
Fetal care teams have value even at centers that don't perform interventions, supporting distributed expertise in emerging subspecialties.

Topic overview

A journal club discussion reviewing three April 2022 Journal of Pediatric Surgery articles selected by Dr. Paul Tam. The first examines surgical outcomes in Wilms tumor with intravascular extension from the SIOP Renal Tumor Study, finding outcome differences based on completeness of tumor thrombus resection. The second reports improved motor function in fetal lambs with myelomeningocele repaired using placental mesenchymal stromal cells on extracellular matrix, representing a pivotal step toward FDA approval for human trials. The third surveys American Pediatric Surgical Association members on fetal surgery practice patterns, revealing that only 4% of self-identified fetal surgery specialists received formal training in the field.

Key takeaways

Complete resection of Wilms tumor thrombus impacts outcomes; surgeons should prioritize total removal when feasible. (0:58)
Placental stem cells on ECM patches significantly improve motor function in fetal myelomeningocele repair in lamb models. (3:54)
Only 4% of fetal surgery specialists received formal training, highlighting gaps in standardized education pathways. (5:13)
UC Davis stem cell study is pivotal for FDA approval, advancing toward first-in-human trials for myelomeningocele repair. (2:54)
Fetal surgery practice patterns show center-to-center disparities; dedicated teams add value even without interventions. (6:38)

Keywords

Wilms tumor myelomeningocele tumor thrombus fetal surgery myelomeningocele repair tumor thrombus resection in utero repair University of Hong Kong UC Davis Medical Center Cincinnati Children's Hospital Mott Children's Hospital University of Michigan American Pediatric Surgical Association NAFNET

Hashtags

#PediatricSurgery #FetalSurgery #WilmsTumor #StemCellTherapy

Transcript

Click "Show Transcript" to view the full text (8141 characters)

