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Pontiggia L, Michalak-Micka K, Hürlimann N, Yosef HK, Böni R, Klar AS, Ehrbar M, Ochsenbein-Kölble N, Biedermann T, Moehrlen U. Raman spectroscopy analysis of human amniotic fluid cells from fetuses with myelomeningocele. Exp Cell Res 2024; 439:114048. [PMID: 38697275 DOI: 10.1016/j.yexcr.2024.114048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/11/2024] [Accepted: 04/13/2024] [Indexed: 05/04/2024]
Abstract
Prenatal surgery for the treatment of spina bifida (myelomeningocele, MMC) significantly enhances the neurological prognosis of the patient. To ensure better protection of the spinal cord by large defects, the application of skin grafts produced with cells gained from the amniotic fluid is presently studied. In order to determine the most appropriate cells for this purpose, we tried to shed light on the extremely complex amniotic fluid cellular composition in healthy and MMC pregnancies. We exploited the potential of micro-Raman spectroscopy to analyse and characterize human amniotic fluid cells in total and putative (cKit/CD117-positive) stem cells of fetuses with MMC in comparison with amniotic fluid cells from healthy individuals, human fetal dermal fibroblasts and adult adipose derived stem cells. We found that (i) the differences between healthy and MMC amniocytes can be attributed to specific spectral regions involving collagen, lipids, sugars, tryptophan, aspartate, glutamate, and carotenoids, (ii) MMC amniotic fluid contains two particular cell populations which are absent or reduced in normal pregnancies, (iii) the cKit-negative healthy amniocyte subpopulation shares molecular features with human fetal fibroblasts. On the one hand we demonstrate a different amniotic fluid cellular composition in healthy and MMC pregnancies, on the other our work confirms micro-Raman spectroscopy to be a valuable tool for discriminating cell populations in unknown mixtures of cells.
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Affiliation(s)
- Luca Pontiggia
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
| | - Katarzyna Michalak-Micka
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
| | - Nadine Hürlimann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
| | | | - Roland Böni
- White House Center for Liposuction, Zurich, Switzerland
| | - Agnes S Klar
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland; University of Zurich, 8091, Zurich, Switzerland
| | - Martin Ehrbar
- Zurich Center for Fetal Diagnosis and Treatment, 8032 Zurich, Switzerland; University of Zurich, 8091, Zurich, Switzerland; Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Zurich Center for Fetal Diagnosis and Treatment, 8032 Zurich, Switzerland; Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland; University of Zurich, 8091, Zurich, Switzerland
| | - Ueli Moehrlen
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, 8032, Zurich, Switzerland; Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland; Zurich Center for Fetal Diagnosis and Treatment, 8032 Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland; University of Zurich, 8091, Zurich, Switzerland.
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Lapa DA, Callado GY, Catissi G, Trigo L, Faig-Leite F, Sevilla APAB. The impact of a biocellulose-based repair of fetal open spina bifida on the need to untether the cord: is it time to unify techniques for prenatal repair? EINSTEIN-SAO PAULO 2024; 22:eAO0557. [PMID: 38695415 PMCID: PMC11081024 DOI: 10.31744/einstein_journal/2024ao0557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/27/2023] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE To report the need for cord untethering after prenatal repair of open spina bifida using a unique biocellulose-based technique performed at a later gestational age. METHODS An observational cohort study was conducted to determine the incidence of tethered cord syndrome. Between May 2013 and May 2022, we performed 172 procedures using the percutaneous fetoscopic approach in fetuses at 26-28 weeks of gestation. After placode dissection, a biocellulose patch was placed to cover the placode, a myofascial flap (when possible) was dissected, and the skin was closed. Owing to death or loss to follow-up, 23 cases were excluded. Cord tethering syndrome was defined as symptoms of medullary stretching, and the infants were evaluated and operated on by local neurosurgeons after an magnetic resonance imaging examination. Infants over 30-month had ambulation and neurodevelopment evaluations (PEDI scale). RESULTS Among 172 cases operated at a median gestational age of 26.7 weeks and delivered at 33.2 weeks, 149 cases were available for postnatal follow-up, and cord untethering was needed in 4.4% of cases (6/136; excluding 13 cases younger than 12 months). Cerebrospinal fluid diversion and bladder catheterization were needed in 38% and 36% of cases, respectively. Of the 78 cases evaluated at 30 months, 49% were ambulating independently, and 94% had normal social function. CONCLUSION The biocellulose-based technique was associated with a low rate of cord tethering, wich may be attributed to the lack of the duramater suture during prenatal repair, the formation of a neoduramater and/or later gestational age of surgery.
