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Zepf J, Vonzun L, Rüegg L, Strübing N, Krähenmann F, Meuli M, Mazzone L, Moehrlen U, Ochsenbein-Kölble N. Fetal Spina Bifida Repair in Obese Mothers: Is Maternal and Fetal Safety Compromised? Fetal Diagn Ther 2024; 51:175-183. [PMID: 38190813 PMCID: PMC10994580 DOI: 10.1159/000536071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION The Management of Myelomeningocele Study (MOMS) eligibility criteria preclude in utero surgery for fetal spina bifida (fSB) when the maternal body mass index (BMI) is ≥35 kg/m2. Some centers still respect this criterion, while others, like ours, do not. This study aimed to assess whether maternal and fetal safety is compromised with higher maternal BMIs. METHODS Data of 192 patients with open fSB repair at our center were retrospectively analyzed. According to their BMI, patients were divided into three groups: group 1 (BMI <30 kg/m2), group 2 (BMI 30-35 kg/m2), and group 3 (BMI >35 kg/m2). Subgroup analysis was performed to assess differences in maternal and fetal outcomes. Additionally, complications were divided into grades 1 to 5 according to their severity and outcome consequences and compared among groups. RESULTS Out of 192 patients, 146 (76.0%) had a BMI <30 kg/m2, 28 (14.6%) had a BMI 30-35 kg/m2, and 18 (9.4%) had a BMI >35 kg/m2. Significant differences occurring more often in either group 2 or 3 compared to group 1 were maternal wound seroma (50% or 56% vs. 32%, p = 0.04), amniotic fluid leakage (14% or 6% vs. 2%, p = 0.01) as well as vaginal bleeding (11% or 35% vs. 9%, p = 0.01). On the contrary, duration of tocolysis with atosiban was shorter in patients with BMI >30 kg/m2 (4 or 5 vs. 6 days, p = 0.01). When comparing severity of maternal or fetal complications, grade 1 intervention-related complications occurred significantly more often in group 3 compared to group 1 or 2 (78% vs. 45% or 57%, p = 0.02). Gestational age at delivery was around 36 weeks in all groups without significant differences. CONCLUSION This investigation did not identify clinically relevant maternal and/or fetal outcome problems related to BMIs >35 kg/m2. Additional studies are however needed to confirm our results.
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Affiliation(s)
- Julia Zepf
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ladina Rüegg
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Nele Strübing
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Franziska Krähenmann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Spina Bifida Study Group Zurich
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
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Marton E, Giordan E, Gioffrè G, Canova G, Paolin A, Mazzucco MG, Longatti P. Homologous cryopreserved amniotic membrane in the repair of myelomeningocele: preliminary experience. Acta Neurochir (Wien) 2018; 160:1625-1631. [PMID: 29858946 DOI: 10.1007/s00701-018-3577-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/23/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Surgical management of spinal dysraphism often requires the use of dural substitutes. Amniotic membrane (AM) has drawn the interest of clinicians for its valuable concentration of cytokines and factors capable of promoting wound healing, re-epithelialization, inhibiting fibrosis and regulating angiogenesis. These beneficial qualities could make AM an interesting dural substitute for spina bifida repair. In this study, we describe the use of banked homologous AM as a dural substitute for the repair of spinal dysraphism in newborns. Our purpose is to test the mechanical characteristics, as well as the safety and effectiveness of AM in preventing postoperative complications and re-tethering. METHODS The AM patch was carefully detached from the chorion of donors undergoing caesarean section, rinsed in saline solution, and cryopreserved in liquid nitrogen. Five newborns were treated using AM: three affected by open spinal dysraphism and two by spina bifida occulta. The AM patch was used as a dural substitute with two different positions and purposes: the amnion-side down covering the placode to prevent adhesions or placed extradurally facing the dura to avoid scarring and facilitating the sliding of the dural sac itself under the extradural tissue layers. RESULTS No adverse events occurred, and the surgical wounds healed without complications. MRI scans taken at 3 and 6 months after surgery showed a satisfying de-tethering of the spinal cord with no obvious evidence of new adherence formation. CONCLUSIONS We present a multimodal interposition technique using AM as a reconstructive and anti-adhesive tissue for the treatment of open myelomeningocele (MMC) and lipomeningocele (LMC) treatment. In our experience, AM proved its efficacy in restoring the dural sac integrity without complications. We support the use of AM as a promising dural substitute, speculating on how the use of AM could potentially change reconstructive strategies for spinal dysraphism.
