Deprest Jan A, Done Elisa, Van Mieghem Tim, Gucciardo Leonardo
Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Belgium.
Curr Opin Anaesthesiol. 2008 Jun;21(3):298-307. doi: 10.1097/ACO.0b013e3282ff8607.
We aimed to review the current clinical status and advances in endoscopic and open surgical interventions on the fetus in terms of indications, technical aspects and reported outcomes.
In numbers, there has been a move away from open toward fetoscopic surgery. The indications for each access modality are, however, different, and hence cannot substitute each other. Complications of monochorionic twinning are the leading indication today. Other increasingly frequent indications are severe congenital diaphragmatic hernia and myelomeningocele, and to a certain extent valvuloplasty by needle puncture. Although maternal safety is not at stake, rupture of the membranes and preterm delivery remain a problem. Today, there is level I evidence that fetoscopic laser surgery for twin-to-twin-transfusion syndrome is the preferred therapy. This has triggered the interest of several units to embark on fetoscopic surgery, although the complexity and the overall rare indications act as a limitation to sufficient turnover.
Fetal surgery seems safe and has therefore become a clinical reality. With the current state of technology, open and endoscopic interventions do not compete, each having their indications. Although the stage of technical experimentation is over, most interventions remain investigational. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience. Healthcare providers and individual centers should be encouraged to consider viability and efficacy of new treatment programs.
我们旨在从适应症、技术层面和报告的结果等方面，回顾目前胎儿内镜手术和开放性手术干预的临床现状及进展。
从数量上看，手术方式已从开放性手术转向胎儿镜手术。然而，每种手术入路方式的适应症不同，因此不能相互替代。双绒毛膜双胎并发症是目前的主要适应症。其他越来越常见的适应症是严重先天性膈疝和脊髓脊膜膨出，以及在一定程度上的经皮穿刺瓣膜成形术。虽然产妇安全没有问题，但胎膜破裂和早产仍然是个问题。如今，有一级证据表明胎儿镜激光手术治疗双胎输血综合征是首选疗法。这引发了多个医疗单位开展胎儿镜手术的兴趣，尽管手术复杂性和总体罕见的适应症限制了足够的病例数。
胎儿手术似乎是安全的，因此已成为临床现实。就目前的技术水平而言，开放性手术和内镜手术并不相互竞争，各有其适应症。虽然技术试验阶段已经结束，但大多数干预措施仍处于研究阶段。应鼓励尽可能将患者纳入试验，而不是积累个别病例经验。应鼓励医疗服务提供者和各个中心考虑新治疗方案的可行性和有效性。
