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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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Theodorou CM, Jackson JE, Stokes SC, Pivetti CD, Kumar P, Paxton ZJ, Matsukuma KE, Yamashiro KJ, Reynaga L, Hyllen AA, de Lorimier AJ, Hassan M, Wang A, Farmer DL, Saadai P. Early investigations into improving bowel and bladder function in fetal ovine myelomeningocele repair. J Pediatr Surg 2022; 57:941-948. [PMID: 35093254 PMCID: PMC10372624 DOI: 10.1016/j.jpedsurg.2021.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSC-ECM would also improve bowel and bladder function. METHODS MMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs (n = 3). RESULTS Eighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs (p = 1). Void volumes were similar (PMSC-ECM 6.1 ml/kg vs. normal 8.8 ml/kg, p = 0.4). Resting mean anal pressures were similar between cohorts (27.0 mmHg PMSC-ECM vs. normal 23.5 mmHg, p = 0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs (p = 0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts. CONCLUSION Ovine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human patients.
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Affiliation(s)
- Christina M Theodorou
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States.
| | - Jordan E Jackson
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Sarah C Stokes
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Christopher D Pivetti
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Zachary J Paxton
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Karen E Matsukuma
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, United States
| | - Kaeli J Yamashiro
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Alicia A Hyllen
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Arthur J de Lorimier
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Maheen Hassan
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Aijun Wang
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Diana L Farmer
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Payam Saadai
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
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Stokes SC, Theodorou CM, Jackson JE, Pivetti C, Kumar P, Yamashiro KJ, Paxton ZJ, Reynaga L, Hyllen A, Wang A, Farmer DL. Long-term safety evaluation of placental mesenchymal stromal cells for in utero repair of myelomeningocele in a novel ovine model. J Pediatr Surg 2022; 57:18-25. [PMID: 34657738 PMCID: PMC9415987 DOI: 10.1016/j.jpedsurg.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Augmentation of in utero myelomeningocele repair with human placental mesenchymal stromal cells seeded onto extracellular matrix (PMSC-ECM) improves motor outcomes in an ovine myelomeningocele model. This study evaluated the safety of PMSC-ECM application directly onto the fetal spinal cord in preparation for a clinical trial. METHODS Laminectomy of L5-L6 with PMSC-ECM placement directly onto the spinal cord was performed in five fetal lambs at gestational age (GA) 100-106 days. Lambs and ewes were monitored for three months following delivery. Lambs underwent magnetic resonance imaging (MRI) of the brain and spine at birth and at three months. All organs from lambs and uteri from ewes underwent histologic evaluation. Lamb spinal cords and brains and ewe placentas were evaluated for persistence of PMSCs by polymerase chain reaction for presence of human DNA. RESULTS MRIs demonstrated no evidence of abnormal tissue growth or spinal cord tethering. Histological analysis demonstrated no evidence of abnormal tissue growth or treatment related adverse effects. No human DNA was identified in evaluated tissues. CONCLUSION There was no evidence of abnormal tissue growth or PMSC persistence at three months following in utero application of PMSC-ECM to the spinal cord. This supports proceeding with clinical trials of PMSC-ECM for in utero myelomeningocele repair. LEVEL OF EVIDENCE N/A TYPE OF STUDY: Basic science.
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Affiliation(s)
- Sarah C Stokes
- Division of Pediatric General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA.
| | - Christina M Theodorou
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Jordan E Jackson
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Christopher Pivetti
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Kaeli J Yamashiro
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Zachary J Paxton
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Alicia Hyllen
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Aijun Wang
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA.,Shriners Hospital for Children Northern California, 3425 Stockton Blvd, Sacramento, CA 95817, USA
| | - Diana L Farmer
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA.,Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA.,Shriners Hospital for Children Northern California, 3425 Stockton Blvd, Sacramento, CA 95817, USA
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