Artikel
Open foetal surgery of myelomeningocele (fMMC) repair – main advantages and controversies
Offene fetale Deckung von Myelomeningozelen – Vorteile und Kontroversen
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Autoren
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Heidi Baechli
- Universitätsklinikum Heidelberg, Neurochirurgische Klinik, Heidelberg, Deutschland
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Michael Elsässer
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Deutschland
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Herbert Fluhr
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Deutschland
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Jörg Rom
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Deutschland
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Johannes Pöschl
- Universitätsklinikum Heidelberg, Neuropädiatrie, Heidelberg, Deutschland
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Bernd Beedgen
- Universitätsklinikum Heidelberg, Neuropädiatrie, Heidelberg, Deutschland
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Sebastian Ronellenfitsch
- Universitätsklinikum Heidelberg, Neuropädiatrie, Heidelberg, Deutschland
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Ines Brösse
- Universitätsklinikum Heidelberg, Neuropädiatrie, Heidelberg, Deutschland
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Rosemarie Schreckenberger
- Universitätsklinikum Heidelberg, Anaesthesie, Heidelberg, Deutschland
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Ahmed El Damaty
- Universitätsklinikum Heidelberg, Neurochirurgische Klinik, Heidelberg, Deutschland
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Christof Sohn
- Universitätsklinikum Heidelberg, Frauenklinik, Heidelberg, Deutschland
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Andreas W. Unterberg
- Universitätsklinikum Heidelberg, Neurochirurgische Klinik, Heidelberg, Deutschland
| Veröffentlicht: | 8. Mai 2019 |
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Gliederung
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Objective: The benefit of fetal surgery versus postnatal surgery in MMC closure could be clearly shown in the randomized multicentric MOMS trial (Management of Myelomeningocele Study), conducted from 2003-2010.This was stopped prematurely because of significant better outcomes with decreased shunt placement, motor function and mental development. On the other hand there are some important maternal and neonatal risks such as maternal uterine dehiscence and preterm delivery. Our experience with open fetal surgery is reported and critically discussed.
Methods: Ten patients underwent fMMC surgery at our institution between the 24th and 25th week of gestation (GA). All women received ultrasound and fetal MRI to verify eligibility and record fetal measurements preoperatively. The lesion level was 3xL4, 5x L5 and 2x S1. The MMC defect was microsurgically operated with a 3 layered repair. The follow up ranged between 2,6years and 1 month.
Results: The repair was successful in all 10 patients without CSF leakage and complete hindbrain herniation was achieved in 9 cases. 2 patients needed hydrocephalus treatment after 1 year (2 VP shunts and 1 ETV). The size of the lateral ventricles before MMC repair varied between 8–12mm (average 10mm) and before delivery 8–16mm (average 10). Motor function outcomes can’t be evaluated finally as the patients are still too young but we can already presume an amelioration, catheterization was needed in 3 cases. The average time of delivery at birth was 35 weeks, 2 preterms <31 weeks and average birth weight was 2360g. We had no maternal or fetal mortality. Our maternal complications: Two uterine dehiscence, one of them with oligohydramnios.
Conclusion: In our opinion the main advantages of open fetal MMC repair so far is a decreased need for hydrocephalus treatment, especially during the first year of life and improvement of hindbrain herniation and the chance of mobility independence with resulting better quality of life. The long-term neurodevelopmental and motor functional outcomes and consecutively the need for orthopedic surgeries and/or neurosurgical interventions are not yet available from the MOMS and have to be further evaluated. To achieve objective comparable data we use the Bayley Scales of Infant Development. The increased risks of prematurity and maternal morbidity is likely to continue to decline in the future as experience grows, but should be critically discussed with the parents.
