Clinical outcome of V-Y flap with latissimus dorsi and gluteal advancement for treatment of large thoracolumbar myelomeningocele defects: a comparative study

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OBJECTIVE

Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%–70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement.

METHODS

This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups.

RESULTS

The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p < 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12–23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group.

CONCLUSIONS

The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.

ABBREVIATIONS MMC = myelomeningocele; NEC = necrotizing enterocolitis; SSI = surgical site infection; VP = ventriculoperitoneal.

Article Information

Correspondence Fariborz Ghaffarpasand: Namazi Hospital, Shiraz, Iran. fariborz.ghaffarpasand@gmail.com; ghafarf@sums.ac.ir.

INCLUDE WHEN CITING Published online April 19, 2019; DOI: 10.3171/2019.1.PEDS18232.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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    Schematic demonstration of the bilateral V-Y flap with latissimus dorsi muscle advancement for closure of large MMC defects. A: Geometric demonstration of the flap design. B: Drawing showing the large thoracolumbar MMC defect. C: The flaps are dissected and elevated to cover the large thoracolumbar MMC defect. D: Drawing depicting the final closure of the defect utilizing bilateral V-Y flap and advancement of the latissimus muscles. Copyright Fariborz Ghaffarpasand. Published with permission. Figure is available in color online only.

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    Representative case of bilateral V-Y latissimus dorsi advancement flap for closure of a large MMC defect. A: Photograph of a large MMC defect measuring 12 × 6 cm with severe kyphosis in a 2-day-old female neonate. B: The patient is positioned prone under general anesthesia with her arms at 90° abduction and pressure sites fully padded. C and D: The flap incision is made after repairing the dural sac (C) and is extended laterally to provide an appropriate flap length while preserving the latissimus and superior gluteal arteries (D). E: Posterior kyphectomy was performed, and the flaps were dissected and elevated. F: Photograph obtained at the 1-year follow-up, revealing complete healing of the wound without dehiscence, necrosis, or infection. The patient did not require VP shunt insertion. Figure is available in color online only.

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