An enormous tumor mass near his throat would have prevented him from breathing at birth. The life of a 37-week-old fetus was saved at birth by a first-of-its-kind operation performed while the newborn was still connected to the placenta. A few minutes are available for surgeons to extract it from the mother’s belly and connect it to the heart-lung machine, before cutting the umbilical cord and completing the cesarean section.
The life-saving procedure, called Exit to Ecmo, was performed at the San Pietro Fatebenefratelli Hospital by a multidisciplinary team coordinated by specialists from the Bambino Gesù Pediatric Hospital in Rome, where three days later the tumor mass was also removed. 4 months later, the child is well and has returned home with his family.
An invasive tumor
The child born with the Exit to Ecmo procedure had developed in intrauterine life a benign but ‘tumultuous’ growing, very compact and voluminous tumor mass. The tumor, located on the neck (from the chin to the shoulder), was as large as the little patient’s head and had now incorporated the arterial vessels (carotid artery) and the respiratory tract (trachea). Due to these characteristics, the mass would have prevented the child from breathing on his own at the time of birth and would also have prevented doctors from proceeding with intubation or tracheotomy (surgical opening of the trachea) to allow breathing, extreme but “standard” procedures ” in similar circumstances.
During gestation, the mother was assisted by Bambino Gesù specialists who followed the evolution of the tumor in the fetus and planned the moment of birth in detail, preparing for all eventualities.
What is the ‘Exit to Ecmo’ procedure
The complexity of the little patient’s case led the medical teams to activate – the first known case in Italy – the Exit to Ecmo procedure (EXIT aimed at ECMO) which allowed the newborn not only to survive but also to preserve the normal function of the brain, put at risk by the inability to breathe.
Birth in EXIT (EX-utero Intrapartum Therapy) consists of partially extracting the fetus from the mother’s belly, via cesarean section, keeping it connected to the umbilical cord and placenta which thus continue to ensure the circulation and oxygenation of the baby’s blood. This procedure gives surgeons a short window of time (approximately 40-50 minutes) before having to complete the delivery with umbilical cord clamping, during which maneuvers such as intubation or tracheotomy can be performed to support respiratory function of child.
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In this specific case, considering the volume and consistency of the tumor which prevented rapid access to the airways with ‘conventional’ techniques, the only possibility for the child was extracorporeal circulation (ECMO – Extra Corporeal Membrane Oxigenation). The positioning of the heart-lung machine which replaces, from the outside, the respiratory and cardiac function, is a very delicate and complex surgical maneuver, even more so in emergency contexts: in a very short time, it involves opening the child’s chest (in this case ‘in EXIT’, i.e. not completely born) and the insertion inside the large blood vessels near the heart of two cannulae connected to the machine. After initiating extracorporeal circulation, the cesarean section was completed.
Removing the tumor and returning home
A few hours after birth – again with the support of ECMO – the child was transferred to the Bambino Gesù Pediatric Hospital to prepare for surgery to remove the tumor. The operation, which lasted approximately 7 hours, was performed 3 days after birth by a multidisciplinary team composed of neonatal surgeons, anesthetists, cardiac surgeons, perfusionists, neurophysiologists, ENT specialists and Bambino Gesù nurses.
In the following weeks the little boy was cared for in hospital for post-surgery recovery and oncological treatment. After 4 months of hospitalization, he finally returned home to spend his first Christmas with his family.