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Affiliation(s)
- Denise Araújo Lapa
- Hospital Israelita Albert EinsteinSão PauloSPBrazilFetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Hospital Infantil SabaraSão PauloSPBrazilHospital Infantil Sabara, São Paulo, SP, Brazil.
| | - Gustavo Yano Callado
- Hospital Israelita Albert EinsteinFaculdade Israelita de Ciências da Saúde Albert EinsteinSão PauloSPBrazilFaculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Giulia Catissi
- Hospital Israelita Albert EinsteinSão PauloSPBrazilFetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Lucas Trigo
- Hospital Sant Joan de Déu BarcelonaCataluñaEspañaHospital Sant Joan de Déu Barcelona, Cataluña, España.
- Hospital Clínic de BarcelonaFetal Medicine Research Center BarcelonaCataluñaEspañaFetal Medicine Research Center Barcelona, Hospital Clínic de Barcelona, Cataluña, España.
| | - Fernanda Faig-Leite
- Hospital Israelita Albert EinsteinSão PauloSPBrazilFetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Preliminary Results of a Reverse Thermal Gel Patch for Fetal Ovine Myelomeningocele Repair. J Surg Res 2021; 270:113-123. [PMID: 34655937 DOI: 10.1016/j.jss.2021.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Prenatal surgical closure of Myelomeningocele (MMC) is considered part of the current age armamentarium. Clinical data has demonstrated the need for innovative patches to maximize the benefits and decrease the risks of this approach. Our team has developed a minimally invasive reverse thermal gel (RTG) patch with cellular scaffolding properties. Here, we demonstrate the initial gross and microscopic histological effects of this RTG patch in the fetal ovine model of MMC. MATERIALS AND METHODS A fetal ovine MMC defect was created at 68-75 days gestation, RTG patch application or untreated at 100-103 days, and harvest at 135-140 days. The RTG was applied to the defect and secured in place with an overlay sealant. Defect areas underwent gross and microscopic analysis for inflammation and skin development. Brains were analyzed for hindbrain herniation and hydrocephalus. RESULTS The untreated fetus (n = 1) demonstrated an open defect lacking tissue coverage, evidence of spinal cord injury, increased caspase-3, Iba1 and GFAP in spinal cord tissues, and hindbrain herniation and ventricular dilation. RTG treated fetuses (n = 3) demonstrated defect healing with well-organized dermal and epidermal layers throughout the entire healed tissue area overlaying the defect with minimal inflammation, reduced caspase-3, Iba1 and GFAP in spinal cord tissues, and no hindbrain herniation or ventricular dilation. CONCLUSION An RTG patch applied to MMC defects in fetal sheep promoted skin coverage over the defect, was associated with minimal inflammation of the spinal cord tissues and prevented brain abnormalities. The present findings provide exciting results for future comprehensive radiological, functional, and mechanistic evaluation of the RTG.
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Soltani Khaboushan A, Shakibaei M, Kajbafzadeh AM, Majidi Zolbin M. Prenatal Neural Tube Anomalies: A Decade of Intrauterine Stem Cell Transplantation Using Advanced Tissue Engineering Methods. Stem Cell Rev Rep 2021; 18:752-767. [PMID: 33742349 DOI: 10.1007/s12015-021-10150-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
Neural tube defects (NTDs) are among the most common congenital defects during neurulation. Spina bifida is a type of NTD that can occur in different forms. Since myelomeningocele (MMC) is the most severe form of spina bifida, finding a satisfactory treatment for MMC is a gold standard for the treatment of spina bifida. The Management of Myelomeningocele Study (MOMS) demonstrated that intrauterine treatment of spina bifida could ameliorate the complications associated with spina bifida and would also reduce the placement of ventriculoperitoneal (VP) shunt by 50%. Recently developed tissue engineering (TE) approaches using scaffolds, stem cells, and growth factors allow treatment of the fetus with minimally invasive methods and promising outcomes. The application of novel patches with appropriate stem cells and growth factors leads to better coverage of the defect with fewer complications. These approaches with less invasive surgical procedures, even in animal models with similar characteristics as the human MMC defect, paves the way for the modern application of less invasive surgical methods. Significantly, the early detection of these problems and applying these approaches can increase the potential efficacy of MMC treatment with fewer complications. However, further studies should be conducted to find the most suitable scaffolds and stem cells, and their application should be evaluated in animal models. This review intends to discuss advanced TE methods for treating MMC and recent successes in increasing the efficacy of the treatment.
