Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
Semin Fetal Neonatal Med. 2010 Feb;15(1):58-67. doi: 10.1016/j.siny.2009.10.002. Epub 2009 Nov 13.
An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.
越来越多的胎儿畸形在出生前被诊断出来，其中一些可以通过胎儿手术干预来治疗。我们讨论了目前的临床现状和内镜及开放手术干预的最新进展。在欧洲，胎儿镜手术得到了广泛的应用，而开放胎儿手术的应用则要少得多。每种入路方式的适应证不同，因此不能相互替代。尽管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。目前有一级证据表明，胎儿镜激光手术治疗双胎输血综合征是首选治疗方法，但该手术实际上是在胎盘上进行的。就胎儿手术而言，越来越常见的适应证是严重的先天性膈疝和脊髓脊膜膨出。总的来说，产妇的安全性很高，但胎膜早破和早产仍然是一个问题。胎儿手术的应用越来越广泛，其媒体关注度也越来越高，这引发了人们对开展胎儿手术治疗的兴趣，尽管手术的复杂性以及总体上罕见的适应证是在个体基础上获得足够经验的限制。我们呼吁增加大容量单位之间的交流和合作研究；也可能需要自我监管。只要有可能，就应该鼓励将患者纳入试验，而不是积累病例经验。
