两种羊膜腔镜下开放性神经管缺陷修复技术的比较：单层 vs 三层关闭。

Comparison of two fetoscopic open neural tube defect repair techniques: single- vs three-layer closure.

机构信息

Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA.

Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA.

出版信息

Ultrasound Obstet Gynecol. 2020 Oct;56(4):532-540. doi: 10.1002/uog.21915.

DOI:10.1002/uog.21915

PMID:31709658

Abstract

OBJECTIVES

We reported previously on an exteriorized-uterus fetoscopic repair for open neural tube defect (ONTD) using a single-layer closure (SLC) technique. However, because SLC was associated with a high rate of cerebrospinal fluid (CSF) leakage at birth, we developed a three-layer closure (3LC) technique comprising a bovine collagen patch, a myofascial layer and a skin layer. The aims of this study were to compare SLC and 3LC in terms of intraoperative, postoperative and obstetric outcomes, as well as short-term neonatal neurologic and non-neurologic outcomes.

METHODS

This was a retrospective analysis of prospectively collected data, from 32 consecutive SLC controls and 18 consecutive 3LC cases, that underwent exteriorized-uterus two-port fetoscopic repair of ONTD at our center, between April 2014 and December 2018. All patients satisfied the Management of Myelomeningocele Study (MOMS) criteria. Obstetric, maternal, fetal and early neonatal outcomes were compared between the SLC and 3LC groups.

RESULTS

Maternal demographics and mean gestational age (GA) at fetal surgery (25.0 ± 0.7 vs 25.0 ± 0.5 weeks' gestation; P = 0.96), and at delivery (36.5 ± 3.5 vs 37.6 ± 3.0 weeks; P = 0.14), were similar between the SLC and 3LC groups, respectively. The rate of preterm prelabor rupture of membranes (PPROM) < 37 weeks (28% vs 29%; P = 0.9), mean GA at PPROM (32.3 ± 3.4 vs 32.7 ± 1.9 weeks; P = 0.83) and rate of vaginal delivery (50% vs 47%; P = 0.84) were similar for the SLC vs 3LC groups, respectively. In pregnancies that had SLC compared with those that had 3LC, there was a significantly higher incidence of CSF leakage at birth (8/32 (25%) vs 0/17 (0%); P = 0.02) and a significantly lower rate of reversal of hindbrain herniation at 6 weeks postoperatively (18/30 (60%) vs 14/15 (93%); P = 0.02). The rate of infants that met the MOMS criteria for shunt placement or died before 12 months of age (23/31 (74%) vs 7/12 (58%); P = 0.31) and those that required treatment for hydrocephalus by 12 months (15/32 (47%) vs 4/12 (33%); P = 0.42) were similar between the SLC and 3LC groups, respectively.

CONCLUSIONS

Compared to SLC, 3LC preserves the fetal and obstetric benefits of fetoscopic repair and shows improved rates of CSF leakage and reversal of hindbrain herniation at 6 weeks postoperatively. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

摘要

目的

我们之前报道了一种使用单层闭合（SLC）技术的开放性神经管缺陷（ONTD）经子宫外显胎儿镜修复方法。然而，由于 SLC 与出生时脑脊液（CSF）漏的发生率较高相关，我们开发了一种包括牛胶原蛋白贴片、筋膜层和皮肤层的三层闭合（3LC）技术。本研究的目的是比较 SLC 和 3LC 在术中、术后和产科结果以及短期新生儿神经和非神经结果方面的差异。

方法

这是对 2014 年 4 月至 2018 年 12 月在我们中心接受经子宫外显胎儿镜修复 ONTD 的 32 例 SLC 对照和 18 例 3LC 连续病例的前瞻性收集数据进行的回顾性分析。所有患者均符合髓脊膜膨出管理研究（MOMS）标准。比较 SLC 和 3LC 组的产科、母体、胎儿和早期新生儿结局。

结果

SLC 和 3LC 组的母体人口统计学特征和胎儿手术时的平均孕龄（GA）（分别为 25.0±0.7 和 25.0±0.5 周；P=0.96）以及分娩时的平均 GA（分别为 36.5±3.5 和 37.6±3.0 周；P=0.14）相似。早产胎膜早破（PPROM）<37 周的发生率（28% vs 29%；P=0.9）、PPROM 时的平均 GA（分别为 32.3±3.4 和 32.7±1.9 周；P=0.83）和阴道分娩率（50% vs 47%；P=0.84）在 SLC 组和 3LC 组之间相似。与 SLC 组相比，行 SLC 的妊娠组出生时 CSF 漏的发生率显著更高（8/32（25%） vs 0/17（0%）；P=0.02），术后 6 周时后颅窝疝逆转的发生率显著更低（18/30（60%） vs 14/15（93%）；P=0.02）。符合 MOMS 标准需要放置分流管或在 12 个月前死亡的婴儿发生率（23/31（74%） vs 7/12（58%）；P=0.31）和需要在 12 个月前治疗脑积水的婴儿发生率（15/32（47%） vs 4/12（33%）；P=0.42）在 SLC 组和 3LC 组之间相似。