剖腹辅助 2 端口经阴道脊柱裂闭合术的实施过程和演变。

Implementation Process and Evolution of a Laparotomy-Assisted 2-Port Fetoscopic Spina Bifida Closure Program.

机构信息

The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA.

Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA.

出版信息

Fetal Diagn Ther. 2021;48(8):603-610. doi: 10.1159/000518507. Epub 2021 Sep 8.

DOI:10.1159/000518507

PMID:34518445

Abstract

INTRODUCTION

Prenatal closure of open spina bifida via open fetal surgery improves neurologic outcomes for infants in selected pregnancies. Fetoscopic techniques that are minimally invasive to the uterus aim to provide equivalent fetal benefits while minimizing maternal morbidities, but the optimal technique is undetermined. We describe the development, evolution, and feasibility of the laparotomy-assisted 2-port fetoscopic technique for prenatal closure of fetal spina bifida in a newly established program.

METHODS

We conducted a retrospective cohort study of women consented for laparotomy-assisted fetoscopic closure of isolated fetal spina bifida. Inclusion and exclusion criteria followed the Management of Myelomeningocele Study (MOMS). Team preparation involved observation at the originating center, protocol development, ancillary staff training, and surgical rehearsal using patient-matched models through simulation prior to program implementation. The primary outcome was the ability to complete the repair fetoscopically. Secondary maternal and fetal outcomes to assess performance of the technique were collected prospectively.

RESULTS

Of 57 women screened, 19 (33%) consented for laparotomy-assisted 2-port fetoscopy between February 2017 and December 2019. Fetoscopic closure was completed in 84% (16/19) cases. Over time, the technique was modified from a single- to a multilayer closure. In utero hindbrain herniation improved in 86% (12/14) of undelivered patients at 6 weeks postoperatively. Spontaneous rupture of membranes occurred in 31% (5/16) of fetoscopic cases. For completed cases, median gestational age at birth was 37 (range 27-39.6) weeks and 50% (8/16) of women delivered at term. Vaginal birth was achieved in 56% (9/16) of patients. One newborn had a cerebrospinal fluid leak that required postnatal surgical repair.

CONCLUSION

Implementation of a laparotomy-assisted 2-port fetoscopic spina bifida closure program through rigorous preparation and multispecialty team training may accelerate the learning curve and demonstrates favorable obstetric and perinatal outcomes.

摘要

简介

通过开放式胎儿手术对开放性脊柱裂进行产前闭合可以改善特定妊娠中婴儿的神经发育结局。对子宫微创的经阴道技术旨在提供等效的胎儿益处，同时最大限度地减少产妇发病率，但最佳技术尚未确定。我们描述了在新建立的项目中，用于经腹腔镜辅助胎儿闭合胎儿脊柱裂的剖腹辅助 2 端口经阴道技术的发展，演变和可行性。

方法

我们对同意进行剖腹辅助经阴道闭合孤立性胎儿脊柱裂的妇女进行了回顾性队列研究。纳入和排除标准遵循了脊髓脊膜膨出管理研究（MOMS）。团队准备包括在起源中心观察，制定方案，辅助人员培训以及在程序实施之前使用患者匹配模型通过模拟进行手术排练。主要结局是能够经阴道完成修复。前瞻性收集了次要的母婴和胎儿结局，以评估技术的性能。

结果

在 57 名接受筛查的妇女中，有 19 名（33％）在 2017 年 2 月至 2019 年 12 月期间同意进行剖腹辅助 2 端口经阴道手术。在 84％（16/19）的病例中完成了经阴道闭合。随着时间的推移，该技术从单层修复改为多层修复。在未分娩的患者中，86％（12/14）的颅内脑疝在术后 6 周时得到改善。在 16 例经阴道病例中，有 31％（5/16）发生自发性胎膜破裂。对于已完成的病例，中位出生时的胎龄为 37 周（范围为 27-39.6），有 50％（8/16）的妇女足月分娩。阴道分娩的成功率为 56％（9/16）。一名新生儿出现脑脊液漏，需要产后手术修复。