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Affiliation(s)
- Elisabetta Marton
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy
| | - Enrico Giordan
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy.
| | - Giorgio Gioffrè
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy
| | - Giuseppe Canova
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy
| | | | - Marina Grazia Mazzucco
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy
| | - Pierluigi Longatti
- Department of Neurosurgery, Treviso Hospital, University of Padova, Via Piazzale 1, 31100, Padova, Treviso, Italy
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Bevan R, Wilson-Jones N, Bhatti I, Patel C, Leach P. How much do plastic surgeons add to the closure of myelomeningoceles? Childs Nerv Syst 2018; 34:737-740. [PMID: 29222684 PMCID: PMC5856885 DOI: 10.1007/s00381-017-3674-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/27/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE This study reviews the outcomes of children undergoing myelomeningocele (MMC) repair in the paediatric neurosurgical department in Cardiff. These procedures are historically performed by paediatric neurosurgeons with occasional support from plastic surgeons for the larger lesions. We reviewed the postoperative outcomes over a 9-year period to assess the efficacy of having a plastic surgeon present at all MMC closures. METHODS Analysis of a prospectively collected database of all MMC closures performed at University Hospital Wales from April 2009 to August 2017 was used. Comparison was made with the published literature especially with regard to complications. RESULTS Thirty-one children, 13 males and 18 females, underwent MMC closure over the 9-year period. Twenty-four (77.4%) defects were closed by direct approximation. Seven patients (22.5%) required a more complex plastic procedure to obtain closure. Two patients (6.5%) had a wound complication, one wound infection and one flap edge necrosis both healing with dressings alone. Two patients had cerebrospinal fluid (CSF) leaks that responded to ventriculo-peritoneal shunting. Two patients died from unrelated conditions during the study period. CONCLUSION In our series, 7/31 (22.5%) cases involved a more complex closure in keeping with the literature. The authors feel that having the plastic surgeon at all closures has led to a low wound complication rate.
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Affiliation(s)
- Rhian Bevan
- University Hospital of Wales College of Medicine, Cardiff, UK.
| | | | - Imran Bhatti
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Chirag Patel
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul Leach
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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Botelho RD, Imada V, Rodrigues da Costa KJ, Watanabe LC, Rossi Júnior R, De Salles AAF, Romano E, Peralta CFA. Fetal Myelomeningocele Repair through a Mini-Hysterotomy. Fetal Diagn Ther 2016; 42:28-34. [PMID: 27656888 DOI: 10.1159/000449382] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/23/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To present the feasibility of fetal myelomeningocele (MMC) repair through a mini-hysterotomy and to describe the perinatal results from our initial experience. METHODS A descriptive study of cases of fetal MMC correction via mini-hysterotomy performed between 2014 and 2016. RESULTS Forty-five women underwent fetal surgery and 87% (39/45) delivered. A complete multilayer correction of the MMC was possible in all cases. There were no maternal, fetal or neonatal deaths. No maternal or fetal complications occurred from fetal MMC correction until maternal hospital discharge. The average gestational age (GA) at surgery was 24.5 weeks (standard deviation, SD: 1.7; range: 20.7-26.9). The median hysterotomy length was 3.05 cm (SD: 0.39; range: 2.50-3.50). One patient (1/39; 2.6%) experienced chorioamniotic separation. Nine patients (9/39; 23.1%) had premature preterm rupture of membranes at a median GA of 34.1 weeks (range: 31.1-36.0). The average GA at delivery was 35.3 weeks (SD: 2.2; range: 27.9-39.1). Ninety-five percent (37/39) of our patients had an intact hysterotomy site at delivery. Ventriculoperitoneal shunt placement was necessary for 7.7% (3/39) of the neonates. CONCLUSION Fetal MMC repair is feasible through a mini-hysterotomy. This approach appears to be associated with reduced risks of very preterm delivery and maternal, fetal and neonatal complications.
