{"id":5000,"date":"2015-11-17T08:21:34","date_gmt":"2015-11-17T08:21:34","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5000"},"modified":"2015-11-17T08:21:34","modified_gmt":"2015-11-17T08:21:34","slug":"operatie-de-mielomeningocel-pentru-bebelus-nenascut","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/operatie-de-mielomeningocel-pentru-bebelus-nenascut\/","title":{"rendered":"Opera\u021bie de mielomeningocel pentru bebelu\u0219 nen\u0103scut"},"content":{"rendered":"<p style=\"text-align: justify\">\n<p style=\"text-align: justify\"><strong>Interven\u021bie extraordinar\u0103, \u00een premier\u0103 na\u021bional\u0103:<\/strong><\/p>\n<p style=\"text-align: justify\"><strong>\u0218apte medici de la Regina Maria \u0219i Brain Institute au realizat cu succes prima opera\u021bie de mielomeningocel (spina bifida) unui bebelu\u0219 nen\u0103scut<\/strong><\/p>\n<p style=\"text-align: justify\">Medicul Hadi Rahimian, Directorul Medical al Spitalului B\u0103neasa (Re\u021beaua de s\u0103n\u0103tate Regina Maria), \u0219i Dr. Sergiu Stoica, co-fondator al Brain Institute, au realizat, \u00een premier\u0103, o opera\u021bie extrem de complex\u0103 \u0219i rar\u0103 \u2013 mielomeningocel (cea mai sever\u0103 form\u0103 de <em>spina bifida<\/em>) operat <em>in utero, <\/em>adic\u0103 direct \u00een burta mamei. Interven\u021bia a avut loc joi, 5 noiembrie, \u0219i este o premier\u0103 absolut\u0103 pentru Rom\u00e2nia. Astfel de opera\u021bii se realizeaz\u0103 doar \u00een centre specializate \u00een chirurgie fetal\u0103 din Statele Unite ale Americii \u0219i \u00een c\u00e2teva centre din Europa. P\u00e2n\u0103 acum, copiii care erau identifica\u021bi cu aceast\u0103 problem\u0103 nu aveau nicio \u0219ans\u0103 real\u0103 de a fi opera\u021bi \u00eenainte de na\u0219tere \u00een \u021bar\u0103.<\/p>\n<p style=\"text-align: justify\">O feti\u021b\u0103 de doar 1250 de grame este primul copil din Rom\u00e2nia care a fost operat de mielomeningocel \u00een burta mamei, \u00eenainte de a se na\u0219te. Premiera medical\u0103 a fost posibil\u0103 datorit\u0103 unei echipe multidisciplinare formate din \u0219apte medici, dintre care au f\u0103cut parte <strong>Dr. Sergiu Stoica<\/strong>, neurochirurg, \u0219i <strong>Dr. Hadi Rahimian<\/strong>, chirurg fetal, obstetrician supraspecializat \u00een medicin\u0103 materno-fetal\u0103 \u2013 \u00a0fiecare cu o expertiz\u0103 deosebit\u0103 \u00een domeniile lor.<\/p>\n<p style=\"text-align: justify\">Pentru copiii diagnostica\u021bi cu mielomeningocel \u00eenainte de a se na\u0219te, chirurgia fetal\u0103 deschis\u0103 \u2013 opera\u021bia copilului <em>in utero,<\/em> \u00eenainte de a se produce afectarea ireversibil\u0103 a nervilor \u0219i a m\u0103duvei spin\u0103rii \u2013 este un standard de \u00eengrijire \u00een Statele Unite ale Americii, \u00eens\u0103 p\u00e2n\u0103 \u00een acest moment, \u00een Rom\u00e2nia, nu s-a mai realizat o astfel de interven\u021bie medical\u0103 complex\u0103.<\/p>\n<p style=\"text-align: justify\">\u00cen 5 noiembrie, \u00een s\u0103pt\u0103m\u00e2na a 28-a de sarcin\u0103, o feti\u021b\u0103 cu mielomeningocel a fost operat\u0103 \u00een uterul mamei. Echipa extraordinar\u0103 de medici a reu\u0219it s\u0103 \u00eenchid\u0103 defectul spinal \u0219i, dup\u0103 o opera\u021bie care a durat o or\u0103 \u0219i jum\u0103tate, feti\u021ba poate continua s\u0103 se dezvolte \u00een uter \u00eenca alte c\u00e2teva s\u0103pt\u0103m\u00e2ni, c\u00e2nd va fi suficient de preg\u0103tit\u0103 s\u0103 vin\u0103 pe lume.