Abstract：
OBJECTIVE: Prenatal spina bifida closure results in improved outcomes for the child compared to postnatal surgery but is associated with significant maternal morbidity. Optimization of the perioperative care for women who underwent fetal spina bifida surgery could improve maternal and pregnancy outcomes. Enhanced Recovery After Surgery (ERAS) protocols are multimodal, evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aims to explore if fetal centers have implemented ERAS principles in this setting. Furthermore, we provide recommendations for the perioperative management of patients undergoing fetal spina bifida surgery.
METHODS: Fifty-three fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on the center\'s compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for cesarean section, gynecologic oncology and colorectal surgery. Each item was scored 1 or 0 when the center did or did not comply with each principle, with a maximum score of 20.
RESULTS: The questionnaire was completed by 46 centers in 17 countries (response rate 87%). Twenty-two centers (48%) exclusively perform open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offer both open and fetoscopic procedures and 10 (22%) use fetoscopy only. The perioperative management of patients undergoing fetoscopic and open surgery was highly similar. The median ERAS score was 12 (mean 12.5, SD 2.4, range 8-17). Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%), and thromboprophylaxis (96%), while the lowest compliance was achieved for preoperative carbohydrate loading (15%), postoperative nausea and vomiting prevention (33%), avoidance of overnight fasting (33%) and a 2-hour fasting period for clear fluids (20%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥11 days) hospital stay (12.8 ± 2.4, 12.1 ± 2.0, and 10.3 ± 3.2, respectively, p=0.15). Furthermore, there was no significant association between ERAS score and surgical technique or center volume.
CONCLUSIONS: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardizing protocols according to ERAS principles may improve patient recovery, reduce maternal morbidity, and shorten hospital stay after fetal spina bifida surgery. This article is protected by copyright. All rights reserved.
METHODS: Fifty-three fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on the center\'s compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for cesarean section, gynecologic oncology and colorectal surgery. Each item was scored 1 or 0 when the center did or did not comply with each principle, with a maximum score of 20.
RESULTS: The questionnaire was completed by 46 centers in 17 countries (response rate 87%). Twenty-two centers (48%) exclusively perform open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offer both open and fetoscopic procedures and 10 (22%) use fetoscopy only. The perioperative management of patients undergoing fetoscopic and open surgery was highly similar. The median ERAS score was 12 (mean 12.5, SD 2.4, range 8-17). Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%), and thromboprophylaxis (96%), while the lowest compliance was achieved for preoperative carbohydrate loading (15%), postoperative nausea and vomiting prevention (33%), avoidance of overnight fasting (33%) and a 2-hour fasting period for clear fluids (20%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥11 days) hospital stay (12.8 ± 2.4, 12.1 ± 2.0, and 10.3 ± 3.2, respectively, p=0.15). Furthermore, there was no significant association between ERAS score and surgical technique or center volume.
CONCLUSIONS: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardizing protocols according to ERAS principles may improve patient recovery, reduce maternal morbidity, and shorten hospital stay after fetal spina bifida surgery. This article is protected by copyright. All rights reserved.
摘要：
目的：与产后手术相比，产前脊柱裂闭合可改善患儿的结局，但与显著的产妇发病率相关。优化胎儿脊柱裂手术的围手术期护理可改善母婴结局。增强手术后恢复（ERAS）协议是多模式的，已在多个外科手术中采用的循证护理计划，以促进更快，更好的患者康复和缩短住院时间。这项研究旨在探讨胎儿中心是否在这种情况下实施了ERAS原则。此外，我们为胎儿脊柱裂手术患者的围手术期处理提供建议.
方法：确定了53个为开放性脊柱裂提供产前手术的胎儿治疗中心，并邀请他们完成数字问卷，术中和术后管理。根据中心对20个关键ERAS原则的遵守情况，计算每个中心的总分，根据ERAS剖宫产指南推断，妇科肿瘤和结直肠手术。当中心遵守或不遵守每个原则时，每个项目得分为1或0，最高20分。
结果：问卷由17个国家的46个中心完成（回复率87％）。22个中心（48％）专门进行开放式胎儿手术（剖腹手术和子宫切开术），而14（30％）提供开放和胎儿镜检查，10（22％）仅使用胎儿镜检查。接受胎儿镜和开放手术的患者的围手术期处理非常相似。ERAS评分中位数为12（平均12.5，SD2.4，范围8-17）。使用区域麻醉的中心依从性最高（98％），避免肠道准备（96％），和血栓预防（96%），虽然术前碳水化合物负荷的依从性最低(15%)，预防术后恶心和呕吐（33%），避免过夜禁食（33％）和2小时禁食期间的透明液体（20％）。ERAS评分在短（2-5天）的中心相似，中（6-10天）和长（≥11天）住院时间（分别为12.8±2.4、12.1±2.0和10.3±3.2，p=0.15)。此外，ERAS评分与手术技术或中心体积无显著相关性.
结论：胎儿脊柱裂手术的围手术期处理在全世界的胎儿治疗中心之间差异很大。根据ERAS原则标准化协议可以改善患者康复，降低产妇发病率，缩短胎儿脊柱裂手术后的住院时间。本文受版权保护。保留所有权利。
方法：确定了53个为开放性脊柱裂提供产前手术的胎儿治疗中心，并邀请他们完成数字问卷，术中和术后管理。根据中心对20个关键ERAS原则的遵守情况，计算每个中心的总分，根据ERAS剖宫产指南推断，妇科肿瘤和结直肠手术。当中心遵守或不遵守每个原则时，每个项目得分为1或0，最高20分。
结果：问卷由17个国家的46个中心完成（回复率87％）。22个中心（48％）专门进行开放式胎儿手术（剖腹手术和子宫切开术），而14（30％）提供开放和胎儿镜检查，10（22％）仅使用胎儿镜检查。接受胎儿镜和开放手术的患者的围手术期处理非常相似。ERAS评分中位数为12（平均12.5，SD2.4，范围8-17）。使用区域麻醉的中心依从性最高（98％），避免肠道准备（96％），和血栓预防（96%），虽然术前碳水化合物负荷的依从性最低(15%)，预防术后恶心和呕吐（33%），避免过夜禁食（33％）和2小时禁食期间的透明液体（20％）。ERAS评分在短（2-5天）的中心相似，中（6-10天）和长（≥11天）住院时间（分别为12.8±2.4、12.1±2.0和10.3±3.2，p=0.15)。此外，ERAS评分与手术技术或中心体积无显著相关性.
结论：胎儿脊柱裂手术的围手术期处理在全世界的胎儿治疗中心之间差异很大。根据ERAS原则标准化协议可以改善患者康复，降低产妇发病率，缩短胎儿脊柱裂手术后的住院时间。本文受版权保护。保留所有权利。
