US team led by SA-trained doctor in an African first

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Belfort

Professor Mike Belfort

A 25-week-old unborn Johannesburg baby has become the first foetus in Africa to receive anaesthetic and undergo ground-breaking “keyhole” surgery to the spine. The four-hour procedure, which involved removing the womb and resting it on the mother’s skin, was performed by a team led by US Baylor College of Medicine professor Mike Belfort, who was born and trained in South Africa.

The Times reports that Belfort and his team secured a licence for a day from the Health Professions Council of SA to perform the operation, which also required specialist anaesthetists to treat mom and baby so that the foetus didn’t move during surgery.

The world leader in foetal surgery said operating in South Africa made him “emotional”. He first trained as a doctor at Wits University and qualified as a gynaecologist through the University of Cape Town. “It’s an honour and a privilege. I was born in South Africa.” The baby has been diagnosed with spina bifida, which could cause paralysis and lead to brain damage.

The report says the operation, at MediClinic Morningside in Sandton, to repair nerve damage to the spine gives the foetus a better chance at walking one day. It also lowers the risk of fluid building up in the brain after birth. It was the first time the surgery had been performed on African soil.

International surgeons opened the mother’s abdomen as they would for a caesarean section and lifted the womb out and laid it on her skin. They then made two small cuts into the womb to insert cameras and tiny instruments. One of the assistants held the womb and foetus steady so surgeons could operate on a stable platform. The report says the little patient received its own anaesthetic in the bottom. At 25 weeks, the baby would be close to 600 grams and not much longer than a school ruler.

The report says spina bifida is an abnormality in the development of the foetal spine where part of the vertebrae does not close properly. The defect and subsequent “exposure” of the nerve can cause nerve damage. Side-effects include club feet, incontinence, death, paralysis of legs, and accumulation of fluid in the brain (hydrocephalus), which can cause brain damage.

The report says Belfort and three of his US team members led the operation and worked with a team of four South African doctors, whom he described as “outstanding”. Wits professor of obstetrics Ermos Nicolaou called him about eight weeks ago, saying there was a patient in need of surgery and “can you help?” The reply came swiftly: “Yes.”

The Texas Childrens Hospital paid for the trip.

Belfort is quoted in the report as saying that foetal surgery reduced the 90% likelihood that the child, with this form of spina bifida, would need a shunt to remove fluid from the brain, to 45%. It also doubles the likelihood that the child will walk.

But it was not an easy decision for the parents. The report says the operation is life-threatening to the foetus and can cause premature labour. The mother met every member of the South African and US medical team on Friday. On Saturday, a neonatologist was on standby in case the foetus was born.

The report says at one point, South African anaesthesiologist Erni Welch counted 24 people in the operating theatre. There were nurses, representatives from equipment companies and two teams of doctors. Welch, who worked alongside US anaesthesiologist Mario Patino, said anaesthetics in foetal surgery is particularly tricky. “You are dealing with two patients and one of the patients you can’t actually see. Not all drugs cross the placenta from the mom to baby so the baby needs its own anaesthetic … you don’t want the baby to move or you can’t see where you need to operate.”

The report says the operation raises ethical questions. The mother has to make the best decision for her child, who she has never met. She also has to have an operation while pregnant, a risk to her with no direct benefits for her body. Belfort explained: “You are asking the mother to take a risk for the baby. She is doing it to benefit of her child and taking the risk for her child. It is a complex ethical problem.” As long as she is fully aware of the risks and benefits and makes an informed decision, it is ethical, he said.

The report says Belfort’s foetal surgery team is supervised by four different medical authorities in the US, including the Food and Drug Administration. Foetal surgery, Nicolaou explained, is usually done if the problem will lead to foetal death or severe handicap. “One needs to mention that this is a very delicate surgery and the success varies. In utero laparoscopic repair can also have complications such as foetal death and premature labour. Careful evaluation and selection of these cases is very important.”
The biggest risk now is premature labour because the operation stimulates the uterus, a muscle that could start to contract.

Welch and Nicolaou say mom and baby are doing very well. On Tuesday, she was sitting up and using her phone, and contemplating eating for the first time in more than 48 hours.

The report says the doctors will only know how successful the surgery was when the child is born. The baby’s legs and feet will be checked to see if it is likely to walk, while the brain will be monitored for hydrocephalus.

Belfort said the surgery is not a cure and requires monitoring and possibly surgery after birth, although the doctors’ aim in this case was to prevent further operations.

Belfort, who has performed the keyhole surgery – which was invented by his team – about 60 times, said in the report that this was “quite frankly, one of my best cases ever”. “Kudos to the Morningside team. They were every bit professional and organised.” It had gone well “in terms of how smoothly the surgery went, the great anaesthetic, how well the team functioned with additional members. There was great camaraderie.”

He discovered that one of the doctors, now a professor of neurosurgery, Graham Fieggan, had been his obstetrics intern at UCT years ago. “Maybe I put him off obstetrics,” he joked, adding that he hoped the South African team would soon visit Houston, Texas, to take part in more operations.

The Times report

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