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Affiliation(s)
- Alireza Soltani Khaboushan
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Shakibaei
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, Pettenkoferstrasse 11, D-80336, Munich, Germany
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.
| | - Masoumeh Majidi Zolbin
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.
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Morphometric Features of the Latissimus Dorsi Muscle in Fetal Cadavers With Meningomyelocele for Prenatal Surgery. J Craniofac Surg 2020; 30:2628-2631. [PMID: 31369512 DOI: 10.1097/scs.0000000000005783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Latissimus dorsi (LD) flaps are frequently used in the prenatal meningomyelocele (MMC) repairs; on that basis, this study aims to reveal the morphometric features of LD, thoracodorsal artery (TDA) and nerve (TDN) in fetal cadavers with MMC defects, with an anatomical perspective. METHODS The study was conducted on 7 formalin-fixed human fetal cadavers (4 males and 3 females) with MMC defects, aged from 18 to 27 weeks of gestation. The size of LD, TDA, and TDN including their area, length, and width were measured by a digital caliper and digital image analysis software. Our direct measurements were compared with the corresponding estimations of a previous study in the literature which provides regression formulae based on gestational age. RESULTS The fetal cadavers with MMC had bilateral LD. No significant differences were found in the numerical data of anatomical structures between the sides or the sexes. LD size (ie, area, length and width) was approximately 3% to 10% smaller in the fetuses with MMC defects than that of the normal fetuses. Unilateral LD flap in a 22-week-old fetus with a large MMC was evaluated as insufficient to close the defects. CONCLUSION Ten percent shrinkage in the area of LD might be too critical to be disregarded by surgeons during the closure of MMC defects. The dimensional findings about LD (area, length, and width) may be helpful in planning of LD flap harvesting for the repairs of MMC.
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Dasargyri A, Reichmann E, Moehrlen U. Bio-engineering of fetal cartilage for in utero spina bifida repair. Pediatr Surg Int 2020; 36:25-31. [PMID: 31576465 DOI: 10.1007/s00383-019-04573-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE During in utero surgical spina bifida repair, a multi-layer closure is used to cover the defect. These soft tissues, however, might be not sufficient to protect the spinal cord during the future life. Our goal is to develop a more rigid protective tissue construct consisting of bioengineered cartilage and skin. METHODS Ovine fetal chondrocytes were tested for their in vitro chondrogenic potential in three-dimensional cultures. Scaffolds based on natural biopolymers (collagen I, fibrin glue) were loaded with varying amounts of fetal chondrocytes and assessed for their ability to support cartilage formation in vitro. The bioengineered constructs were analyzed using cartilage-specific histology stainings and compared to native fetal cartilage. RESULTS Fetal chondrocytes actively produced cartilage extracellular matrix in three-dimensional cultures, even at high passages. Among all bioengineered scaffolds, only the collagen I-based hydrogels loaded with high densities of fetal chondrocytes showed cartilage-like structure in vitro but also extensive shrinking. CONCLUSION Fetal chondrocytes represent a good cell source for cartilage bioengineering. Collagen I scaffolds support cartilage formation in vitro, but the construct shrinking constitutes a major limitation. Future steps include the identification of suitable bioprintable materials which maintain their shape and size, as well as the analysis of the interphase between bioengineered cartilage and skin.
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Affiliation(s)
- Athanasia Dasargyri
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ernst Reichmann
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland. .,Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland. .,Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.
