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Despite advances in neonatal and surgical care, the outcome of severe congenital diaphragmatic hernia (CDH) is still quite poor. Improvements in the ability to diagnose and risk stratify CDH prenatally have led to investigations into whether the more severe forms of CDH may benefit from in-utero intervention to ameliorate the accompanying pulmonary hypoplasia. Fetal endoscopic tracheal occlusion (FETO) is an example of a prenatal surgical intervention that was made possible by the technological advancements in endoscopic surgery. FETO is generally performed in fetuses with more severe forms of CDH to stimulate prenatal lung growth. While FETO is still considered investigational therapy and has not attained standard of care status, the results from published data to date have been promising. The complexity of FETO, coupled with the surgical and anesthetic risk to the mother and fetus requires a highly functional multidisciplinary fetal team, which includes obstetrics, pediatric surgery, and anesthesiology. This chapter will provide an in-depth understanding of the history of fetal endoscopic tracheal occlusion for CDH, the operative and anesthetic approach to FETO and associated perioperative considerations. Congenital diaphragmatic hernia continues to be a disease that perplexes obstetricians, neonatologists, surgeons, anesthesiologists, and the entire care team.
The founding physicians of fetal surgery recognized that experimental procedures involving a fetus were morally sensitive and would require a formal review to assess their ethical justification. A Fetal Therapy Board (FTB) is one of the groups assembled to provide such formal ethical reviews; and as such, this group would logically have members representing certain medical/surgical specialties beyond the fetal surgeon. A framework to be used by a FTB as applied to the fetal status, the components of an ethical justification, and the informed consent process for fetal interventions is presented. In addition, some hypothetical examples of a FTB review are provided to highlight specific ethical dilemmas.
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