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Attenello FJ, Tuchman A, Christian EA, Wen T, Chang KE, Nallapa S, Cen SY, Mack WJ, Krieger MD, McComb JG. Infection rate correlated with time to repair of open neural tube defects (myelomeningoceles): an institutional and national study. Childs Nerv Syst 2016; 32:1675-81. [PMID: 27444296 DOI: 10.1007/s00381-016-3165-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/30/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal time to closure of a newborn with an open neural tube defect (NTD-myelomeningocele) has been the subject of a number of investigations. One aspect of timing that has received attention is its relationship to repair site and central nervous system (CNS) infection that can lead to irreversible deficits and prolonged hospital stays. No studies have evaluated infection as a function of surgical timing at a national level. We hypothesized an increase in wound infection in those patients with delays in myelomeningocele repair when evaluated in both a single-center and national database. METHODS Treatment outcomes following documented times to transfer and closure were evaluated at Children's Hospital of Los Angeles (CHLA) for the years 2004 to 2014. Data of newborns with a myelomeningocele with varying time to repair were also obtained from non-overlapping abstracts of the 2000-2010 Kids' Inpatient Database (KID) and Nationwide Inpatient Sample (NIS). Poisson multivariable regression analyses were used to assess the effect of time to repair on infection and time to discharge. RESULTS At CHLA, 95 neonates who underwent myelomeningocele repair were identified, with a median time from birth to treatment of 1 day. Six (6 %) patients were noted to have postrepair complications. CHLA data was not sufficiently powered to detect a difference in infection following delay in closure. In the NIS, we identified 3775 neonates with repaired myelomeningocele of whom infection was reported in 681 (18 %) patients. There was no significant difference in rates of infection between same-day and 1-day wait times (p = 0.22). Wait times of two (RR = 1.65 [1.23, 2.22], p < 0.01) or more days (RR = 1.88 [1.39, 2.54], p < 0.01), respectively, experienced a 65 % and 88 increase in rates of infection compared to same-day procedures. Prolonged wait time was 32 % less likely at facilities with increased myelomeningocele repair volume (RR = 0.68 [0.56 0.83], p < 0.01). The presence of infection was associated with a 54 % (RR = 1.54 [1.36, 1.74], p < 0.01) increase in the length of stay when compared to neonates without infection. CONCLUSION Myelomeningocele closure, when delayed more than 1 day after birth, is associated with an increased rate of infection and length of stay in the national cohort. High-volume centers are associated with fewer delays to repair. Though constrained by limitations of a national coded database, these results suggest that early myelomeningocele repair decreases the rate of infection.
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Affiliation(s)
- Frank J Attenello
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| | - Alexander Tuchman
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - Eisha A Christian
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - Timothy Wen
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ki-Eun Chang
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | | | - Steven Y Cen
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
- Department of Preventive Medicine, Keck School of Medicine of USC, Los Angeles, CA, USA
- Department of Radiology, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - William J Mack
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - Mark D Krieger
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
- Division of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - J Gordon McComb
- Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA
- Division of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Golinko MS, Patel K, Cai R, Smith A, Ocal E. The deepithelialized skin flap for closure of large myelomeningoceles: a common plastic surgery technique for a novel neurosurgery application. Childs Nerv Syst 2016; 32:1503-6. [PMID: 27272947 DOI: 10.1007/s00381-016-3133-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/26/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE The study aims to demonstrate proof of principle of a common plastic surgery technique of deepithelialization for repair of large myelomeningoceles (MMCs). Whereas repair typically consists of a watertight dural closure followed by a muscle or fasciocutaeneous layer, excess skin, however, need not be discarded and can be deepithelialized to augment or, in selective cases, replace the muscle repair. METHODS The study was performed through a retrospective chart review of two patients. RESULTS Step-by-step figures illustrate the technique. Two patients each born with large MMCs measuring 10 × 11 cm and 6 × 9 cm, respectively, were reviewed. Excess skin was deepithelialized to create an additional layer of vascularized tissue over the muscle repair. There were no post-operative complications at 3-month follow-up. CONCLUSIONS In large MMCs with excess skin, the use of a deepithelialized skin flap can potentially be an alternative or adjunct to a muscle flap to buttress the dural repair.
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Affiliation(s)
- Michael S Golinko
- Division of Plastic Surgery, Department of Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - Kumar Patel
- Division of Plastic Surgery, Department of Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Rong Cai
- Department of Neurosurgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Aaron Smith
- Division of Plastic Surgery, Department of Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Eylem Ocal
- Department of Neurosurgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA
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