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Mazzone L, Moehrlen U, Ochsenbein-Kölble N, Pontiggia L, Biedermann T, Reichmann E, Meuli M. Bioengineering and in utero transplantation of fetal skin in the sheep model: A crucial step towards clinical application in human fetal spina bifida repair. J Tissue Eng Regen Med 2019; 14:58-65. [PMID: 31595702 DOI: 10.1002/term.2963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/02/2019] [Accepted: 09/05/2019] [Indexed: 11/09/2022]
Abstract
An intricate problem during open human fetal surgery for spina bifida regards back skin closure, particularly in those cases where the skin defect is much too large for primary closure. We hypothesize that tissue engineering of fetal skin might provide an adequate autologous skin substitute for in utero application in such situations. Eight sheep fetuses of four time-mated ewes underwent fetoscopic skin biopsy at 65 days of gestation. Fibroblasts and keratinocytes isolated from the biopsy were used to create fetal dermo-epidermal skin substitutes. These were transplanted on the fetuses by open fetal surgery at 90 days of gestation on skin defects (excisional wounds) created during the same procedure. Pregnancy was allowed to continue until euthanasia at 120 days of gestation. The graft area was analyzed macroscopically and microscopically. The transplanted fetal dermo-epidermal skin substitutes was well discernable in situ in three of the four fetuses available for analysis. Histology confirmed healed grafts with a close to natural histological skin architecture four weeks after in utero transplantation. This experimental study generates evidence that laboratory grown autologous fetal skin analogues can successfully be transplanted in utero. These results have clinical implications as an analogous procedure might be applied in human fetuses undergoing prenatal repair to facilitate primary skin closure. Finally, this study may also fertilize the field of fetal tissue engineering in general, particularly when more interventional, minimally invasive, and open fetal surgical procedures become available.
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Affiliation(s)
- Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Luca Pontiggia
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ernst Reichmann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Basler M, Pontiggia L, Biedermann T, Reichmann E, Meuli M, Mazzone L. Bioengineering of Fetal Skin: Differentiation of Amniotic Fluid Stem Cells into Keratinocytes. Fetal Diagn Ther 2019; 47:198-204. [PMID: 31509837 DOI: 10.1159/000502181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE Open fetal spina bifida repair has become a novel clinical standard of care. In very large spina bifida lesions, the skin defect cannot be covered primarily, asking for alternative solutions. We hypothesize that amniotic fluid stem cells (AFSC) could be differentiated into keratinocytes that could then be used to bioengineer autologous skin usable for in utero back coverage. METHODS To obtain human AFSC, amniotic fluid samples obtained from fetal surgeries were subjected to immunoselection for c-kit. C-kit-positive samples and controls were cultured with the additives morphogenetic protein 4 and vitamin C to induce differentiation towards keratinocytes. This process was monitored by measuring the expression of K8 and K14 via immunohistochemical staining, flow cytometry, and polymerase chain reaction. RESULTS After immunoselection and expansion, most cells were positive for K8, but none for K14. After completion of the differentiation protocol, cell colonies with keratinocyte-like appearance could be observed, but cells remained positive for K8 and negative for K14, indicating failed differentiation into keratinocytes. CONCLUSIONS Culturing of keratinocyte-like cells from AFSC, harvested intraoperatively, was not feasible in this setting. The reasons for failure must be investigated and eliminated, as bioengineering of fetal skin for clinical use during fetal surgery for spina bifida remains an attractive goal.
