In utero myelomeningocele repair: baby steps and giant leaps for fetal surgery.

1016 May 2013 A FTER decades of preparing the theoretical framework of fetal surgery,1 the reality of it finally hit home in 2011 when Adzick et al. published their National Institutes of Health-supported study on outcomes after in utero surgery for myelomeningocele. Aptly named MOMS (Management of Myelomeningocele Study), the investigators terminated enrollment early after demonstrating that children who received in utero repair of myelomeningocele had a decreased incidence of ventriculoperitoneal shunt placement and less mental and motor disability at 30 months of age.2 In this issue of Anesthesiology, Ferschl et al.3 detail their early experience anesthetizing pregnant women undergoing in utero myelomeningocele repair. On the surface, it appears to be a review article. But we believe it belongs to a unique genre of scientific communication that provides an introduction to the anesthetic considerations for an emerging new technology. Unlike most review articles, there is little directly relevant anesthetic research data to review as fetal surgery takes its first steps—rigorous investigation in this area does not yet exist. Ferschl’s description of anesthesia for fetal surgery mirrors similar pioneering articles in our field, such as Vandam’s description of anesthetic considerations for renal transplantation4 and early descriptions of anesthesia for liver transplantation,5 laparoscopic cholecystectomy,6 bariatric surgery,7 and transcatheter aortic valve replacement,8 to name a few. These publications have introduced us to emerging surgical technologies and heralded new eras marked by rapid evolution of surgical techniques, innovation, outcomes, and protocols. They have the power to stimulate and shape the development of research agendas around the emerging technology. For fetal myelomeningocele repair, examples of this might include the following: what is the most effective way to relax the myometrium during the procedure? Can certain anesthetic drugs or techniques prevent or reduce the risk of preterm labor? Is the fetus anesthetized and free of pain? Does it matter? What is the best comprehensive anesthetic approach that optimizes maternal and fetal well-being? Research into the anesthetic aspects of this highly complex procedure is still in its infancy.9,10 Ferschl et al. describe the anesthetic protocol from their center, which was one of the three that participated in MOMS. Although the protocol they describe is similar to that used at the other two original participating institutions, over time there will be evolution and divergence across centers that venture into this area. The challenges and strategies of successfully transferring this new technology from the trial centers to other medical centers are among the most pressing and difficult issues. Similar to solid organ transplantation and bariatric surgery, fetal surgery requires high levels of interprofessional teamwork, coordination, and longitudinal care to optimize outcomes and reduce and manage complications. If in utero myelomeningocele repair is as beneficial as the MOMS trial suggests, then it would be desirable to expand the number of centers capable of performing it as rapidly as possible to ensure equitability of access. The intensive longitudinal care from mid-gestation surgery through delivery makes geographical location an access-limiting factor. As with other high-stakes, heavily resource-intensive, and costly programs, such as solid organ transplantation, how will these centers be chosen? Should there be criteria or limitations based on case volume, expertise, or geographic region? Hospitals stand to derive great benefit (financial, prestige, career In Utero Myelomeningocele Repair