Update Course Rewind: Fetal Endotacheal Occlusion (FETO) for CDH 2022

Congenital diaphragmatic hernia, or CDH, is a rare congenital anomaly, affecting one in 2,500 births. Innovation in surgery has changed the landscape of therapeutic options for babies and their families with this pathology. Today, we'll hear about one of those surgical innovations from Dr. Craig Lillehei, a pediatric surgeon at Boston Children's Hospital, in this Update Course Rewind. So as a review, CDH is a defect in an infant's diaphragm, which is frequently found in utero. Most commonly, this occurs on the left side, but right sided defects do occur. Let's start with our case. Here, you're seeing a mother carrying a fetus diagnosed with left-sided CDH. Observed to expected rate LHR using a tracing mesh at 24 weeks is 28%. OELHR means observed to expected lung to head ratio. From prenatal imaging, we can calculate the ratio of the area of the contralateral lung to the head circumference. Then, we compare the patient's LHR to their expected LHR based on their gestational age. OELHR is frequently used to predict outcomes and guide prenatal counseling. The lower the value, the worse the outcomes. Follow up measurement at 26 weeks is 32%. The parents conceived this baby after significant difficulty and are asking about the outcomes of fetal tracheal occlusion or fetotherapy for their baby. You could argue that some folks might opt for B. I would go for D, but there are people I think that would opt for B. I would agree with that. There is data to suggest that feto is an effective procedure in very select population of patients. I think that's sort of where we are right now. I've tried to put all the results of the Total trial, 2021, lead articles in the New England Journal of Medicine. The first and second article, the first was severe CDH, the second article was moderate CDH. And interesting that they came to somewhat different conclusions. In the severe group, FETO, or fetoscopic endoluminal tracheal occlusion, significantly improved survival. In the moderate group, there was some improvement, but it didn't approach significance. So the authors concluded that in moderate CDH, feto was not beneficial, while it was beneficial in severe CDH. And this is where the debate begins. Well, there's a few problems with this. Number one, it was a study that was done over an 11 year period where these patients were accumulated. Number two, it was at a lot of different centers. There was a protocol for how you manage a CDH, but it varied considerably from place to place, undoubtedly. And lastly, if you're going to apply this, maybe these were very experienced feto centers. So the real question is, what should pediatric surgeons of today do? And right now, we can definitively say that feto is an emerging therapy, which is very appealing for severe CDH babies. But it isn't without problems. Prematurity is a big one, premature rupture of membranes. What's the price of that? These kids pay for later on down the line and that's still something that needs to be worked out. For the severe, it's impressive. And for those of us who have seen babies who have had a feto, it's a different scenario. Even when they're born prematurely, they often don't go on ECMO, which is just crazy. But for the moderate, I think you have to know your numbers. And if your center's survival is better than what they're producing in this trial, then maybe you don't need to do feto for those moderate babies. I think it's highly variable. I think it's a theme that we've been hearing a lot already today is that keep your eyes wide open. It often isn't just a binary. Thanks for joining Dr. Lillehei along with the rest of the APs of Professional Development Committee for this update course rewind. Remember to check out the Stay Current app for more content related to pediatric surgery and more.