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Affiliation(s)
- Michelle Basler
- Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Luca Pontiggia
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ernst Reichmann
- Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland, .,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland, .,Tissue Biology Research Unit, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland, .,Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland, .,Spina Bifida Academy, University Children's Hospital Zurich, Zurich, Switzerland, .,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland,
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Lapa Pedreira DA, Acacio GL, Gonçalves RT, Sá RAM, Brandt RA, Chmait RH, Kontopoulos EV, Quintero RA. Percutaneous fetoscopic closure of large open spina bifida using a bilaminar skin substitute. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:458-466. [PMID: 29314321 DOI: 10.1002/uog.19001] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/04/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We have described previously our percutaneous fetoscopic technique for the treatment of open spina bifida (OSB). However, approximately 20-30% of OSB defects are too large to allow primary skin closure. Here we describe a modification of our standard technique using a bilaminar skin substitute to allow closure of large spinal defects. The aim of this study was to report our clinical experience with the use of a bilaminar skin substitute and a percutaneous fetoscopic technique for the prenatal closure of large OSB defects. METHODS Surgery was performed between 24.0 and 28.9 gestational weeks with the woman under general anesthesia, using an entirely percutaneous fetoscopic approach with partial carbon dioxide insufflation of the uterine cavity, as described previously. If there was enough skin to be sutured in the midline, only a biocellulose patch was placed over the placode (single-patch group). In cases in which skin approximation was not possible, a bilaminar skin substitute (two layers: one silicone and one dermal matrix) was placed over the biocellulose patch and sutured to the skin edges (two-patch group). The surgical site was assessed at birth, and long-term follow-up was carried out. RESULTS Percutaneous fetoscopic OSB repair was attempted in 47 consecutive fetuses, but surgery could not be completed in two. Preterm prelabor rupture of membranes (PPROM) occurred in 36 of the 45 (80%) cases which formed the study group, and the mean gestational age at delivery was 32.8 ± 2.5 weeks. A bilaminar skin substitute was required in 13/45 (29%) cases; in the remaining 32 cases, direct skin-to-skin suture was feasible. There were 12 cases of myeloschisis, of which 10 were in the two-patch group. In all cases, the skin substitute was located at the surgical site at birth. In five of the 13 (38.5%) cases in the two-patch group, additional postnatal repair was needed. In the remaining cases, the silicone layer detached spontaneously from the dermal matrix (on average, 25 days after birth), and the lesion healed by secondary intention. The mean operating time was 193 (range, 83-450) min; it was significantly longer in cases requiring the bilaminar skin substitute (additional 42 min on average), although the two-patch group had similar PPROM rate and gestational age at delivery compared with the single-patch group. Complete reversal of hindbrain herniation occurred in 68% of the 28 single-patch cases and 33% of the 12 two-patch cases with this information available (P < 0.05). In four cases there was no reversal; half of these occurred in myeloschisis cases. CONCLUSIONS Large OSB defects may be treated successfully in utero using a bilaminar skin substitute over a biocellulose patch through an entirely percutaneous approach. Although the operating time is longer, surgical outcome is similar to that in cases closed primarily. Cases with myeloschisis seem to have a worse prognosis than do those with myelomeningocele. PPROM and preterm birth continue to be a challenge. Further experience is needed to assess the risks and benefits of this technique for the management of large OSB defects. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D A Lapa Pedreira
- Fetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G L Acacio
- Obstetrics Department, University of Taubaté, Taubaté, Brazil
| | - R T Gonçalves
- Fetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - R A M Sá
- Fetal Medicine, Perinatal da Barra, Rio de Janeiro, Brazil
| | - R A Brandt
- Pediatric Neurosurgeon, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - R H Chmait
- The USFetus Research Consortium, Miami, Florida, USA
| | | | - R A Quintero
- The USFetus Research Consortium, Miami, Florida, USA
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Joyeux L, De Bie F, Danzer E, Van Mieghem T, Flake AW, Deprest J. Safety and efficacy of fetal surgery techniques to close a spina bifida defect in the fetal lamb model: A systematic review. Prenat Diagn 2018; 38:231-242. [PMID: 29388237 DOI: 10.1002/pd.5222] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/16/2017] [Accepted: 01/23/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of different neurosurgical techniques for closure of spina bifida (SB) in the fetal lamb model. METHOD Systematic review of studies reporting on fetal lambs undergoing induction and closure of SB compared with non-operated normal lambs (negative controls) and/or lambs not undergoing closure of the defect (positive controls). Primary outcomes were (1) survival at birth (safety) and/or (2) presence of Somatosensory Evoked Potentials on hind limbs and/or improvement in quantitative histological spinal cord findings and/or reversal of hindbrain herniation (efficacy). RESULTS Out of 1311, 36 full-text articles were eligible. Nineteen were included for quality assessment. Due to high bias, only 2 adequately powered studies were included in the final analysis. An open approach using a 2-layer closure (muscle flap or acellular-dermal-matrix patch plus skin) was the only safe (patch + skin) and effective (both techniques) technique for prenatal closure in this animal model. No comparable level of evidence was identified for other techniques. CONCLUSION The experimental literature on prenatal SB closure underscores the lack of standardization. At present, there is animal experimental evidence that a 2-layer closure by hysterotomy is safe and effective. This technique is currently clinically used in a subset of patients. As new clinical techniques are introduced, it would seem logic to preclinically validate them against this experimental standard.