Welcome back. It's the JPS Article Review podcast. We got a big team today. I'm Brittany Levy. I'm I'm Tom Bash, and I'm Rod Gerardo from Cincinnati Children's. And this month, we have 3 articles selected by Doctor Paul Tam, who is an editor for the Journal of Pediatric Surgery and the chair of Pediatric Surgery at the University of Hong Kong. The first is about Wilm's tumor, while the second two review recent article updates and fetal surgery procedures and practice patterns. OK, let's get into it. Our first article coming from London, it's surgical Management, staging and outcomes of W's tumors. With intravascular extension, results of the import study. That's the International Society of Pediatric Oncology Renal Tumor Study. If you want to read more about this, we have the links of the articles in the description below the video for you. Follow the links and read along with us. So we weren't able to discuss with the original authors, but basically their study was looking at children with Wilms tumor, where tumor thrombus extended into the renal vein. And they provided the outcomes for when complete resection of tumor thrombus was successful or it wasn't. Worm's tumor has been a great success story for pediatric surgery and pediatric oncology. That's Dr. Paul Tam, the JPS editor we told you about. So how do you improve a great success? What are we doing as far as surgical management? How is that? Having an effect on the stage of their Wilms tumor and this can probably then be used to figure out where we want to go next with the care for these patients. The obvious thing to do is to identify areas, uh, subgroups of patients who are not, still not doing so well and try to improve in this. Particular area. Is there an outcome benefit? You know, if, if you had all these kids and you removed their, you didn't remove their tumor, you did remove the tumor, and it didn't matter, then why are we trying so hard to remove all the tumor? You know, there's no outcome benefit. But here, if half of them get removed and half of them don't, and there is an outcome difference, then we should still try really hard to remove all of it. Next article. This article is entitled Efficacy of Clinical grade Human P placental Mesenchymal stromal Cells and fetal ovine myelomeningocele repair. And you may remember this topic from a few months back when we discussed the safety of this approach. And we are discussing the efficacy this time with the first author out of UC Davis. My name is Christina Theodoro, and I am a PGI 6 general surgery resident at UC Davis Medical Center in Sacramento. Article discussed the use of mesenchy. stromal cells on an extracellular matrix in ovine fetuses to determine if there was a benefit to motor function in fetal lambs that were given the intervention. This study, a pivotal study in obtaining approval from the FDA for use of clinical grade stem cells in fetal myeloma meningocele repair. We can see that we are one step closer. To first in human clinical trial. So the premise is basically, they had a lamb model that would have a myelo meningocele. They would then do fetal surgery on that test subject. Here's Dr. Theodoro explains their technique and how repairs are performed. We expose the fetal back, we re-expose the spinal cord, we identify the MMC defect, and then we take our extracellular matrix patch that has the placental. Stem cells on it, it is, uh, placed with the cells facing the spinal cord in direct contact, and then the skin is closed and the baby is returned to the uterus to continue gestation until term. And then when it's full term, then the lamb is born, and then they evaluate the motor skills of those lambs. And we found that lambs were paired with these clinical grade subfrontal stem cells have significantly improved motor function compared to lambs that did not receive the stem cells. I mean, that's pretty groundbreaking. This was Doctor Todd Ponsky. He's a pediatric surgeon at Cincinnati Children's Hospital. So, we already have shown a benefit of repairing these in utero, and now to take it a step further, if you impregnate it with mesenchymal stromal cells, you actually have even a larger benefit in the chance of ambulation. I've said this before and I'll say it again. If left to our own devices, we would probably just choose clinical research articles because that's kind of where our head's at. I am not smart enough to select an article like this, and I'm absolutely astounded by it. So, to continue the theme of fetal surgery, the next article is titled Current Status of Sub-specialization in Pediatric Surgery, a Focus on fetal Surgery, and we were lucky enough to talk to the first author. I'm Natalie Lopian. I'm a clinical lecturer at the Department of Pediatric Surgery at Mott Children's Hospital in the University of Michigan. This study was a survey of non-traineee surgeons within the American Pediatric Surgical Association. And they wanted to gauge some idea of practice patterns in fetal surgery across the country. These were self-identified specialists within the field of fetal surgery, um, and yet only 4% of those people, uh, reported receiving formal training in fetal. Surgery. So shocking to me that only 4% had formal training in this like very specialized, like intricate anatomy and physiology operations. In the survey, a lot of respondents reported that they received their fetal training during their pediatric surgery fellowship training. And yet when the question was posed in a different way, a lot of them responded that they didn't have exposure to fetal surgery during their fellowship training. Fetal surgery is a frontier for pediatric surgery. That's Doctor Paul Tam again. It is thought provoking. I felt that this survey gives us a reality check on how we should develop a front. treatment which up to this stage remains rare and often experimental. So it will be interesting to see as this sort of field expands, um, whether we start to make it be a requirement that there's at least some exposure to fetal surgery during training or if we really do hone in on those fetal centers and make those be the sort of feeding ground. For fetal surgeons. I think this paper highlights that this is what happens in an emerging field. You have disparities in what is happening. We're seeing the value of fetal surgery and fetal intervention, and so it's reasonable to expect that there are different levels of what different hospitals do, but it, I think it's great that there are some centers that don't necessarily do interventions, but are having a dedicated team focusing on fetal care. It's kind of interesting as we talked to a lot of authors over multiple months about subspecialization and how that's working all around the world, it seems like this was kind of a pilot, you know, feel out the waters and see would people be interested in doing that for fetal surgery in America. And really from these results, it seems like no for a variety of reasons. This study was not designed to link subspecialization of fetal surgery to outcomes, and it also wasn't really designed to provide a clear definition of a fetal surgery center. Um, and so certainly that work, I think it Forthcoming from NAFNET, um, and that'll be interesting to see. And here's a couple more questions for the future. Have we defined on paper what constitutes a fetal care center? What services they should provide? Who constitutes the complement of the fetal surgery team? I think finding these answers would be advantageous for patient care, both for moms and for babies. Yeah, very interesting to see, you know, the future of fetal surgery and Sub-specialization within pediatric surgery as a whole, curious what's gonna happen to it. So there you have it, the April Journal of Pediatric Surgery article Review podcast, articles handpicked by Doctor Paul Tam, given to you in this podcast format. If you want to read more about them, scroll down under the media player, click on the links and open them. But until next time, I'm Rod Gerardo. I'm I'm Tom Bash, and I'm Brittany Levy. And remember, knowledge should be free.

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