In the Court of the King

I was a guest of the Children’s Hospital of Philadelphia (CHOP) during the week of the recent regal wedding with its world turned upside down connotations of a biracial bride, a fire and brimstone Episcopalian bishop from the USA and the general cheer of people having a good time. CHOP is a venerable institution, founded in 1855, and is still pushing the envelope to its limits and broadening the boundaries of surgical possibilities.

In the midst of this surgical world is N Scott Adzick (Fig. 1, 2), self-proclaimed King of all he surveys. And what a kingdom: 7 attending general surgeons, over 4000 operations a year, and THE centre for fetal intervention stateside. It was indeed a privilege to watch the team in action. Fetal operating is not new, indeed one could say it was conceived on the West Coast in San Francisco in the 1980s but moved East to reach its current apogee in CHOP in the 2000s.

The key operation in the States now is fetal closure of a myelomeningocele. While not currently available in the UK, it is central to activity here and shown by randomised trial (the MOMs trial) to reduce neurological consequence and diminish the need for shunting (1). Nevertheless it remains a major undertaking and I counted a team of 20 or so in an enlarged operations room, all swirling around NSA. Fetal heart monitoring and live-imaging; general anaesthesia for the two patients; a bit of version to get the baby orientated and then wheel in a certified neurosurgeon for the actual closure. And then 20 minutes later it’s all done. Mother on strict bed rest for the next few months until delivery.

All of this novel clinical activity was driven by research and down in the bunker the new Dark Lord, Alan Flake, surveys his domain (Fig, 2). This is the 21st century research into the artificial placenta and is a serious undertaking with a multiplicity of research fellows present 24/7 to ensure everything remains operational. The concept of the artificial placenta is pushing ahead, no question and although humans are not yet on the immediate horizon, plenty of sheep have been through the “bag” for weeks at a time (Fig. 3). Underwater umbilical arterial and venous catheterisation allows total intravenous parenteral support, and oxygenation occurs through a pumpless machine.

The fetus being maintained within a thermo-regulated plastic bag which allows some movement. A lot of research has gone into these sheep, most of it at CHOP, and venture (vulture) capitalists are circling the skies sensing future applications and money to be made. The Canadian princess, Emily Partridge MD PhD MSc FRCSC RCMP, dripping with post-nominals, good taste and ludicrously over-qualified for a fellow puts in the shifts on the NICU and in the FSICU alike and illustrates the intense competition needed to work here.

There are others in this team of heavy hitters. Pablo Laje, for instance, is more of a passionate Argentinian prince of the blood but he is fast becoming a very prolific writer on all things to do with congenital lung anomalies, adding to the lustre of the CHOP brand, but obviously over-remunerated with a head-turning BMW i8 series car [N.B. 0 – 60 in 4.4 seconds! And it is saving the planet as a plug-in hybrid-electric vehicle].

Figure 5 The Liberty Bell – originally cast in Whitechapel, London in 1753. Cracked on arrival in Philadelphia and had to be re-cast. “It was alright when it left us..” said the Cockney bell-makers. Philadelphia is a great city, the site of the first American capital founded in 1682 as the city of brotherly love and religious tolerance by a Londoner, the Quaker William Penn. It was once the only place in the 18th century British Empire where a Roman catholic mass could legally be carried out. Some parts of it, adjacent to the Delaware, still retain that historical core but it’s still a modern American metropolis with a skyscraper skyline and an inexplicable devotion to baseball, basketball and now (gridiron) football. Apparently they (The Eagles) won the Superbowl (LII) this season, whatever that is. There are also a lot of universities there, almost 20 scattered along the banks of the Schuylkill river, private mainly but also state and it certainly gives the impression of a city within a city. So there it is Philadelphia: old city with new horizons!

With many thanks to Dr Erin Brown for facilitating my visit and Holly Hedrick and William Peranteau for enlightening my mind.

More information:

Adzick NS, Thom EA, Spong CY, et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011;364(11):993-1004.
https://closeronline.co.uk/real-life/news/artificial-womb-premature-babies-grow-special-bags-lamb-experiment/

Prof Mark Davenport
President of BAPS
(June 2018)