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Affiliation(s)
- Luc Joyeux
- Academic Department Development and Regeneration, Cluster Organ Systems, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Felix De Bie
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Enrico Danzer
- Center for Fetal Diagnosis and Treatment, the Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Children's Center for Fetal Research, Abramson Research center, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, Mt. Sinai Hospital, University of Toronto, Toronto, Canada
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, the Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Children's Center for Fetal Research, Abramson Research center, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Organ Systems, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospital Gasthuisberg UZ Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
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11
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de Bakker BS, Driessen S, Boukens BJD, van den Hoff MJB, Oostra RJ. Single-site neural tube closure in human embryos revisited. Clin Anat 2017; 30:988-999. [PMID: 28795440 DOI: 10.1002/ca.22977] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/06/2017] [Indexed: 12/16/2022]
Abstract
Since the multi-site closure theory was first proposed in 1991 as explanation for the preferential localizations of neural tube defects, the closure of the neural tube has been debated. Although the multi-site closure theory is much cited in clinical literature, single-site closure is most apparent in literature concerning embryology. Inspired by Victor Hamburgers (1900-2001) statement that "our real teacher has been and still is the embryo, who is, incidentally, the only teacher who is always right", we decided to critically review both theories of neural tube closure. To verify the theories of closure, we studied serial histological sections of 10 mouse embryos between 8.5 and 9.5 days of gestation and 18 human embryos of the Carnegie collection between Carnegie stage 9 (19-21 days) and 13 (28-32 days). Neural tube closure was histologically defined by the neuroepithelial remodeling of the two adjoining neural fold tips in the midline. We did not observe multiple fusion sites in neither mouse nor human embryos. A meta-analysis of case reports on neural tube defects showed that defects can occur at any level of the neural axis. Our data indicate that the human neural tube fuses at a single site and, therefore, we propose to reinstate the single-site closure theory for neural tube closure. We showed that neural tube defects are not restricted to a specific location, thereby refuting the reasoning underlying the multi-site closure theory. Clin. Anat. 30:988-999, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Bernadette S de Bakker
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Stan Driessen
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bastiaan J D Boukens
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Maurice J B van den Hoff
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
PURPOSE Fetal repair of spina bifida results in improved outcomes and has therefore become a standard clinical procedure in some highly specialized centers. However, optimization of the procedure technique and timing is needed. Both might be achieved by facilitating the procedure using laboratory-grown fetal skin substitutes. The aim of this study was therefore to test in vivo the suitability of such a fetal skin substitute for an in utero application. METHODS Collagen-based hydrogels containing fetal ovine fibroblasts were seeded with fetal ovine keratinocytes and transplanted on immuno-incompetent nu/nu rats. After 3 weeks, grafts were harvested and analyzed histologically and by immunohistochemistry. RESULTS Laboratory-grown fetal ovine dermo-epidermal skin substitutes showed successful engraftment at 3 weeks. Histologically, grafts revealed a neo-dermis populated by fibroblasts and with ingrowth of vessels, and an epidermis with an adult-like, mature appearance depicting clearly basal, spinous, granular, and a corneal layer. Immunostaining confirmed a physiologically organized epidermis. CONCLUSION Fetal dermo-epidermal skin substitutes of ovine origin can successfully be grafted in vivo. In a next step, we will have to test whether favorable results can also be obtained when grafts are used in utero. If so, then human fetal spina bifida repair using laboratory-grown autologous fetal skin for defect closure may be envisaged.
