Fetal surgery is performed in spina bifida cases

We already have experience with fetal interventions for spina bifida cases in Italy, of which we are highly encouraged states Professor Nicola Persico of Milan University Hospital who is the leading Italian fetal surgeon. He was one of the international lecturers at the Third Maternity-Fetal Medicine Congress. Professor Nicola Persico was in Bulgaria to observe the work of his Bulgarian colleagues – the team of Dr. Petya Chaveeva – in performing an intrauterine operation of a diaphragmatic hernia.

You are one of the leading European fetal surgeons in Europe. Tell us what has motivated you to dedicate yourself to one of the newest and very sophisticated medical sub-specialties – the Fetal Surgery?

The motivation came from my studies, when I was resident. Then I had the luck to go to London in one of the leading fetal centers in the world – the one that is managed by Prof. Nikolaides. There was an equipped room where he was entering the amniotic cavity with a camera and was able to look inside and see the baby in a sort of “real vision”. Then you say “I want to do the same”. That was my motivation especially considering that this helps the babies to be born, to survive and to have a normal quality of life.

How many procedures do you perform annually at the University Hospital in Milan?

We started after my training in London in 2011 and so far have performed altogether around 300 procedures. They comprise procedures for twins, like the one we did today for diaphragmatic hernia and the newest procedure for spina bifida.

This is the reference center in Italy?

Yes. All the available procedures can be done in the University Hospital in Milan. We perform the highest number of the operations.

Would you share the success rate of the clinic you are managing?

The success rate means whether the baby will survive or not. You can be technically successful but the most important is the saved life. The outcome is survival or quality of life. The success rates are different according to the procedures. In the most common complication in twins – twin-to-twin transfusion syndrome – if you do nothing most of the babies will die or if the one survives it will have severe neurological damage. With the fetal intervention we may reach 80% survival of the one twin and 60-65% of both twins with low rate of neurological complications. For diaphragmatic hernia we know that in the severe forms if we don’t conduct a procedure before birth we can reach only 10-15% of survival and with a fetal procedure we raise it to 50-60%. More or less it depends on the type of disease we treat. For spina bifida survival is not a problem. We measure there the neurological outcome especially in the following years. We have 3 cases after we have started in June. We have imported from Brazil a brand new technique. It was invented by Prof. Lapa Pedreira who is also a research fellow of Prof. Nikolaides. Its unique in a sense that it is completely endoscopic. The minimally invasive technique is very important at least for me. When you operate on a baby, you have always to think that the baby is inside the body of the mother. We cannot be too aggressive on the mother with the objective to operate the baby. Compared with the other technique used for spina bifida which is open Fetal Surgery I think that it is the right approach. Here we do not have to do laparotomy or hysterotomy with all the possible risks for the mother, especially for subsequent pregnancies. That is the concept of Minimally Invasive Fetal Surgery.

What are the most common cases where Fetal Surgery is the only solution and when it is the first method of choice?

Fetal Surgery is more or less always the only choice. If there is a good chance to have a good outcome without Fetal Surgery, we must not do Fetal Surgery. In the natural history of the disease, when we assume, that if we do not do anything – the outcome will be very poor, then you consider Fetal Surgery and it really is the last hope. If we don’t perform it most probably the baby will day during the pregnancy or soon after birth. It is a first line choice as a last hope, when it has been proved trough randomized trials or research that treatment is effective and is more effective than doing nothing – the expectant management. For laser for twin-to-twin transfusion syndrome we know from big randomized study performed many years ago that Fetal Surgery is the first line treatment compared to was had been conducted before – amniodrainage. With diaphragmatic hernia we see more and more often that trachea occlusion is the best available treatment. That doesn’t mean that it is the best in absolute terms. Fetal Surgery is an evolving specialty and we see a new treatment for diaphragmatic hernia together with what we do today. Or we may see a better technique for repair of spina bifida and that is why it is so interesting. It is so new and we will have to develop it further.

What is the next step, what is the next disease to be fought by Fetal Surgery?

I think the next step is to improve what we have now. Technology has done incredible advance in the last 10 years. Now we can use really small instruments while operating the fetus. 20-30 years ago the pioneers like Prof. Nikolaides couldn’t even dream of having this type of technology. It is our responsibility today to use it to improve the rate of complications that we have with current treatment procedures. Then the more we go, e.g. with spinal bifida we know that we can go inside with 2 or 3 instruments to suture on a fetuse or to cut, with the open operations before there was a lot of fear. Now the instruments are much better than before, it is visible and therefore we will start thinking of new treatment methods as we go. For example we are now thinking about gastroschisis – how to repair it before birth. I don’t know really which the next target disease is. It will become clearer in line with the constant advance of fetal medicine.

What is the next professional challenge you have set yourself up?

My next challenge is to consolidate the spina bifida surgery. We have just started and there is space for improvement. That is the objective now. Also to improve the fetal treatment for diaphragmatic hernia. But we can do more by increasing the survival of these babies.

Today with Dr. Chaveeva you have performed such kind of procedure? Tell us more about the case, what result did you achieve and what follow-up is to be done?

First of all, Dr. Chaveeva and her team performed the Fetal Surgery today. I was just watching and supervising. This procedure is quite complicated. It was for diaphragmatic hernia. In some types of this disease – the severe diaphragmatic hernia – there is a herniation of a lot of abdominal organs into the chest with huge compression of the lungs. The objective of the procedure is to try to improve the growth of the lungs by placing a small balloon inside the trachea of the baby in the amniotic cavity with a tiny endoscope. Thus the fluid produced by the lungs cannot escape from the mouth but it stays, stretching the lungs and helping the growth. The baby that was operated today is 29-30 gestation weeks. We would like to see in the next few weeks that the very very small lung at the current moment will grow. Before the baby is born the balloon has to be taken out otherwise the baby cannot breathe. What we would like to see is the baby to be born with grown enough lungs, and to be stabilized to undergo a surgery for diaphragmatic hernia. To go through this process, to survive and to have a normal life.

This year, you were one of the international speakers of the Third Congress of Maternal and Fetal Medicine. How do you evaluate the event and experience of Matenal and Fetal Medicine specialists in Bulgaria?

I think the event is brilliant, because it covers the most important topics in obstetrics that you can see in other international congresses. The quality of the speakers was very high, there were many international speakers, not only me. Of course, the most important speaker was our professor – Prof. Nikolaides. And it is not easy at all to bring him as a lecturer. I could see, first of all, a high number of people taking part. Their attention to the lectures was dedicated. Your society is doing a very significant activity – to spread the knowledge in Obstetrics and in Fetal Medicine according to the highest standards that we have today. Even in Italy we have a problem of passing the knowledge to all obstetricians and gynecologists, especially in very specific fields like Fetal Surgery. There are still problems in diagnosing diaphragmatic hernia and twin-to-twin transfusion syndrome at the right time in order to refer the patients to Fetal Surgery. In many parts of Italy doctors don’t have the competence and the knowledge to do that. Any initiative that has the objective to spread the knowledge of letting people know that today in 2018 we need to follow the published standards. We should keep spreading information more and more. At some point more doctors will be aware how to manage these patients.