Masoudi Mohammad Sadegh, Hoghoughi Mohammad Ali, Ghaffarpasand Fariborz, Yaghmaei Shekoofeh, Azadegan Maryam, Ilami Ghazal
1Department of Neurosurgery.
2Department of Plastic and Reconstructive Surgery, and.
J Neurosurg Pediatr. 2019 Jul 1;24(1):75-84. doi: 10.3171/2019.1.PEDS18232. Epub 2019 Apr 19.
Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%-70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement.
This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups.
The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p < 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12-23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group.
The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.
脊髓脊膜膨出（MMC）缺损的手术修复和闭合非常重要且至关重要，因为未经治疗的患者死亡率高达65%-70%。对于小儿神经外科医生和整形外科医生而言，闭合大型MMC缺损具有挑战性。本研究的目的是报告一系列采用V-Y皮瓣并结合背阔肌或臀肌推进术治疗的伊朗大型MMC缺损患者的手术特点及结果。
本对比研究于2013年9月至2017年10月在伊朗南部设拉子纳马齐医院小儿神经外科进行，为期4年。作者纳入了24例接受双侧V-Y皮瓣并结合背阔肌和臀肌推进术的大型MMC缺损患者，还回顾性纳入了19例年龄、性别和缺损大小相似且在其中心接受一期或延迟闭合技术手术的患者。进行了至少2年的随访。比较两组之间渗漏、坏死、裂开、全身感染（败血症、肺炎）、是否需要插入脑室腹腔分流管以及死亡率的发生频率。
与一期闭合组相比，双侧V-Y皮瓣结合肌肉推进术的手术时间显著更长（p<0.001）。接受双侧V-Y皮瓣结合肌肉推进术的患者手术部位感染率（p = 0.038）、伤口裂开率（p = 0.013）和术后脑脊液渗漏率（p = 0.030）均显著低于接受一期修复的患者。双侧V-Y皮瓣结合肌肉推进术的死亡率也低于一期闭合（p = 0.038；OR 5.09 [95% CI 1.12 - 23.1]）。在接受双侧V-Y皮瓣和肌肉推进术的患者中，手术时间延长与死亡率显著相关（p = 0.008）。此外，手术部位感染（p = 0.032）、伤口裂开（p = 0.011）和术后渗漏（p = 0.011）是死亡率的预测因素。新生儿败血症（p = 0.002）和术后坏死性小肠结肠炎（p = 0.011）是该组死亡率的其他预测因素。
双侧V-Y皮瓣结合背阔肌或臀肌推进术是覆盖大型MMC缺损的一种安全有效的手术方法，且手术部位感染、裂开、脑脊液渗漏和死亡率较低。需要进一步研究以阐明长期结果。
