Major Surgery Before Birth

By ANDREW PURVIS

Blake Schultz appeared to be doomed before he was even born. While he was in his mother's womb, a hole opened up in his diaphragm and allowed his stomach, spleen and intestines to press into his chest cavity and put pressure on his lungs. The grim prognosis: at birth, he would probably be unable to breathe.

But Blake did breathe, and today he is a healthy nine-month-old -- thanks to a dramatic operation carried out when he was still a fetus. This procedure, the most impressive achievement yet in the young field of fetal surgery, was performed by Dr. Michael Harrison and colleagues at the University of California, San Francisco and reported last week in the New England Journal of Medicine. Seven weeks before Blake was born, the doctors cut into his mother's uterus and partly removed the fetus. Then they opened his left side, patched the hole in his diaphragm and put his organs back in the right places.

Since the early 1980s, doctors have operated on fetuses, fixing urinary- tract blockages, for example, or inserting needles to drain excess fluid from the brain. But never before had physicians successfully performed such major surgery in the womb. Harrison hopes that his technique can be used to correct other potentially fatal problems, including large lung or spinal tumors and certain heart conditions. Several experts echoed that optimism. "We're in a whole new era of fetal treatment," said Dr. Eugene Pergament, head of reproductive genetics at Northwestern Memorial Hospital.

That era may take a while to unfold, however. For now, the procedure seems useful only for rare ailments. Blake Schultz's diaphragmatic hernia, for example, occurs in 1 out of every 2,200 births, and 90% of those cases are considered unsuitable for surgery. Moreover, while Harrison has proved that this operation is feasible, only long-term clinical trials can establish that the surgery will be effective for a majority of patients.

Harrison spent five years practicing and refining his technique on hundreds of sheep and monkeys. Even so, his first six operations on human fetuses with problems similar to Blake's failed: he was unable to save the babies because of difficulties encountered in handling their organs. After his success with Blake, Harrison performed a comparable prenatal operation on a little girl, who was also born healthy.

Not many surgeons are likely to develop similar expertise soon. Nonetheless, Harrison's work may herald a time when doctors can routinely help the unborn victims of nature's mistakes.