Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies

Abstract

Fetoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) has become the optimal treatment choice since the release of the Eurofetus randomized clinical trial. These techniques have been adopted throughout the globe, and many institutions have instituted or will soon institute fetoscopic laser surgery procedures; however, laser surgery has a steep learning curve because of the following: challenging placental location, complex and unexpected communicating anastomoses, residual anastomoses after surgery, or discolored amniotic fluid. We have been performing laser surgery since 2002 in Japan; to date, we have compiled a series of 170 cases. Our data indicates a 78% of overall survival with 5% neonatal morbidity, 63% of survival of both twins, and 93% survival of at least one twin. The recurrent TTTS rate was 1% and the residual vessel rate was 3%.To improve the learning curve of laser surgery, the employment of various techniques is recommended to achieve a successful surgical outcome: (1) Mapping: before laser ablation, a very thorough mapping of vascular anastomoses should be done, and should be repeated after ablation; (2) Sequential order: obliteration of arterio-venous anastomoses from donor to recipient should be done first to avoid donor hypotension and/or anemia; (3) Trocar (cannula) assisted technique: Trocar assisted technique: Using gentle indent the trocar to the placenta by withdrawing the scope shortly, then anastomoses could be ablated easily; (4) Line method: to avoid residual anastomoses, the laser should draw a virtual line at the hemodynamic equator; The operator must be careful not to miss small anastomoses.These techniques can help achieve a successful outcome for fetoscopic laser surgery and improve the outcome for cases of severe TTTS.

Comparison of Solomon technique with selective laser ablation for twin–twin transfusion syndrome: a systematic review

“…The full text of 63 manuscripts was reviewed for eligibility and 36 were subsequently excluded, as they did not meet the selection criteria. The remaining 27 papers all contained data on the use of selective or sequential FLA techniques, however only three compared directly the selective technique with the Solomon technique. For the purpose of this review, we focused primarily on the three comparative papers, which form the basis of our evidence synthesis.…”

“…All three papers reported on all four of the outcomes of interest and included the Quintero stage (Appendix S1) for all cases, however we did not have the individual patient data to meta‐analyze the outcomes by Quintero stage. When reviewing the data from all 27 papers, recurrence of TTTS following FLA was reported in eight studies, with rates ranging from 0.7–11.6% following the selective FLA technique, while the rates varied from 0–3.9% following the Solomon technique. The incidence of TAPS was reported in seven studies, with rates ranging from 1.3–15.6% following the selective technique and from 0–2.9% following the Solomon technique.…”

Anaesthesia for foetoscopic Laser ablation- a retrospective study

“…One of the twins receives excess blood flow called ‘recipient twin’ from the other twin called ‘donor twin’. [2] In TRAP a twin with absent or non-functioning heart, called ‘acardiac twin’ gets its blood perfused from other twin called ‘pump twin’ through placental arterial anastomoses. [3] This results in overloading the heart in “pump” twin, resulting in polycythaemia, hydrops foetalis and congestive cardiac failure.…”