CONTRIBUTIONWhat are the novel findings of this work? For fetal surgery of spina bifida aperta (SBA), the learning curve (LC) is significant regardless of the approach, and the number of cases operated on is correlated with outcome. Competency is reached after 35 consecutive cases for standard hysterotomy and is predicted to be achieved after ≥ 57 cases for mini-hysterotomy and after ≥ 56 for percutaneous two-layer fetoscopy.
What are the clinical implications of this work?Standard hysterotomy for closure of fetal SBA has the shortest LC and remains the gold-standard technique, with regards to safety and efficacy. Mini-hysterotomy and percutaneous fetoscopy have a longer LC. Percutaneous fetoscopy requires advanced endoscopic dissection and suturing skills and adequate preliminary training.
ABSTRACTObjective The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques. Methods MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only Learning curves of fetal surgery for spina bifida Conclusiones El número de casos operados está correlacionado con el resultado del cierre de la EBA fetal, y el número de casos operados necesarios para alcanzar la competencia estuvo entre 35 para la histerotomía estándar y ≥56-57 para las operaciones con mínima agresividad. Las observaciones realizadas proporcionan información importante para las instituciones que buscan establecer un nuevo centro fetal, desarrollar una nueva técnica de cirugía fetal o entrenar a su equipo, e informar a los médicos que remiten a especialistas a los posibles pacientes y a terceros.
OBJECTIVERecent trials have shown the safety and benefits of fetoscopic treatment of myelomeningocele (MMC). The authors’ aim was to report their preliminary results of prenatal fetoscopic treatment of MMC using a biocellulose patch, focusing on neurological outcomes, fetal and maternal complications, neonatal CSF leakage, postnatal hydrocephalus, and radiological outcomes.METHODSPreoperative assessment included clinical examination, ultrasound imaging, and MRI of the fetus. Patients underwent purely fetoscopic in utero MMC repair, followed by postoperative in utero and postnatal MRI. All participants received multidisciplinary follow-up.RESULTSFive pregnant women carrying fetuses affected by MMC signed informed consent for the fetoscopic treatment of the defect. The mean MMC size was 30.4 mm (range 19–49 mm). Defect locations were L1 (2 cases), L5 (2 cases), and L4 (1 case). Hindbrain herniation and ventriculomegaly were documented in all cases. The mean gestational age at surgery was 28.2 weeks (range 27.8–28.8 weeks). Fetoscopic repair was performed in all cases. The mean gestational age at delivery was 33.9 weeks (range 29.3–37.4 weeks). After surgery, reversal of hindbrain herniation was documented in all cases. Three newborns developed signs of hydrocephalus requiring CSF diversion. Neurological outcomes in terms of motor level were favorable in all cases, but a premature newborn died due to CSF infection and sepsis.CONCLUSIONSThe authors’ preliminary results suggest that fetoscopic treatment of MMC is feasible, reproducible, and safe for mothers and their babies. Neurological outcomes were favorable and similar to those in the available literature. As known, prematurity was the greatest complication.
What are the novel findings of this work?This study demonstrates that half of fetuses eligible for prenatal open spina bifida repair have structural brain anomalies, such as an abnormal corpus callosum or heterotopia. Such anomalies were more likely in the presence of a lumbar or higher lesion and wider lateral ventricles (≥ 15 mm).
What are the clinical implications of this work?Our findings highlight the relevance of detailed prenatal and preoperative assessment of the brain in fetuses with open spina bifida. One can expect that around half of affected fetuses will present with central nervous system anomalies prior to fetal surgery, which may be considered as additional information for presurgical counseling.
Our study shows that neoskin can develop in the fetus using a 3-layer graft, including epidermal growth beneath the silicone layer of the bilaminar skin graft. These findings suggest that the fetus is able to reepithelialise even large skin defects. Further experience is necessary to assess the quality of this repair.
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