<\/p>\n<p style=\"text-align: justify\"><strong>Mielomeningocelul, forma sever\u0103 de <em>spina bifida <\/em><\/strong><\/p>\n<p style=\"text-align: justify\"><em>Spina bifida<\/em> este un defect de \u00eenchidere osos la nivelul coloanei vertebrale. Defectul poate fi acoperit de tegument (<em>spina bifida<\/em> oculta), sau poate fi asociat cu un sac care con\u021bine meninge \u0219i lichid cefalorahidian (meningocel) sau elemente ale m\u0103duvei spin\u0103rii \u0219i nervi (mielomeningocel).<\/p>\n<p style=\"text-align: justify\">Mielomeningocelul este forma cea mai sever\u0103 de <em>spina bifida<\/em> \u0219i este cauzat de \u00eenchiderea incomplete, \u00een zilele 26-30 de sarcin\u0103, a tubului neural embrionar. Acesta apare \u00een special \u00een zona lombar\u0103, unde arcurile vertebrale ale uneia sau a mai multor vertebre nu se sudeaz\u0103. Prin aceasta deschidere proemin\u0103 r\u0103d\u0103cinile nervilor spinali \u0219i meningele, care nu sunt acoperite de piele.<\/p>\n<p style=\"text-align: justify\">\n<p style=\"text-align: justify\">Copiii se nasc cu deficite neurologice severe, de tipul tulbur\u0103rilor de sensibilitate \u0219i paralizia membrelor inferioare, incontinen\u021ba urinar\u0103 \u0219i fecal\u0103, \u0219i hidrocefalia (acumulare excesiv\u0103 de lichid cefalorahidian care comprim\u0103 creierul, cu grade variate de retard mental). Odat\u0103 ce copilul se na\u0219te cu paralizie, \u0219ansele de recuperare sunt practic nule.<\/p>\n<p style=\"text-align: justify\"><strong>Repararea defectului \u00eenainte de na\u0219tere <em>vs<\/em>. dup\u0103 na\u0219tere \u2013 \u0219ansa de a evita paralizia<\/strong><\/p>\n<p style=\"text-align: justify\">De\u0219i defectul de tub neural apare \u00een prima lun\u0103, cea mai mare parte a deficitelor neurologice se produc t\u00e2rziu \u00een sarcin\u0103, \u00een perioda de dezvoltare fetal\u0103, ca urmare a lez\u0103rii cronice \u0219i progresive a m\u0103duvei spin\u0103rii de c\u0103tre lichidul amniotic. De aceea, este important ca acest \u021besut s\u0103 fie protejat \u00eenainte de deteriorarea lui, iar alegerea momentului interven\u021biei chirurgicale este esen\u021bial.<\/p>\n<p style=\"text-align: justify\">Recent, cercet\u0103torii \u00een chirurgia fetal\u0103 au finalizat un studiu clinic \u00een trei dintre cele mai importante centre de chirurgie fetal\u0103 din SUA. Studiul a comparat efectul chirurgiei prenatale <em>in utero<\/em> versus chirurgia postnatal\u0103 tradi\u021bional\u0103 \u00een ceea ce prive\u0219te complica\u021biile neurologice invalidante. Studiul, ap\u0103rut \u00een 2011 \u00een revista \u201cNew England Journal of Medicine\u201d, a eviden\u021biat rezultate semnificativ mai bune \u00een cazul opera\u021biei <em>in utero<\/em>.*<\/p>\n<p style=\"text-align: justify\">Astfel, dac\u0103 repararea defectului se face \u00eenainte de s\u0103pt\u0103m\u00e2na a 26-a de sarcin\u0103, complica\u021biile serioase asociate cu mielomeningocel pot fi prevenite sau reduse. Chirurgia fetal\u0103 reduce nevoia de montare a unui \u0219unt \u2013 un tub implantat chirurgical care s\u0103 dreneze excesul de lichid de la nivelul creierului \u00een abdomen. \u00cen primul an dup\u0103 na\u0219tere, aproape jum\u0103tate din copii au putut s\u0103 mearg\u0103 f\u0103r\u0103 c\u00e2rje p\u00e2n\u0103 la v\u00e2rsta de doi ani.