2015, Number 01
The EXIT procedure: Indications, limitations, risks and progress to the fetal endoscopical tracheal intubation
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ABSTRACTCongenital oral and neck masses are associated with a high perinatal mortality and morbidity secondary to airway obstruction due to a mass effect of the tumor with subsequent neonatal asphyxia and/or neonatal death. In 1997, the Ex Utero Intrapartum Treatment (EXIT) technique was designed to establish a secure neonatal airway. This procedure allows neonatal tracheal intubation while the uteroplacental circulation maintains fetal oxygenation in a partial fetal delivery during cesarean section. However, it must be emphasized that this technique requires a multidisciplinary team, maternal general anesthesia, high surgery times and potential maternal risks such as placental abruption and increased maternal blood loss due to uterine atony. In addition, the clinical algorithm to obtain a neonatal airway can be quite challenging and neonatal mortality has been reported due to the inability in obtaining an airway at birth. Recently, our Mexican group described a novel minimally invasive fetoscopical technique before cesarean delivery that allows prenatal airway control by means of a fetal endoscopic tracheal intubation (FETI) under maternal peridural anesthesia. This procedure attempted to avoid the need for an EXIT procedure and its potential risks. In this review we described the indications, risks and potential benefits of the EXIT technique and its possible replacement by the fetal endoscopic tracheal intubation technique.
Elmasalme F, Giacomantonio M, Clarke KD, Othman E, et al. Congenital cervical teratoma in neonates. Case report and review. Eur J Pediatr Surg 2000;10:252-257.
Jordan RB, Gauderer MW. Cervical teratomas: an analysis. Literature review and proposed classification. J Pediatr Surg 1988;23:583-591.
Mychaliska GB, Bealer JF, Graf JL, Rosen MA, et al. Operating on placental support: the ex utero intrapartum treatment procedure. J Pediatr Surg 1997;32:227-230; discussion 230-221.
Liechty KW, Crombleholme TM, Flake AW, Morgan MA, et al. Intrapartum airway management for giant fetal neck masses: the EXIT (ex utero intrapartum treatment) procedure. Am J Obstet Gynecol 1997;177:870-874.
Hedrick MH, Ferro MM, Filly RA, Flake AW, et al. Congenital high airway obstruction syndrome (CHAOS): a potential for perinatal intervention. J Pediatr Surg 1994;29:271-274.
Hedrick HL, Flake AW, Crombleholme TM, Howell LJ, et al. The ex utero intrapartum therapy procedure for highrisk fetal lung lesions. J Pediatr Surg 2005;40:1038-1043; discussion 1044.
Kunisaki SM, Barnewolt CE, Estroff JA, Myers LB, et al. Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia. J Pediatr Surg 2007;42:98-104; discussion 104-106.
Liechty KW. Ex-utero intrapartum therapy. Semin Fetal Neonatal Med 2010;15:34-39.
Liechty KW, Crombleholme TM, Weiner S, Bernick B, et al. The ex utero intrapartum treatment procedure for a large fetal neck mass in a twin gestation. Obstet Gynecol 1999; 93:824-825.
Bilgin F, Cekmen N, Ugur Y, Kurt E, et al. Congenital Cervical Teratoma:Anaesthetic Management (The EXIT Procedure). Indian J Anaesth 2009;53:678-682.
Hirose S, Harrison MR. The ex utero intrapartum treatment (EXIT) procedure. Semin Neonatol 2003;8:207-214.
Catalano PJ, Urken ML, Alvarez M, Norton K, et al. New approach to the management of airway obstruction in “high risk” neonates. Arch Otolaryngol Head Neck Surg 1992;118:306-309.
Schulman SR, Jones BR, Slotnick N, Schwartz MZ. Fetal tracheal intubation with intact uteroplacental circulation. Anesth Analg 1993;76:197-199.
Marwan A, Crombleholme TM. The EXIT procedure: principles, pitfalls, and progress. Semin Pediatr Surg 2006;15:107-115.
Hirose S, Sydorak RM, Tsao K, Cauldwell CB, et al. Spectrum of intrapartum management strategies for giant fetal cervical teratoma. J Pediatr Surg 2003;38:446-450; discussion 446-450.
Hullett BJ, Shine NP, Chambers NA. Airway management of three cases of congenital cervical teratoma. Paediatr Anaesth 2006;16:794-798.
Liao AY, Levin B, Daniel M, Chan L, et al. Emergency EXIT: an urgent ex utero intrapartum tracheostomy for giant fetal neck mass. ANZ J Surg 2013;83:684-685.
Lazar DA, Olutoye OO, Moise KJ, Jr., Ivey RT, et al. Ex-utero intrapartum treatment procedure for giant neck masses- -fetal and maternal outcomes. J Pediatr Surg 2011;46: 817-822.
Steigman SA, Nemes L, Barnewolt CE, Estroff JA, et al. Differential risk for neonatal surgical airway intervention in prenatally diagnosed neck masses. J Pediatr Surg 2009; 44:76-79.
Laje P, Johnson MP, Howell LJ, Bebbington MW, et al. Ex utero intrapartum treatment in the management of giant cervical teratomas. J Pediatr Surg 2012;47:1208-1216.
Butwick A, Aleshi P, Yamout I. Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. Can J Anaesth 2009;56:437-442.
Cruz-Martinez R, Moreno-Alvarez O, Garcia M, Pineda- Aleman H, et al. Fetal endoscopic tracheal intubation: a new fetoscopic procedure to ensure extrauterine tracheal permeability in a case with congenital cervical teratoma Fetal Diagn Ther 2014, in press.