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13
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North WD, Khoury L, Christopher Spears R, Liau JY, Pittman T. Use of dermal regeneration template to close a giant myelomeningocele in a newborn. J Neurosurg Pediatr 2016; 18:635-637. [PMID: 27503247 DOI: 10.3171/2016.6.peds16127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Many techniques are available to close a myelomeningocele, but large lesions can be particularly difficult to close given the absence of surrounding tissue. The authors present the case of a 2-day-old girl with a large lumbosacral myelomeningocele who underwent a staged repair using dermal regeneration template (DRT; Integra) followed by split-thickness skin grafting. The results demonstrated that the combined use of myofascial turnover flaps and DRT with delayed skin grafting is a safe, effective option for this challenging reconstructive dilemma.
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Affiliation(s)
| | - Laith Khoury
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - R Christopher Spears
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - James Y Liau
- Division of Plastic and Reconstructive Surgery; and
| | - Thomas Pittman
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, Kentucky
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14
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Araujo Júnior E, Eggink AJ, van den Dobbelsteen J, Martins WP, Oepkes D. Procedure-related complications of open vs endoscopic fetal surgery for treatment of spina bifida in an era of intrauterine myelomeningocele repair: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:151-160. [PMID: 26612040 DOI: 10.1002/uog.15830] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/19/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery. METHODS Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic. RESULTS The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%). CONCLUSION Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Araujo Júnior
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
| | - A J Eggink
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J van den Dobbelsteen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - D Oepkes
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
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15
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Bevilacqua NS, Pedreira DAL. Fetoscopy for meningomyelocele repair: past, present and future. EINSTEIN-SAO PAULO 2015; 13:283-9. [PMID: 26154549 PMCID: PMC4943825 DOI: 10.1590/s1679-45082015rw3032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/13/2015] [Indexed: 01/18/2023] Open
Abstract
Meningomyelocele is a malformation with high prevalence, and one of its main comorbidities is Arnold-Chiari malformation type II. The intrauterine repair of this defect has been studied to reduce the progressive spinal cord damage during gestation. The purpose of the present review was to describe the evolution of fetal surgery for meningomyelocele repair. Searches on PubMed database were conducted including articles published in the last 10 years. Twenty-seven articles were selected, 16 experimental studies and 11 studies in humans. A recent study demonstrated that the fetal correction results in better prognosis of neurological and psychomotor development, but open surgery, which has being used widely, has considerable maternal risks. Studies in animal and human models show that the endoscopic approach is feasible and leads to lower maternal morbidity rates. Two endoscopic techniques are currently under assessment - one in Germany and another in Brazil, and we believe that the endoscopic approach will be the future technique for prenatal repair of this defect.
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16
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Gironi LC, Boggio P, Colombo E. Reconstruction of scalp defects with exposed bone after surgical treatment of basal cell carcinoma: the use of a bilayer matrix wound dressing. Dermatol Ther 2014; 28:114-7. [DOI: 10.1111/dth.12193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Laura C. Gironi
- Dermatology Clinic; Department of Clinical and Experimental Medicine; University of Piemonte Orientale, Amedeo Avogadro; Novara Italy
| | - Paolo Boggio
- Dermatology Clinic; Department of Clinical and Experimental Medicine; University of Piemonte Orientale, Amedeo Avogadro; Novara Italy
| | - Enrico Colombo
- Dermatology Clinic; Department of Clinical and Experimental Medicine; University of Piemonte Orientale, Amedeo Avogadro; Novara Italy
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Abstract
PURPOSE In some human fetuses undergoing prenatal spina bifida repair, the skin defect is too large for primary closure. The aim of this study was to engineer an autologous fetal skin analogue suitable for in utero skin reconstruction during spina bifida repair. METHODS Keratinocytes (KC) and fibroblasts (FB) isolated from skin biopsies of 90-day-old sheep fetuses were cultured. Thereafter, plastically compressed collagen hydrogels and fibrin gels containing FB were prepared. KC were seeded onto these dermal constructs and allowed to proliferate using different culture media. Constructs were analyzed histologically and by immunohistochemistry and compared to normal ovine fetal skin. RESULTS Development of a stratified epidermis covering the entire surface of the collagen gel was observed. The number of KC layers and degree of organization was dependent on the cell culture media used. The collagen hydrogels exhibited a strong tendency to shrink after eight to ten days of culture in vitro. On fibrin gels, we did not observe the formation of a physiologically organized epidermis. CONCLUSION Collagen-gel-based ovine fetal cell-derived skin analogues with near normal anatomy can be engineered in vitro and may be suitable for autologous fetal transplantation.
