Fetoscopic laser coagulation for severe twin‐to‐twin transfusion syndrome: factors influencing perinatal outcome, learning curve of the procedure and lessons for new centres

Abstract

Objective To evaluate the effects of operator experience on perinatal outcome in a single centre.Design Prospective consecutive cohort study.Setting Regional tertiary referral Fetal Medicine Centre in the UK.Population Pregnant women with monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome (TTTS) (at £26 completed weeks of gestatiuon) treated by fetoscopic laser coagulation (FLC) between October 2004 and November 2009.Methods Pregnancy characteristics and outcomes were collected. Logistic regression analysis was employed to determine the effect of a priori defined variables on outcome.Main outcome measure Perinatal survival (survival to 28 days or beyond) for one or more twins.Results There were 164 consecutive sets of monochorionic twins. The median gestational age (GA) at FLC was 20.4 weeks (interquartile range 18-22.1 weeks), the median interval from FLC to delivery was 88.5 days (interquartile range 53-101 days) and the median GA at delivery was 33.2 weeks (interquartile range 29.7-34.9 weeks). The overall survival was 62%; perinatal survival of one or more twins was 85%. These outcomes improved after about 61 procedures were performed, and after about 3.4 years of experience. Univariate logistic regression analysis indicated that Quintero stage-IV disease decreased (OR 0.26; 95% CI 0.10-0.69) and prolongation of GA at delivery increased the survival of the twins (OR 1.34; 95% CI 1.12-1.60) (P < 0.01). Increasing experience of the procedure by operator led to a significant increase in perinatal survival (P < 0.01; OR 4.59; 95% CI 1.84-11.44). Multivariate logistic regression analysis indicated that only GA at delivery increased survival overall (OR 1.34; 95% CI 1.12-1.60; P = 0.01).Conclusions These data indicate that both relatively large numbers treated and experience with FLC minimises any adverse outcome in monochorionic pregnancies with severe TTTS.Keywords Fetoscopic laser, perinatal outcome, Twin-to-twin transfusion syndrome.Please cite this paper as: Morris R, Selman T, Harbidge A, Martin W, Kilby M. Fetoscopic laser coagulation for severe twin-to-twin transfusion syndrome: factors influencing perinatal outcome, learning curve of the procedure and lessons for new centres.

Stage-Related Outcome after Fetoscopic Laser Ablation in Twin-to-Twin Transfusion Syndrome

“…Both fetuses survived in 25.9% of the cases, while at least one fetus survived in 57.6% of the total cohort. These rates were lower than the previous reports in which the overall survival ranged between 47 and 82.5% [8,15,16,17,18,19,20], while in 73-92% of the cases at least one fetus [8,16,17,18,19,20,21] and in 36-73.7% of the cases both fetuses survived [8,17,20,21]. Apart from these studies performed in experienced centers, there are a few reports from developing countries (table 2).…”

“…However, the association between the staging system and survival rate in cases treated with laser ablation has been controversial. Some of the studies found increased perinatal mortality rates with increasing stage [6,7,8], while others failed to show such a relationship [5,9]. Furthermore, the vast majority of the reports about TTTS outcome after laser therapy came from highly experienced centers in the USA and Europe.…”

Fetal and Maternal Complications after Selective Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: A Single-Center Experience

“…Albeit rare, reversal of TTTS is another possible reported complication [9]. The operator’s experience and the presence of a learning curve seem to have a role in increasing perinatal survival [10], although a systematic review of treated cases failed to demonstrate a significant impact of high caseloads [11]. …”

Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution?

“…For example, De Lia et al (1999) reported an increase in overall perinatal survival after laser surgery for TTTS from 55% for the first 50 cases, to 69% in a series of 67 cases published several years later. Hecher et al (2000) also described improved outcomes in a second cohort of patients treated with laser surgery for TTTS when compared to the first cohort and Morris et al (2010) used logistic regression analysis to show that outcomes improved over time after their center first started performing laser surgery for TTTS. Meriki et al (2010) noted that their institutional learning curve revealed results that stabilized after the first 25 cases performed in a center with three primary operators, but did not make comment on individual learning curves.…”