Genoa, Antonio operated on the Gaslini while he was in his mother’s womb: it is the second time in the world for this type of surgery
Genoa – During the pregnancy a malformation incompatible with life was diagnosed, laryngeal atresia.
But a ILife-saving intervention performed All’Giannina Gaslini Institute of Genoa saved the little one from the unfortunate diagnosis: by combining the skills of the Genoese pediatric polyclinic it was possible to coordinate all professionalism necessary to carry out two subsequent interventions that guaranteed the child’s survival.
Renato Botti, General Manager of Gaslini explains: “The case was exceptional for various reasons: the first is the decision of the parents, extremely courageousto carry the pregnancy to term despite a malformation in theory incompatible with life, unless a very delicate operation in the fetal period, and performed alone occasionally and experimental in very few cases before this, and never performed at Gaslini “.
And again: “We are proud to have offered an alternative life and a path of growth to this family, thanks to the synergistic and close-knit doctors, midwives and nurses of 5 operating units complex: a perfect organization of the many and diverse medical, technical and nursing skills that are there wealth of this pediatric hospital “.
“We are really proud of the great professional and organizational capacity shown by the Gaslini teams – commented the president of the Liguria Region and councilor for health Giovanni Toti.
The diagnosis
“Laryngeal atresia – specifies Michele Torre, doctor in charge of Uusd – Airway and Thoracic Surgery Team – consists in the presence of a membrane at the level of the vocal cords that the flow of air can go to the trachea: it is a very serious malformation of the upper airways that leads to neonle death in almost all casesI. To date, only a dozen survivors are described worldwide ”.
“This malformation, which Ms. FS was diagnosed with at 22 weeks of gestation, certain risk conditions which often lead to intrauterine death from the heart failure that accompanies the dilation of the lungs in the presence of the laryngeal membrane “.
“The couple – says Dario Paladini, director of the Uoc of Fetal and Perinatal Medicine and Uoc Gynecology and Obstetrics – she decided to carry on the pregnancy, agreeing to move from Naples to Genoa to give her child a real chance of survival “says Dario Paladini, director of the Fetal and Perinatal Medicine Uoc and Uoc Gynecology and Obstetrics.
“In the absence of an intervention – he underlines – fetal mortality from heart failure is very high. Therefore, the multidisciplinary team (Fetal Surgeon, Neonatologists-Resuscitators, Airway Surgeons and Otolaryngologists) of Gaslini proposed to the couple the execution of an experimental approach to fetal surgery to reduce the risk of fetal mortality.
Dario Paladini “This fetal surgery was performed alone once in the world before the one performed at Gaslini, and a second similar intervention was published immediately after the procedure performed at the Genoese pediatric hospital.
The intervention was illustrated and proposed to the couple during a session Consulting multidisciplinary.
The intervention
The fetal surgery event, is still Paladini, consists of a fetoscopic access to the airway and laser perforation – and subsequent dilationand with miniaturized gripper – the atretic (obstructed) larynx, which reduces the pressure in the lungs and the risk of stillbirth from heart failure.
Was performed at 29 weeks of gestation and it was effective in restoring a first minimum, albeit of a small caliber, in the airways, therefore the continuation of the pregnancy.
However, the minimal opening of the airways obtained with fetal intervention is not sufficient to allow autonomous driving of the newborn at the time of birth. In these cases, even in the case of spontaneous onset of labor, delivery can only be carried out through a very sophisticated cesarean technique called Exit (intrapartum treatment ex utero).
Caesarean section with exit
With the Exit technique, the fetus is extracted from the maternal uterus and kept connected to the placenta, which allows oxygenation. This allows the Neonatologists-Resuscitators and surgeons to gain effective access to the airways, without the child going to meet them to a hypoxic suffering. Once intubated or, come in this case, after performing a tracheostomythe baby is extracted completely, as breathing can be easily assisted through the tracheal tube or la tracheostomy tube” explains Andrea Moscatelli doctor and director of the Neonatal and Pediatric Intensive Care Unit.
