Since opening as one of the first fetal centers based in a children’s hospital, the Elizabeth J. Ferrell Fetal Health Center at Children’s Mercy has delivered nearly 1,000 high-risk babies, with more than one third having complex heart disease. The addition of Emmanuel “Mike” Vlastos, MD further expands the center’s fetoscopy experience, which includes open myelomeningocele repair and other advanced in-utero procedures. While fetal surgery has been around for decades, the hope has not always lived up the hype.
In this podcast, Dr. Vlastos discusses the current status of open and minimally invasive fetal procedures, where we’ve seen success, and where the field is heading.
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Fetal Surgery Interventions: Hope, Hype and the Future
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Learn more about Emmanuel “Mike” Vlastos, MD
Emmanuel “Mike” Vlastos, MD
Emmanuel “Mike” Vlastos, MD, started his career as a family physician and later expanded his education and training to become an OB-GYN, Maternal Fetal Medicine specialist and fetal surgeon. This background allows Dr. Vlastos to look at the complete picture; not only the problem with the fetus but with the mother and the entire family. Dr. Vlastos received his medical degree from Creighton University. He completed his Family Medicine residency at University of Wyoming and his Obstetrics and Gynecology residency at Region’s Hospital in St. Paul Minnesota. His fellowship in Maternal Fetal Medicine was completed at Washington University in St. Louis. He is triple board certified in Maternal Fetal Medicine, Obstetrics and Gynecology, and Family Practice.Learn more about Emmanuel “Mike” Vlastos, MD
Transcription:
Fetal Surgery Interventions: Hope, Hype and the Future
Dr. Michael Smith (Host): Our topic today, is Fetal Surgery Interventions, Hope, Hype, and the Future. My guest is Dr. Emmanuel “Mike” Vlastos. Dr. Vlastos is a Maternal-Fetal Medicine Specialist and Fetal Surgeon. Dr. Vlastos or as your patients know you as, Dr. Mike, welcome to the show.
Dr. Emmanuel “Mike” Vlastos (Guest): Thank you very much. I really appreciate the opportunity to talk with you.
Dr. Smith: Awesome. Let’s just start with this – I think it’s safe to say that most physicians – most healthcare practitioners – even for us when we think of fetal surgery, it seems so science fiction, right? It seems so Sci-fi. Tell us a little bit of the history of fetal surgery, how long it’s actually been going on, where we are currently, and where you think this specialty is headed?
Dr. Vlastos: I appreciate that, Mike. Looking back in the textbooks, way back in 1954, a gynecologist actually put a very large laparoscope into the uterus to check out a baby who they thought had a problem. This was mind-boggling to me because I had no clue until looking backward into the history of this. A debate raged in the ‘70s to say should we continue using a scope to check out the baby or should we use this new emerging technology called ultrasound. Ultimately, at the time, ultrasound won out because of its noninvasive nature. However, because of ultrasound’s ability to see into the womb, and to note that there were fetal problems, then folks – physicians and generalists started saying is there any possibility of getting back into the womb to actually perform a procedure – surgery on a fetus?
That question was asked in many ways by different groups, but there was a pediatric surgeon -- still at the University of California San Francisco -- named Michael Harrison, who first, in the mid ‘70s, placed tubes in a baby’s kidneys which was unable to urinate to try to help that baby survive in utero. Unfortunately, that baby was lost several days after. However, the paradigm had been shifted so that people started thinking maybe we could get back in there. That’s where many different niduses around America and outside of America – in Europe, Australia, and New Zealand – started to take a look at actually going into the uterus, into the bag of water, and performing surgeries on fetuses to try to help them have a better start at the time of birth.
Dr. Smith: Right. So currently, where do we stand, Dr. Vlastos? What are the current procedures that are commonly performed in hospitals throughout the United States?
