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英国首例子宫内脊柱裂胎儿产前闭合手术

10/24/2018
多米尼克 . 汤普森医生
神经外科医师多米尼克 . 汤普森

近日,一个由大奥蒙德街儿童医院(GOSH), 伦敦大学学院医院(UCLH)以及伦敦大学学院(UCL)的联合小组,成功完成了英国历史上首例针对两个患脊髓裂的胎儿进行子宫内产前闭合手术。

今年夏天,伦敦大学学院(UCL)的研究人员与大奥蒙德街儿童医院(GOSH)的国家健康系统内的临床医生以及伦敦大学学院医院(UCLH)的临床医生一起,与比利时鲁汶大学医院合作,首次在英国开展了针对两个患脊髓裂的胎儿进行子宫内产前闭合手术。现在,妈妈和宝宝都恢复得很好。

至今为止,英国目前的做法是母亲可以选择在英国国外做在子宫内的胎儿手术,或者在孩子出生后做产后手术。由于患有脊柱裂的婴儿通常无法行走,并且可能需要在以后的生活中进行一系列的手术来排出大脑中的液体(分流管放置)。因此,与出生后手术相比,这种专门的子宫内胎儿手术将会给婴儿提供更好的生存机会。

大奥蒙德街儿童医院的神经外科主治医师多米尼克·汤普森 (Dominic Thompson)解释道:“在脊柱裂的病例中,椎管在子宫内并不完全闭合,使脊髓在怀孕早期就暴露在外。这将会导致大脑发生进一步变化,并对下半身的神经造成严重的永久性损伤”。

在子宫内进行手术,我们需要打开子宫,使脊柱裂的部分暴露出来,但是不接生出婴儿,关闭缺陷,然后修复子宫,让婴儿安全地留在子宫内。” 伦敦大学学院医院及比利时鲁汶大学医院的胎儿外科主治医师扬·德普瑞斯特(Mr Jan Deprest)说道。

使用这种方法在子宫内闭合脊柱裂是产后手术的一种替代方法。它已被证明可以改善短期和中期的预后。虽然这两种干预方法都不能百分百完全治愈脊柱裂,但在子宫内胎儿手术中,这种缺陷会提前愈合,从而防止在孕期最后三分之一的时候脊髓受损。同时,我们也在通过GIFT-Surg项目框架研究最小存取 (fetoscopic) 技术,如果我们能证明它具有同等的效益,我们将为患者提供这种治疗选择。”

GOSHUCLH的联合团队自2012年起就在比利时接受Deprest教授及其团队的培训,总共参与了包括从UCLH过去的英国患者在内的40多次手术。他们还受益于与费城儿童医院的密切联系,该医院由N斯科特·阿齐克 (N Scott Adzick) 领导的团队率先开展了这项手术,自2011年以来已经开展了320多次类似手术。

参与前两次手术的30多人的团队是由伦敦大学学院妇女健康研究所和UCLH的胎儿医学医师安娜·戴维协调的。戴维教授还得到了英国国立卫生研究院(NIHR) UCLH生物医学研究中心的支持。她说: “我们已经努力了三年,通过在UCLUCLHGOSH建立产前治疗中心,将这项服务带给英国的患者。”

我们提供这项服务的决心是基于美国一项大型、多中心、随机的对照试验结果,该试验将产前闭合和产后闭合脊柱裂的结果进行了比较,并观察到通过适当的培训,欧洲可以安全地进行子宫内胎儿手术。美国的这项实验发现到产前闭合使脊柱裂新生儿对于外科分流手术的需要减少了50%,并且新生儿在30个月大时运动功能能显著改善。”

“减少分流的需要是尤其重要的”, 伦敦大学学院大奥蒙德街儿童健康研究所的保罗··科比教授(Prof Paolo De Coppi)说道, “对子宫内进行产前关闭的脊柱裂儿童进行长期随访表明,5岁时未分流的儿童的大脑功能、活动能力和完全独立能力均高于接受过分流的儿童。保罗··科比教授由英国国立卫生研究院(NIHR) GOSH生物医学研究中心的支持。  

UCLH女性健康临床主任唐纳德·皮伯斯教授 (Prof Donald Peebles) 补充道: “虽然我们目前只采用开放的胎儿手术方法,但我们正在临床前模型中开发胎儿镜方法,希望这能进一步减少产妇并发症。” GIFT-Surg项目旨在开发新的胎儿镜工具和成像技术,以支持产前治疗,该项目由Wellcome Trust和工程与物理科学研究理事会 (EPSRC)资助。

About open fetal surgery for spina bifida

While the baby is still in the womb, the mother undergoes a surgical procedure where her skin and then her uterus are opened using an incision in the bikini line; this is slightly wider than the cut used for a caesarean section but is in the same place in the abdomen. The uterus (womb) is then opened to allow the surgeons to access the baby. The spina bifida defect is examined and surgically closed by the paediatric neurosurgeon in exactly the same way as a postnatal closure. The mother’s uterus and abdomen are then both closed. The baby remains in their mother’s womb until approximately 37 weeks, before being born by caesarean section. This type of surgery is only suitable for some babies with spina bifida as not all babies will benefit from fetal repair.

Great Ormond Street Hospital for Children in London

Great Ormond Street Hospital is one of the world’s leading children’s hospitals with the broadest range of dedicated, children’s healthcare specialists under one roof in the UK. The hospital’s pioneering research and treatment gives hope to children from across the UK with the rarest, most complex and often life-threatening conditions. Our patients and families are central to everything we do – from the moment they come through the door and for as long as they need us.

About UCLH

UCLH (University College London Hospitals NHS Foundation Trust) provides first-class acute and specialist services in five hospitals in North Central London. UCLH is committed to education and research and forms part of UCLPartners which in March 2009 was officially designated as one of the UK's first academic health science centres by the Department of Health. UCLH works closely with UCL, translating research into treatments for patients. Please see our website www.uclh.nhs.uk for more information, we are also on Facebook (UCLHNHS), Twitter (@uclh), Youtube (UCLHvideo) and instagram (@uclh).

About UCL

UCL was founded in 1826. We were the first English university established after Oxford and Cambridge, the first to open up university education to those previously excluded from it, and the first to provide systematic teaching of law, architecture and medicine. We are among the world's top universities, as reflected by performance in a range of international rankings and tables. UCL currently has over 39,000 students from 150 countries and over 12,500 staff. Our annual income is more than £1 billion.