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18
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Meuli M, Moehrlen U. Fetal surgery for myelomeningocele is effective: a critical look at the whys. Pediatr Surg Int 2014; 30:689-97. [PMID: 24908159 DOI: 10.1007/s00383-014-3524-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
Formerly, the disastrous cluster of neurologic deficits and associated neurogenic problems in patients with myelomeningocele (MMC) was generally thought to solely result from the primary malformation, i.e., failure of neurulation. Today, however, there is no doubt that a dimensional additional pathogenic mechanism exists. Most likely, it contributes much more to loss of neurologic function than non-neurulation does. Today, there is a large body of compelling experimental and clinical evidence confirming that the exposed part of the non-neurulated spinal cord is progressively destroyed during gestation, particularly so in the third trimester. These considerations gave rise to the two-hit-pathogenesis of MMC with non-neurulation being the first and consecutive in utero acquired neural tissue destruction being the second hit. This novel pathophysiologic understanding has obviously triggered the question whether the serious and irreversible functional loss caused by the second hit could not be prevented or, at least, significantly alleviated by timely protecting the exposed spinal cord segments, i.e., by early in utero repair of the MMC lesion. Based on this intriguing hypothesis and the above-mentioned data, human fetal surgery for MMC was born in the late nineties of the last century and has made its way to become a novel standard of care, particularly after the so-called "MOMS Trial". This trial, published in the New England Journal of Medicine, has indisputably shown that overall, open prenatal repair is distinctly better than postnatal care alone. Finally, a number of important other topics deserve being mentioned, including the necessity to work on the up till now immature endoscopic fetal repair technique and the need for concentration of these extremely challenging cases to a small number of really qualified fetal surgery centers worldwide. In conclusion, despite the fact that in utero repair of MMC is not a complete cure and not free of risk for both mother and fetus, current data clearly demonstrate that open fetal-maternal surgery is to be recommended as novel standard of care when pregnancy is to be continued and when respective criteria for the intervention before birth are met. Undoubtedly, it is imperative to inform expecting mothers about the option of prenatal surgery once their fetus is diagnosed with open spina bifida.
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Affiliation(s)
- Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland,
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19
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Osinga R, Mazzone L, Meuli M, Meuli-Simmen C, von Campe A. Assessment of long-term donor-site morbidity after harvesting the latissimus dorsi flap for neonatal myelomeningocele repair. J Plast Reconstr Aesthet Surg 2014; 67:1070-5. [PMID: 24865618 DOI: 10.1016/j.bjps.2014.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/27/2014] [Accepted: 04/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM The latissimus dorsi flap (LDF) has been employed very successfully over decades to cover large soft-tissue defects. Its donor-site morbidity has been extensively investigated in adults - but not in children - and is considered to be nonrestrictive. The aim of this long-term study was to assess donor-site morbidity with the modified Constant score more than 8 years after coverage of large myelomeningocele (MMC) defects with a reverse latissimus dorsi flap. METHODS Within the first days after birth, the reverse latissimus dorsi muscle flap was used uni- or bilaterally in three neonates to cover a large MMC defect. Bilateral shoulder function was tested more than 8 years postoperatively according to the modified Constant score. RESULTS The mean age at follow-up was 11.7 years. None of the patients experienced any pain or shoulder restrictions during normal daily activities. They all managed to position both of their arms comfortably above the head. Forward flexion was normal in all patients as was abduction and external rotation. Dorsal extension was minimally reduced on the operated side. Internal rotation was symmetric in all patients; the extent of active movement varied from excellent to poor. CONCLUSIONS Our long-term data suggest that there is no specific and significant impairment of shoulder function after using the distally pedicled reverse LDF for neonatal MMC repair.
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Affiliation(s)
- R Osinga
- Clinic of Hand, Reconstructive and Plastic Surgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - L Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - M Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - C Meuli-Simmen
- Clinic of Hand, Reconstructive and Plastic Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - A von Campe
- Clinic of Hand, Reconstructive and Plastic Surgery, Kantonsspital Aarau, Aarau, Switzerland
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