1Department of Neurosurgery, Leiden University Medical Center, Leiden.
2Department of Neurosurgery, Erasmus University Medical Center Rotterdam.
Neurosurg Focus. 2019 Oct 1;47(4):E10. doi: 10.3171/2019.7.FOCUS19362.
Improvements in imaging and surgical technological innovations have led to the increasing implementation of fetal surgical techniques. Open fetal surgery has demonstrated more favorable clinical outcomes in children born with open myelomeningocele (MMC) than those following postnatal repair. However, primarily because of maternal risks but also because of fetal risks, fetal surgery for MMC remains controversial. Here, the authors evaluated the contemporary management of MMC in the hope of identifying barriers and facilitators for neurosurgeons in providing fetal surgery for MMC.
An online survey was emailed to members of the Congress of Neurological Surgeons (CNS) and the International Society for Pediatric Neurosurgery (ISPN) in March 2019. The survey focused on 1) characteristics of the respondents, 2) the practice of counseling on and managing prenatally diagnosed MMC, and 3) barriers, facilitators, and expectations of fetal surgery for MMC. Reminders were sent to improve the response rate.
A total of 446 respondents filled out the survey, most (59.2%) of whom specialized in pediatric neurosurgery. The respondents repaired an average of 9.6 MMC defects per year, regardless of technique. Regardless of the departments in which respondents were employed, 91.0% provided postnatal repair of MMC, 13.0% open fetal repair, and 4.9% fetoscopic repair. According to the surgeons, the most important objections to performing open fetal surgery were a lack of cases available to become proficient in the technique (33.8%), the risk of maternal complications (23.6%), and concern for fetal complications (15.2%). The most important facilitators according to advocates of prenatal closure are a decreased rate of shunt dependency (37.8%), a decreased rate of hindbrain herniation (27.0%), and an improved rate of motor function (18.9%). Of the respondents, only 16.9% agreed that open fetal surgery should be the standard of care.
The survey results showed diversity in the management of patients with MMC. In addition, significant diversity remains regarding fetal surgery for MMC closure. Despite the apparent benefits of open fetal surgery in selected pregnancies, only a minority of centers and providers offer this technique. As a more technically demanding technique that requires multidisciplinary effort with less well-established long-term outcomes, fetoscopic surgery may face similar limited implementation, although the surgery may pose fewer maternal risks than open fetal surgery. Centralization of prenatal treatment to tertiary care referral centers, as well as the use of sophisticated training models, may help to augment the most commonly cited objection to the implementation of prenatal closure, which is the overall limited caseload.
成像和外科技术创新的进步导致胎儿外科技术的应用日益增多。与出生后修复相比，开放性胎儿手术在开放性脊髓脊膜膨出（MMC）患儿中的临床效果更为理想。然而，主要由于产妇风险，也由于胎儿风险，MMC 的胎儿手术仍存在争议。在此，作者评估了 MMC 的当代治疗方法，希望为神经外科医生提供 MMC 的胎儿手术提供障碍和促进因素。
2019 年 3 月，向神经外科学会（CNS）和国际小儿神经外科学会（ISPN）的成员发送了在线调查。该调查侧重于 1）受访者的特征，2）对产前诊断的 MMC 进行咨询和管理的实践，以及 3）胎儿手术治疗 MMC 的障碍，促进因素和期望。发送了提醒以提高回复率。
共有 446 名受访者填写了调查，其中大多数（59.2％）专门从事小儿神经外科。受访者每年平均修复 9.6 例 MMC 缺陷，无论采用哪种技术。无论受访者在哪个部门工作，91.0％的人都提供 MMC 的产后修复，13.0％的人提供开放性胎儿修复，4.9％的人提供经阴道修复。根据外科医生的说法，进行开放性胎儿手术的最重要反对意见是缺乏掌握该技术的病例（33.8％），产妇并发症的风险（23.6％）和对胎儿并发症的担忧（15.2％）。根据产前闭合术的拥护者，最重要的促进因素是分流依赖性降低（37.8％），后脑疝发生率降低（27.0％）和运动功能改善（18.9％）。在受访者中，只有 16.9％的人同意开放性胎儿手术应成为护理标准。
调查结果显示，MMC 患者的管理方式存在差异。此外，关于 MMC 闭合的胎儿手术仍然存在明显差异。尽管在某些妊娠中开放性胎儿手术具有明显的优势，但只有少数中心和提供者提供这种技术。由于该技术要求更高的技术水平，需要多学科的努力，并且长期结果不太确定，因此经阴道手术可能会面临类似的限制实施，尽管与开放性胎儿手术相比，该手术对产妇的风险可能较低。将产前治疗集中到三级医疗转诊中心，并使用复杂的培训模型，可能有助于解决实施产前闭合术的最常见反对意见，即总体上病例数有限。