Dr. Vlastos: Sure, there are probably around 25, 26 fetal centers that do interventions. They fall into two basic categories, minimally invasive and open procedures. The minimally invasive is predicated on using a 2 to 3 mm scope to look in the uterus at a fetus and to perform surgery – often laser-based. The second is open procedures, and that’s similar to performing a cesarean section. However, rather than delivering the fetus or the baby, the baby is rotated to expose that part that needs to have surgery. That might be a mass in the chest, but most commonly, open fetal repair is done for spina bifida. Those babies with known spina bifida then have repair as a fetus, the uterus is closed, and pregnancy is promoted until around 37 weeks for delivery.
Dr. Smith: Let’s talk a little bit then – so you said about 25 procedures correct, or so are currently being performed? What is it going to take to get us to that next step? What technology do you see coming down the line, and where do you see really the specialty of fetal medicine going?
Dr. Vlastos: Probably two-fold again, Mike. One of them will literally be doing operations. As time as moved forward, the technique on being able to open the uterus, secure the bag of water, perform a surgery, replace the base, close the bag of water, close the uterus – that has been refined to where we can usually by 7 to 10 weeks after a surgery – so I feel in this realm, we will do better on being able to monitor the fetal patients during procedures and be able to do more invasive procedures for some of the congenital problems that the fetus may have.
The second, which is really going into that scientific, mind-boggling component, is that of the potential of gene therapy. A quick example would be found on a fetus that we know has sickle cell disease. There is the potential of introducing the normal gene for the hemoglobin molecule into a fetus and that fetus accepting it because they haven’t developed their immune system to the point that that baby now makes normal hemoglobin. I use that as simply one example of how understanding the genetics may allow us to change the path of a fetus who becomes a newborn, who becomes a child, then an adult.
Dr. Smith: Right, that’s pretty amazing when you think about that – the genetic therapies. When we were in medical school, Dr. Mike, where just things have – far future stuff, and really, it’s just around the corner, and we’ve even seen some procedures happen just in the past couple of years, so that’s fascinating to me. Tell us a little bit though, about the fetal health center at Children’s Mercy. How many patients do you see? How many surgical procedures are you guys performing?
Dr. Vlastos: Absolutely, The Center started about six years ago, and unique to the Fetal Health Center is its position actually within Children’s Mercy Hospital. Here, we have two operating rooms and four labor and delivery suites where moms with special kids can literally be delivered and cared for here and throughout the postpartum period that close to their newborn. Since arriving in September, we have performed two spina bifida repairs here and numerous fetoscopic procedures using that very small laparoscope inside the uterus. Their delivery numbers are now above 860 since The Center opened, and we’re moving into the fetal therapy and fetal surgery component and hoping just to watch that expand with time.
Dr. Smith: Well, Dr. Vlastos, what an amazing field that you are in, and I want to thank you for the work that you’re doing at The Center at Children’s Mercy, and also, thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, you can go to ChildrensMercy.org, that’s ChildrensMercy.org. I’m Dr. Mike Smith. Thanks for listening.
Fetal Surgery Interventions: Hope, Hype and the Future
Dr. Michael Smith (Host): Our topic today, is Fetal Surgery Interventions, Hope, Hype, and the Future. My guest is Dr. Emmanuel “Mike” Vlastos. Dr. Vlastos is a Maternal-Fetal Medicine Specialist and Fetal Surgeon. Dr. Vlastos or as your patients know you as, Dr. Mike, welcome to the show.
Dr. Emmanuel “Mike” Vlastos (Guest): Thank you very much. I really appreciate the opportunity to talk with you.
Dr. Smith: Awesome. Let’s just start with this – I think it’s safe to say that most physicians – most healthcare practitioners – even for us when we think of fetal surgery, it seems so science fiction, right? It seems so Sci-fi. Tell us a little bit of the history of fetal surgery, how long it’s actually been going on, where we are currently, and where you think this specialty is headed?
Dr. Vlastos: I appreciate that, Mike. Looking back in the textbooks, way back in 1954, a gynecologist actually put a very large laparoscope into the uterus to check out a baby who they thought had a problem. This was mind-boggling to me because I had no clue until looking backward into the history of this. A debate raged in the ‘70s to say should we continue using a scope to check out the baby or should we use this new emerging technology called ultrasound. Ultimately, at the time, ultrasound won out because of its noninvasive nature. However, because of ultrasound’s ability to see into the womb, and to note that there were fetal problems, then folks – physicians and generalists started saying is there any possibility of getting back into the womb to actually perform a procedure – surgery on a fetus?
