title: The ex utero intrapartum treatment procedure: Looking back at the EXIT.
abstract: OBJECTIVE
  The ex utero intrapartum treatment (EXIT) procedure was developed originally for management of airway obstruction after fetal surgery, and indications have continued to expand for a variety of fetal anomalies. The authors review their single-institution experience with EXIT.
  
  
  METHODS
  Retrospective review of all patients who underwent an EXIT procedure from 1993 to 2003 (n = 52) was performed. Variables evaluated include indication for EXIT, gender, gestational age at EXIT, birth weight, maternal blood loss, operative complications, operative time, and survival rate. Technique, personnel, and anesthesic management were reviewed.
  
  
  RESULTS
  Long-term follow-up was available for all patients. Fifty-one of 52 patients were born alive; currently, 27 of 52 patients (52%) are alive. All deaths have been in patients with congenital diaphragmatic hernia. Forty-five patients underwent EXIT for reversal of tracheal occlusion for congenital diaphragmatic hernia. Of these patients, 30 underwent tracheal clip removal. Two patients had repair of tracheal injury from clipping at EXIT. Fifteen patients underwent bronchoscopy and tracheal balloon removal. Five patients underwent EXIT procedure for neck masses. Tracheostomy was performed in 3 of these patients. One patient was intubated successfully, and 1 patient underwent resection of the neck mass while on placental support. Two patients underwent EXIT procedure and tracheostomy for congenital high-airway obstruction syndrome. Average gestational age at delivery was 31.95 +/- 2.55 weeks. Average birth weight was 1,895 +/- 653 g. Average maternal blood loss was 970 +/- 510 mL. Average operating time on placental support was 45 +/- 25 minutes with a maximum of 150 minutes.
  
  
  CONCLUSIONS
  EXIT procedures can be performed with minimal maternal morbidity and with good outcomes. It is an excellent strategy for establishing an airway in a controlled manner, avoiding "crash" intubation or tracheostomy. Longer procedures on placental support allowing for definitive management of neck masses and airway obstruction have been realized. EXIT procedures have evolved from an adjunct to fetal surgery to a potentially life-saving procedure in fetuses with airway compromise at birth.
authors.affiliation: Division of Pediatric Surgery and the Fetal Treatment Center, Department of Surgery, University of California, San Francisco, San Francisco, CA 94143-0570, USA.
authors.forename: Shinjiro
authors.initials: S
authors.lastname: Hirose
authors.forename: Diana L
authors.initials: DL
authors.lastname: Farmer
authors.forename: Hanmin
authors.initials: H
authors.lastname: Lee
authors.forename: Kerilyn K
authors.initials: KK
authors.lastname: Nobuhara
authors.forename: Michael R
authors.initials: MR
authors.lastname: Harrison
mesh_terms: D000402:Airway Obstruction / Q000151:congenital* / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D005315:Fetal Diseases / Q000601:surgery*; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D020883:Hysterotomy; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D014132:Trachea / Q000601:surgery; D014139:Tracheostomy; D016216:Ultrasonography, Prenatal