<\/p>\n<p style=\"text-align: justify\">Ca urmare a acestui studiu, chirurgia fetal\u0103 deschis\u0103 pentru mielomeningocel nu mai este considerat\u0103 experiemental\u0103 \u0219i a devenit standardul de tratament \u00een centrele de chirurgie fetal\u0103 din SUA \u0219i \u00een unele centre din Europa.<\/p>\n<p style=\"text-align: justify\">Opera\u021bia <em>in utero<\/em> realizat\u0103 \u00een cadrul Spitalului B\u0103neasa a fost o reu\u0219it\u0103 ca urmare a dot\u0103rii tehnice ultraperformante a s\u0103lii de opera\u021bie, a colabor\u0103rii permanente a tuturor medicilor implica\u021bi \u00een opera\u021bie \u0219i a gradului ridicat de expertiz\u0103 a echipei multidisciplinare de speciali\u0219ti \u00een medicin\u0103 materno-fetal\u0103, chirurgie fetal\u0103, neurochirurgie pediatric\u0103, anestezie cu risc \u00eenalt, \u0219i a asistentelor medicale \u00eenalt specializate.<\/p>\n<p style=\"text-align: justify\">Totodat\u0103, opera\u021bia a fost posibil\u0103 datorit\u0103 dorin\u021bei p\u0103rin\u021bilor de a-i oferi feti\u021bei lor cea mai bun\u0103 \u0219ans\u0103 de a merge \u2013 de\u0219i decizia nu a fost una u\u0219oar\u0103. P\u0103rin\u021bii au venit din Gura Humorului la Dr. Hadi Rahimian pentru un <em>second opinion<\/em> privind tratamentul feti\u021bei lor, deoarece li se spusese c\u0103 tot ce se putea face era interven\u021bia chirurgical\u0103 imediat dup\u0103 na\u0219tere.<\/p>\n<p style=\"text-align: justify\">\n<p style=\"text-align: justify\"><strong>\u00cen ce const\u0103 opera\u021bia <em>in utero<\/em> pentru tratarea mielomengocelului<\/strong><\/p>\n<p style=\"text-align: justify\">Chirurgia fetal\u0103 deschis\u0103 este o procedur\u0103 \u00eenalt specializat\u0103, complex\u0103, delicat\u0103 \u0219i riscant\u0103 \u00een acela\u0219i timp, at\u00e2t pentru mam\u0103, c\u00e2t \u0219i pentru f\u0103t. De aceea, ea trebuie efectuat\u0103 doar \u00een centre de expertiz\u0103, de c\u0103tre medici cu experien\u021b\u0103 \u00een astfel de interven\u021bii. \u00cen plus fa\u021b\u0103 de neurochirurg si chirurgul fetal, un\u00a0rol important \u00eel are medicul anestezist, care administreaz\u0103 anestezia at\u00e2t mamei, c\u00e2t \u0219i copilului, dup\u0103 un protocol bine stabilit.<\/p>\n<p style=\"text-align: justify\">Mama este supus\u0103 unei anestezii generale, care relaxeaz\u0103, totodat\u0103, uterul \u0219i anesteziaz\u0103 \u0219i f\u0103tul. Chirurgul fetal efectueaz\u0103 o incizie \u00een abdomenul mamei, prin care scoate uterul \u00een exterior. Acest lucru este posibil deoarece uterul are form\u0103 de urn\u0103 greceasc\u0103, fiind ata\u0219at doar \u00een partea sa inferioar\u0103. Cu ajutorul unui marker, sub ghidaj ecografic, medicul identific\u0103 unde se afl\u0103 placenta, pentru a evita sec\u021bionarea acesteia, precum \u0219i zona din spatele copilului unde este localizat mielomeningocelul. Corespunz\u0103tor acestei zone, chirurgul fetal face o incizie de aproximativ 7 centimetri \u00een \u00a0uterul mamei, prin care se expune spatele f\u0103tului unde se afl\u0103 mielomeningocelul. Incizia uterin\u0103 este realizat\u0103 cu ajutorul unui instrument special care taie \u0219i capseaz\u0103 vasele \u00een acela\u0219i timp, reduc\u00e2ndu-se la minimum