Pioneering surgery in Europe: a fetus with its intestines outside the body is operated on

BarcelonaDoctors in Barcelona have made history in European fetal medicine by successfully operating on a fetus weighing only 700 grams affected by severe gastroschisis, a congenital malformation that leaves a large part of the intestines outside the abdomen. The intervention was performed inside the mother's womb at 28 weeks of gestation and has resolved the infant's digestive system problems without further complications. The baby was born by cesarean section six weeks after the intervention. The infant is progressing favorably and is, in fact, feeding normally.

The operation was led by a multidisciplinary team from BCNatal – the consortium for maternal-fetal medicine and neonatology comprising Sant Joan de Déu Hospital and Hospital Clínic de Barcelona – with the participation of specialists in pediatric surgery and anesthesiology. Until now, this type of fetal surgery had only been performed on a few occasions in the United States and Colombia.

The malformation the infant suffered from (gastroschisis) is infrequent, occurring in approximately three to four cases per 10,000 births. In Spain, about 120 cases are registered each year. In this malformation, the intestines exit the abdominal wall, located to the right of the umbilical cord, which does not close properly during pregnancy. In this case, it was detected during a routine ultrasound at 20 weeks of pregnancy and was confirmed to be complex gastroschisis, which is the most severe form and accounts for around 20% of all cases.

The fetus had almost all of its intestines outside the abdomen and showed signs of compression and inflammation. The situation raised concerns that, before birth, it could suffer from possible intestinal necrosis – meaning, when a part of the intestines becomes inflamed and loses blood supply, and the tissues eventually die biologically – which could have very serious consequences for the survival and quality of life of the future infant.

"There was a risk of suffering from short bowel syndrome and requiring long-term parenteral nutrition – with injections or catheters – and even a bowel transplant," warned Xavier Tarrado, head of the surgery department at Sant Joan de Déu. Faced with this scenario, the specialists evaluated the case and, after consulting with the ethics committee, opted to perform an exceptional fetal surgery.

An exceptional surgery

The intervention took place on February 10 and lasted about two and a half hours. Surgeons accessed the uterus through an abdominal incision in the mother –who was 20 years old– and were able to change the fetus's position to, using fetal laparoscopy techniques, progressively reintroduce the intestines into the abdominal cavity. The procedure required extreme precision, as the fetus weighed only 700 grams, the intestine measured about 80 centimeters, and it had to be reintroduced through an opening of 1.5 centimeters.

This is the first time this intervention has been performed in Europe. “What we propose in cases like this is fetal therapy that until now had not been carried out, partly due to its complexity, and which consists of repairing this defect during fetal life”, explained this Thursday the director of BCNatal, Eduard Gratacós.

After the intervention, ultrasound monitoring confirmed a reduction in intestinal inflammation and a progressive recovery of the normal appearance of the bowel. The pregnancy continued until week 34, when the baby was born by C-section. Despite presenting a low weight at birth, the clinical evolution has been good and the baby was able to be discharged from the hospital after a brief stay.

Currently, he is feeding normally, which professionals consider a very hopeful result for the future of fetal surgery in Europe. “The experience was overwhelming at first, but now we are very happy with the result of the surgery and how everything went”, admitted the mother, Maria Camila.