The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
Department of Pediatric Surgery, Children's Memorial Hermann Hospital, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
Ultrasound Obstet Gynecol. 2022 Nov;60(5):666-672. doi: 10.1002/uog.26018. Epub 2022 Oct 12.
During in-utero spina bifida (SB) repair, closure of large defects is often challenging, requiring tissue graft for watertight skin closure. No prior studies have compared primary skin closure vs patch-based repair. Our objective was to compare neonatal and 1-year outcomes associated with these two types of skin closure for in-utero SB repair.
This was a prospective cohort study of 102 patients undergoing open prenatal SB repair from September 2011 to August 2021 at a single institution. All patients met the inclusion criteria of the Management of Myelomeningocele Study (MOMS), and the surgical procedure for in-utero SB repair was similar to that described in the MOMS trial. During the surgery, if primary skin approximation was not feasible due to the large size of the defect, the decision was at the discretion of the pediatric neurosurgeon to utilize a patch for closure. Neonatal outcomes at birth and 1-year outcomes were compared between the primary skin and patch-based closure groups.
Of 102 patients included in the study, 70 (68.6%) underwent primary skin closure and 32 (31.4%) patch-based closure. The patch type included acellular bovine skin matrix (Durepair®; n = 31) and human acellular dermal matrix (Alloderm®; n = 1). Fetuses with myeloschisis were more likely to require patch-based repair than those with myelomeningocele. The median time of fetal repair was 4 min longer for patch-based compared with primary skin closure (37 vs 33 min; P = 0.001). Following patch-based repair, neonates had a longer length of stay in the neonatal intensive care unit (NICU) by 24 days (adjusted risk ratio, 2.40 (95% CI, 1.41-4.29)) compared to those that underwent primary skin closure. There was no difference between the two groups in the other neonatal outcomes, including the need for ventriculoperitoneal shunt placement and cerebrospinal fluid leakage. Outcome at 1 year of age was available for 90 infants. Need for wound revision within their first year after birth was more common in infants who underwent patch-based vs those with primary skin closure (19.4% vs 5.1%; P = 0.05). There was no difference between the two groups in other 1-year outcomes, including the need for ventriculoperitoneal shunt placement by 1 year of age and surgery for tethered cord.
Patch-based closure during SB repair is often needed in fetuses with myeloschisis and is associated with prolonged fetal surgery time, long NICU stay and need for wound revision within the first year after birth. Further studies are required to identify optimal patches for SB repair or alternative methods to improve outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
在胎儿脊柱裂（SB）修复过程中，较大的缺陷往往难以闭合，需要组织移植物进行防水皮肤闭合。之前没有研究比较过原发性皮肤闭合与基于补丁的修复。我们的目的是比较这两种皮肤闭合方法在胎儿 SB 修复中的新生儿和 1 年结局。
这是一项前瞻性队列研究，纳入了 2011 年 9 月至 2021 年 8 月在一家机构接受开放性产前 SB 修复的 102 例患者。所有患者均符合 Myelomeningocele 研究（MOMS）的纳入标准，胎儿 SB 修复的手术过程与 MOMS 试验中描述的相似。在手术中，如果由于缺陷较大而无法进行原发性皮肤接近，则由儿科神经外科医生决定使用补丁进行闭合。比较原发性皮肤和基于补丁的闭合组之间的新生儿出生时和 1 年时的结局。
在纳入研究的 102 例患者中，70 例（68.6%）接受了原发性皮肤闭合，32 例（31.4%）接受了基于补丁的闭合。补丁类型包括脱细胞牛真皮基质（Durepair®；n=31）和人脱细胞真皮基质（Alloderm®；n=1）。脑脊膜膨出胎儿比脊髓脊膜膨出胎儿更有可能需要基于补丁的修复。基于补丁的修复比原发性皮肤闭合的胎儿修复时间中位数长 4 分钟（37 分钟比 33 分钟；P=0.001）。在基于补丁的修复后，与接受原发性皮肤闭合的新生儿相比，新生儿在新生儿重症监护病房（NICU）的住院时间延长了 24 天（调整后的风险比，2.40（95%CI，1.41-4.29））。两组在其他新生儿结局方面无差异，包括需要放置脑室腹腔分流和脑脊液漏。90 名婴儿可获得 1 岁时的结局。与接受原发性皮肤闭合的婴儿相比，接受基于补丁的闭合的婴儿在出生后第一年需要进行伤口修正的情况更为常见（19.4%比 5.1%；P=0.05）。两组在其他 1 年结局方面无差异，包括 1 岁时需要脑室腹腔分流和脊髓栓系松解手术。
在脑脊膜膨出胎儿中，SB 修复时通常需要基于补丁的闭合，这与胎儿手术时间延长、新生儿重症监护病房住院时间延长和出生后第一年需要进行伤口修正有关。需要进一步研究以确定 SB 修复的最佳补丁或改善结局的替代方法。
