First-Person Perspective

20 Years in Fetal Surgery

Laurie Scudder, DNP, NP; N. Scott Adzick, MD

Disclosures

June 20, 2015

Editorial Collaboration

Medscape &

The concept of repairing these anatomic defects before birth was very controversial when we first introduced this concept more than three decades ago. To get to the point of being able to do this clinically (and this was long before we were thinking about intrauterine repair for myelomeningocele), we had to do our homework—experimental work—mostly in fetal sheep and fetal rhesus monkeys, to make sure that the biology was right, such that if we fixed a birth defect prenatally, it could be done safely, and the fetus's condition would be dramatically improved by the time of birth. Years of experimental work were done (that continue to this day) during which we problem-solved to make the eventual clinical enterprise safe. For example: how to quickly and bloodlessly open the uterus by development of a uterine stapling device; how to monitor the fetus during the operation; how to treat the mother after the operation; which tocolytic medicines to use to prevent preterm labor; whether this intervention would have an effect on the mother's future reproductive capacity. Along the way we did work at the California National Primate Research Center in Davis, California, with rhesus monkeys. We operated on more than 400 maternal monkeys and showed that we could safely do fetal surgery with low risk, although not risk-free. We could effectively control preterm labor after the fetal surgery, although that is by no means a solved problem clinically. We followed the mother monkeys after they returned to the breeding colony to show that doing the fetal surgical intervention did not impair their future reproductive capacity.

After that work, we were ready to offer this to the first human patients clinically in the 1980s and early 1990s. Initially we treated only the most severe cases. Early on we had more failures than successes, but the failures fueled innovation that would subsequently facilitate success and help mothers and babies. To this day, all of this "homework" must be done prior to clinical implementation of any new fetal therapy.

Dr Alan Flake, in our group, is doing in utero hematopoietic stem cell transplantation to treat cellular-deficiency diseases before birth in the "preimmune" fetus early in gestation by giving normal stem cells that will take over the missing function. He has been working on this experimentally for 30 years and is now poised to apply this work clinically in fetuses with prenatally diagnosed sickle cell anemia at 12-14 weeks gestation. That doesn't just happen; it takes work—and in this particular circumstance, three decades of work.

Another surprise in the field of fetal surgery—and perhaps "surprise" is not the right word—is the courage of the mothers who decide to undergo fetal surgery to try to save or help their unborn babies. My admiration for them is boundless. I am continually amazed and inspired by the fortitude and resilience of the mothers. The mothers are just incredible, really almost beyond human understanding.

Another surprise was in terms of fetal biology. We learned that, early in gestation, fetal skin wounds heal without scarring, so we are trying to unravel the secrets of scar-free fetal wound repair and hopefully apply those lessons to treat conditions that cause scarring and fibrosis after birth. That phenomenon was a remarkable, serendipitous finding.

Medscape: What would you say is the thing that keeps you most energized about your field? Is it the clinical? Is it the research? Or is it that marriage of the two?

Dr Adzick: I can answer that question with one more quote. My predecessor as surgeon-in-chief at CHOP was Dr C. Everett Koop. He said of pediatric surgery that if you save a child, you save a lifetime. That is really true. Talk about being energized. I am incredibly energized, driven, and focused. I love working hard, every day. For me it is not work; it is a passion, a mission, an honor, a privilege, and a miracle. I have found something that I love to do, and it is all about making patients better. Dr W. Hardy Hendren taught me that when you face problems in pediatric surgery, if you don't succeed in solving them at first, you just have to keep trying until you get it right. So you have to persist. You have to persist almost to the point of obstinacy, because it's worth it.

Medscape: What one or two key pieces of advice do you have for young physicians, young surgeons, who hope to pursue your area of practice? Burnout in the physician community is extraordinarily high, but you are clearly not burned out. You love what you are doing. Is there a way to help people develop that love for what they do?

Dr Adzick: I think it comes from inside. Each year I give a lecture about fetal surgery during the embryology course to first-year University of Pennsylvania medical students. One of the reasons why I do that is because I think there might be one or two spectacular students who might be inspired to consider the sort of work that we do here at CHOP. I also do it because Dr Folkman gave this type of lecture, about how embryology is important for pediatric surgery, to my first-year Harvard Medical School class in January 1976. So now I give an hour lecture, and then I stay for a long time afterwards so that the students can ask questions.

There are those students who ask, "How can I be like you?"—which is flattering, of course. But I think it's important for those who choose a career in pediatric surgery to understand what is involved in that commitment. I finished training when I was 35 years old. Our current pediatric surgery fellows are usually in their late 30s when they finally finish training, and their careers are just beginning! You have to enjoy the process. You can't just be thinking about the end result. That is important.

The other advice is from Dr Francis D. Moore, in a biographical article[2] that he published in JAMA almost three decades ago as a Harvard "surgical professor."

He wrote:

Young physicians and surgeons should study whatever wild ideas they have and try to find whatever grain of truth is out there, encourage others to achieve, place the welfare of their patients and of biological science above their own petty comforts, and above all be married to the right spouse, raise a family and have a good time as citizen, parent, participant. These human values, not solely those of fame or fortune, provide the role models attractive to the young in any field.

How about that? That is good advice.

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