That question was asked in many ways by different groups, but there was a pediatric surgeon -- still at the University of California San Francisco -- named Michael Harrison, who first, in the mid ‘70s, placed tubes in a baby’s kidneys which was unable to urinate to try to help that baby survive in utero. Unfortunately, that baby was lost several days after. However, the paradigm had been shifted so that people started thinking maybe we could get back in there. That’s where many different niduses around America and outside of America – in Europe, Australia, and New Zealand – started to take a look at actually going into the uterus, into the bag of water, and performing surgeries on fetuses to try to help them have a better start at the time of birth.
Dr. Smith: Right. So currently, where do we stand, Dr. Vlastos? What are the current procedures that are commonly performed in hospitals throughout the United States?
Dr. Vlastos: Sure, there are probably around 25, 26 fetal centers that do interventions. They fall into two basic categories, minimally invasive and open procedures. The minimally invasive is predicated on using a 2 to 3 mm scope to look in the uterus at a fetus and to perform surgery – often laser-based. The second is open procedures, and that’s similar to performing a cesarean section. However, rather than delivering the fetus or the baby, the baby is rotated to expose that part that needs to have surgery. That might be a mass in the chest, but most commonly, open fetal repair is done for spina bifida. Those babies with known spina bifida then have repair as a fetus, the uterus is closed, and pregnancy is promoted until around 37 weeks for delivery.
Dr. Smith: Let’s talk a little bit then – so you said about 25 procedures correct, or so are currently being performed? What is it going to take to get us to that next step? What technology do you see coming down the line, and where do you see really the specialty of fetal medicine going?
Dr. Vlastos: Probably two-fold again, Mike. One of them will literally be doing operations. As time as moved forward, the technique on being able to open the uterus, secure the bag of water, perform a surgery, replace the base, close the bag of water, close the uterus – that has been refined to where we can usually by 7 to 10 weeks after a surgery – so I feel in this realm, we will do better on being able to monitor the fetal patients during procedures and be able to do more invasive procedures for some of the congenital problems that the fetus may have.
The second, which is really going into that scientific, mind-boggling component, is that of the potential of gene therapy. A quick example would be found on a fetus that we know has sickle cell disease. There is the potential of introducing the normal gene for the hemoglobin molecule into a fetus and that fetus accepting it because they haven’t developed their immune system to the point that that baby now makes normal hemoglobin. I use that as simply one example of how understanding the genetics may allow us to change the path of a fetus who becomes a newborn, who becomes a child, then an adult.
Dr. Smith: Right, that’s pretty amazing when you think about that – the genetic therapies. When we were in medical school, Dr. Mike, where just things have – far future stuff, and really, it’s just around the corner, and we’ve even seen some procedures happen just in the past couple of years, so that’s fascinating to me. Tell us a little bit though, about the fetal health center at Children’s Mercy. How many patients do you see? How many surgical procedures are you guys performing?
Dr. Vlastos: Absolutely, The Center started about six years ago, and unique to the Fetal Health Center is its position actually within Children’s Mercy Hospital. Here, we have two operating rooms and four labor and delivery suites where moms with special kids can literally be delivered and cared for here and throughout the postpartum period that close to their newborn. Since arriving in September, we have performed two spina bifida repairs here and numerous fetoscopic procedures using that very small laparoscope inside the uterus. Their delivery numbers are now above 860 since The Center opened, and we’re moving into the fetal therapy and fetal surgery component and hoping just to watch that expand with time.
Dr. Smith: Well, Dr. Vlastos, what an amazing field that you are in, and I want to thank you for the work that you’re doing at The Center at Children’s Mercy, and also, thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, you can go to ChildrensMercy.org, that’s ChildrensMercy.org. I’m Dr. Mike Smith. Thanks for listening.