s\u00e2ngerarea. Pentru anestezia suplimentar\u0103 a f\u0103tului, medicul ATI\u00a0 administreaz\u0103 intramuscular o combina\u021bie de narcotic \u0219i relaxant muscular. Acesta este momentul \u00een care neurochirurgul \u00eencepe repararea defectului, o parte crucial\u0103 a interven\u021biei chirurgicale. Opera\u021bia se efectueaz\u0103 minim-invaziv, sub microscop operator de \u00eenalt\u0103 rezolu\u021bie. Repararea mielomeningocelului trebuie s\u0103 se fac\u0103 astfel \u00eenc\u00e2t lichidul cefalorahidian s\u0103 nu poat\u0103 s\u0103 ias\u0103 \u00een exterior, iar lichidul amniotic s\u0103 nu poat\u0103 p\u0103trunde la nivel medular.<\/p>\n<p style=\"text-align: justify\">De\u0219i neurochirurgul folose\u0219te aceea\u0219i tehnic\u0103 de acoperire a meningocelului ca \u00een opera\u021bia efectuat\u0103 dup\u0103 na\u0219tere, interven\u021bia <em>in utero<\/em> este o procedur\u0103 mult mai complex\u0103 \u0219i delicat\u0103 din punct de vedere tehnic:<\/p>\n<ul style=\"text-align: justify\">\n<li>Accesul este mai mic, neurochirurgul trebuind s\u0103 lucreze printr-o fereastr\u0103 uterin\u0103 mic\u0103;<\/li>\n<li>Structurile nervoase sunt mai mici \u0219i foarte delicate, trebuind s\u0103 fie manipulate cu mult\u0103 aten\u021bie, fiind poten\u021bial func\u021bionale;<\/li>\n<li>Evitarea pierderilor de s\u00e2nge este critic\u0103, pentru a preveni transfuzia de s\u00e2nge fetal\u0103;<\/li>\n<li>Interven\u021bia trebuie efectuat\u0103 c\u00e2t mai rapid posibil, pentru a se limita expunerea f\u0103tului la mediul extrauterin;<\/li>\n<li>Succesul opera\u021biei necesit\u0103 o comunicare permanent\u0103 \u00eentre neurochirurg, chirurgul fetal, specialistul \u00een medicina materno-fetal\u0103 \u0219i anestezist, astfel \u00eenc\u00e2t s\u0103 se poat\u0103 interveni prompt dac\u0103 apar complica\u021bii.<\/li>\n<\/ul>\n<p style=\"text-align: justify\">Pe toat\u0103 durata interven\u021biei \u0219i \u00eenainte de \u00eenchiderea uterului la sf\u00e2r\u0219itul opera\u021biei, volumul acestuia se men\u021bine cu un lichid care \u00eenlocuie\u0219te lichidul amniotic. De asemenea, pentru a se asigura c\u0103 nu au ap\u0103rut complica\u021bii la nivelul copilului, al doilea medic specializat \u00een medicina materno-fetal\u0103 din echipa operatorie supravegheaz\u0103 ecografic f\u0103tul continuu, pe toat\u0103 durata interven\u021biei.<\/p>\n<p style=\"text-align: justify\">\u00cen final, dup\u0103 aproape o or\u0103 \u0219i jum\u0103tate, medicii ginecologi \u00eenchid uterul \u0219i abdomenul mamei, strat cu strat.<\/p>\n<p style=\"text-align: justify\">\u00cens\u0103, de\u0219i interven\u021bia chirurgical\u0103 se \u00eencheie, suspansul continu\u0103. Chirurgia fetal\u0103 este o procedur\u0103 care presupune un risc ridicat postoperator, at\u00e2t pentru copil, c\u00e2t \u0219i pentru mam\u0103. Imediat dup\u0103 opera\u021bie, exist\u0103 un risc foarte mare de na\u0219tere prematur\u0103, ceea ce ar fi dezastruos. De aceea, mama va sta la pat \u00een urm\u0103toarele s\u0103pt\u0103m\u00e2ni \u0219i va primi medica\u021bie care s\u0103 previn\u0103 contrac\u021biile uterine. \u00cen plus, exist\u0103 o probabilitate semnificativ mai mare de ruptur\u0103 prematur\u0103 de membrane. V\u00e2rsta gesta\u021bionala la care se nasc ace\u0219ti copiii este \u00een medie de 34 de s\u0103pt\u0103m\u00e2ni, adic\u0103 cu 3 s\u0103pt\u0103m\u00e2ni \u00eenainte de termen, \u00eensa poate\u00a0fi \u0219i mai mic\u0103. \u00cen Spitalul B\u0103neasa REGINA MARIA, medicii din Sec\u021bia de Terapie Intensiv\u0103 Neonatologie sunt pregati\u021bi \u0219i au o experien\u021b\u0103 important\u0103 \u00een \u00eengrijirea prematurilor mici \u0219i foarte mici.