开放性胎儿显微神经外科手术治疗宫内脊柱裂修复

Open Fetal Microneurosurgery for Intrauterine Spina Bifida Repair.

作者信息

Cruz-Martínez Rogelio, Chavelas-Ochoa Felipe, Martínez-Rodríguez Miguel, Aguilar-Vidales Karla, Gámez-Varela Alma, Luna-García Jonahtan, López-Briones Hugo, Chávez-Vega Joel, Pérez-Calatayud Ángel Augusto, Díaz-Carrillo Manuel Alejandro, Ahumada-Angulo Edgar, Castelo-Vargas Andrea, Chávez-González Eréndira, Juárez-Martínez Israel, Villalobos-Gómez Rosa, Rebolledo-Fernández Carlos

机构信息

Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and the Fetal Medicine Foundation of Mexico, Queretaro, Mexico,

Instituto de Ciencias de la Salud (ICSa) , Universidad Autónoma del Estado de Hidalgo (UAEH), Hidalgo, Mexico,

出版信息

Fetal Diagn Ther. 2021;48(3):163-173. doi: 10.1159/000513311. Epub 2021 Feb 12.

DOI:10.1159/000513311

PMID:33582666

Abstract

OBJECTIVES

The aim of the study was to describe the feasibility of open fetal microneurosurgery for intrauterine spina bifida (SB) repair and to compare perinatal outcomes with cases managed using the classic open fetal surgery technique.

METHODS

In this study, we selected a cohort of consecutive fetuses with isolated open SB referred to our fetal surgery center in Queretaro, Mexico, during a 3.5-year period (2016-2020). SB repair was performed by either classic open surgery (6- to 8-cm hysterotomy with leakage of amniotic fluid, which was replaced before uterine closure) or open microneurosurgery, which is a novel technique characterized by a 15- to 20-mm hysterotomy diameter, reduced fetal manipulation by fixing the fetal back, and maintenance of normal amniotic fluid and uterine volume during the whole surgery. Perinatal outcomes of cases operated with the classic open fetal surgery technique and open microneurosurgery were compared.

RESULTS

Intrauterine SB repair with a complete 3-layer correction was successfully performed in 60 cases either by classic open fetal surgery (n = 13) or open microneurosurgery (n = 47). No significant differences were observed in gestational age (GA) at fetal intervention (25.4 vs. 25.1 weeks, p = 0.38) or surgical times (107 vs. 120 min, p = 0.15) between both groups. The group with open microneurosurgery showed a significantly lower rate of oligohydramnios (0 vs. 15.4%, p = 0.01), preterm rupture of the membranes (19.0 vs. 53.8%, p = 0.01), higher GA at birth (35.1 vs. 32.7 weeks, p = 0.03), lower rate of preterm delivery <34 weeks (21.4 vs. 61.5%, p = 0.01), and lower rate of perinatal death (4.8 vs. 23.1%, p = 0.04) than the group with classic open surgery. During infant follow-up, the rate of hydrocephalus requiring ventriculoperitoneal shunting was similar between both groups (7.5 vs. 20%, p = 0.24). All patients showed an intact hysterotomy site at delivery.

CONCLUSION

Intrauterine spina repair by open fetal microneurosurgery is feasible and was associated with better perinatal outcomes than classic open fetal surgery.

摘要

目的

本研究旨在描述开放性胎儿显微神经外科手术修复宫内脊柱裂（SB）的可行性，并将围产期结局与采用经典开放性胎儿手术技术治疗的病例进行比较。

方法

在本研究中，我们选取了在3.5年期间（2016 - 2020年）转诊至墨西哥克雷塔罗市我们的胎儿手术中心的一组连续的孤立开放性SB胎儿。SB修复通过经典开放性手术（6至8厘米的子宫切开术，羊水渗漏，在子宫关闭前进行置换）或开放性显微神经外科手术进行，开放性显微神经外科手术是一种新技术，其特点是子宫切开术直径为15至20毫米，通过固定胎儿背部减少胎儿操作，并在整个手术过程中维持正常的羊水和子宫容积。比较采用经典开放性胎儿手术技术和开放性显微神经外科手术治疗的病例的围产期结局。

结果

60例患者通过经典开放性胎儿手术（n = 13）或开放性显微神经外科手术（n = 47）成功进行了宫内SB修复，实现了完整的三层矫正。两组在胎儿干预时的孕周（GA）（25.4周对25.1周，p = 0.38）或手术时间（107分钟对120分钟，p = 0. $15）方面均未观察到显著差异。开放性显微神经外科手术组羊水过少发生率显著较低（0%对15.4%，p = 0.01），胎膜早破发生率较低（19.0%对53.8%，p = 0.01），出生时GA较高（35.1周对32.7周，p = 0.03），孕周<34周的早产发生率较低（21.4%对61.5%，p = 0.01），围产期死亡率较低（4.8%对23.1%，p = 0.04）。在婴儿随访期间，两组需要进行脑室腹腔分流术的脑积水发生率相似（7.5%对20%，p = 0.24）。所有患者在分娩时子宫切开部位均完整。