The caesarean section in Exit, a procedure with a high risk of maternal haemorrhage, was performed in the cardiac surgery operating room adjacent to the Neonatal and Pediatric Intensive Care, according to a defined approach Dricu (Intensive care unit in the delivery room) which involves the transfer to the delivery / operating room of all the technology necessary to create a neonatal intensive care station.
Anesthesia
Gabriele De Tonetti, anesthetist, performed l‘maternal-fetal anesthesia, ensuring the mother’s hemodynamic stability. The caesarean section was performed by Paladini with the specialist Pedretti, of the UOC of Fetal and Perinatal Medicine / Obstetrics.
Having extracted the fetus while still the oxygen supply was secured by the umbilical cord, the fe was placed on the womb and a first attempt was made to fiber-assisted intubation da Lampugnani, of the Neonatal and Pediatric Intensive Care Unit. Intubation proved impossible for the very small caliber of laryngeal patency obtained with previous fetal surgery.
The tracheotomy
Subsequently, the doctors Roberto D’Agostino and Michele Torre have successfully performed a trachetomy, placing an endotracheal cannula – very difficult operation for the operating conditions (infant placed on the womb, still connected to the placental circulation) and the limited weight of the premature baby. This allowed for ventilation of the newborn as well autonomization from the placental circulation. The assistance and support procedures were completed for the child who was then transferred to stable conditions in the Intensive Care Unit. The baby weighed 1.7 kg at birth.
The challenge of malformation
The importance of the challenge is underlined by Roberto D’Agostino, director of the Otolaryngology UOC: “This type of intervention is exceptional for a number of reasons: it is the first time that we have performed a tracheotomy in fetal-placental circulation; the type of patient (premature and low weight)the need to act in a very short time, the difficulty caused by the absence of ventilation, the impossibility of preventive intubation, together with the difficult recognition of tissues in such a small patient, they make surgery a real challenge ”
Despite the prematurity, the subsequent course was extremely favorable from the respiratory point of view, the Gaslini institute said, even if the little one has developed an intestinal complication typical of premature babieswho required abdominal surgery with subsequent ileostomy.
In addition, other problems were diagnosed in the following weeks of hospitalization and are still being treated.
The growth of the child
“Antonio is currently 40 weeks of correct age, weighs 3 kg, is very responsive and lively. It is still connected to the fan through tracheostomy and is dependent on parenteral nutrition.
Michele Torre further explains: “The child is fine and growing but will have to face when it will be bigger a difficult surgery to be able to breathe alone without the tracheostomy. Atresia of the larynx is a malformation that is incompatible with life but can be treated with success only in centers that can guarantee prenatal treatment, delivery and post-natal care of the highest level. The path will then be completed with the intervention of reconstruction of the larynx and tracheafor which our Institute is an Italian and European excellence “.
18 people in the operating room
Raffaele Spiazzi, director of Gaslini, comments: “Antonio’s birth mobilized doctors, midwives and nurses from 5 complex healthcare units of the institute. This organizational effort is articulated and complex and requires a high-profile functional integration among all the professionals involved. Just think that in the operating room – where for a routine caesarean section they are present 4-6 people, between doctors and midwives / nurses – were present 18 hospital staff members, activated in emergency “.
A team effort
“This case is certainly exceptional and demonstrates how results of this type can only be obtained in hyper-specialized centers of reference, in which a continuum of care is possible from fetal to post-natal life “.
And again, Spiazzi: “The Giannina Gaslini Institute is one of the few structures in Europe where, in the context of a pediatric polyclinic equipped with all medical and surgical specialties, there is also a birth point. This allows you to guarantee the newborn all the procedures high specialty It includes fetal and neonatal surgery, intensive therapy, up to extra-body life support techniques, such as the neonatal Ecmo, necessary to deal with such complex cases “.
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