<\/p>\n<p style=\"text-align: justify\">Mama va ram\u00e2ne \u00een spital sub supraveghere \u0219i tratament de sus\u021binere \u0219i preven\u021bie a complica\u021biilor postoperatorii immediate. Dup\u0103 aprooximativ patru zile se va externa, dac\u0103 nu au ap\u0103rut probleme. \u00cen urm\u0103toarele s\u0103pt\u0103m\u00e2ni, pentru a se evita travaliul prematur, mama va sta \u00een repaus la pat.<\/p>\n<p style=\"text-align: justify\">P\u00e2n\u0103 \u00een momentul na\u0219terii, starea de s\u0103n\u0103tate a mamei, precum \u0219i cea a copilului va fi supravegheat\u0103 atent: se vor efectua ecografii s\u0103pt\u0103manale sau la dou\u0103 s\u0103pt\u0103m\u00e2ni care s\u0103 evalueze starea f\u0103tului, cantitatea de lichid amniotic \u0219i apari\u021bia hidrocefaliei. Dac\u0103 totul decurge bine, copilul se va na\u0219te dup\u0103 aproximativ 8 s\u0103pt\u0103m\u00e2ni.<\/p>\n<p style=\"text-align: justify\">Din echipa operatorie au f\u0103cut parte:<\/p>\n<p style=\"text-align: justify\"><strong>Echip\u0103 Medicin\u0103 Fetal\u0103 \u0219i Anestezie Spitalul B\u0103neasa:<\/strong><\/p>\n<ul style=\"text-align: justify\">\n<li><strong> Hadi Rahimian, <\/strong>Medic Primar Obstetric\u0103-Ginecologie, Supraspecializare \u00een Medicin\u0103 Materno-fetal\u0103, Doctorand \u00een \u0218tiinte Medicale \u2013 coordonatorul singurului Centru Fetal din Rom\u00e2nia \u00een care se efectueaz\u0103 opera\u021bii fetoscopice<\/li>\n<li><strong> Ani Rahimian, <\/strong>Medic Primar ATI<\/li>\n<li><strong> Denise Borali<\/strong>, Medic Specialist Obstetric\u0103-Ginecologie<\/li>\n<li><strong> Oana Zaharia<\/strong>, Medic Primar Obstetric\u0103-Ginecologie<\/li>\n<\/ul>\n<p style=\"text-align: justify\"><strong>Echipa Neurochirurgie Brain Institute:<\/strong><\/p>\n<ul style=\"text-align: justify\">\n<li><strong> Sergiu Stoica<\/strong>, Medic Primar Neurochirurgie \u2013 neurochirurg cu experien\u021b\u0103 extrem de mare \u00een tratarea cazurilor considerate anterior inoperabile<\/li>\n<li><strong> Mihai Cr\u0103ciun<\/strong>, Medic Specialist Neurochirurgie, Doctorand \u00een Neurochirurgie<\/li>\n<li><strong> Anca Vi\u0219an<\/strong>, Medic Primar ATI, Neuro-anestezist<\/li>\n<\/ul>\n<p style=\"text-align: justify\"><strong>*Surs\u0103 informa\u021bii<\/strong>: \u201cA Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele,\u201d New England Journal of Medicine, 2011<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Interven\u021bie extraordinar\u0103, \u00een premier\u0103 na\u021bional\u0103: \u0218apte medici de la Regina Maria \u0219i Brain Institute au realizat cu succes prima opera\u021bie de mielomeningocel (spina bifida) unui bebelu\u0219 nen\u0103scut Medicul Hadi Rahimian, [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":5001,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-5000","post","type-post","status-publish","format-standard","has-post-thumbnail","category-stiri-noutati"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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