Identification of essential steps in laser procedure for twin–twin transfusion syndrome using the Delphi methodology: <scp>SILICONE</scp> study

Peeters, Suzanne; Akkermans, Joost; Westra, Marijke M.; Lopriore, Enrico; Middeldorp, Johanna M.; Klumper, Frans; Lewi, Liesbeth; Devlieger, Roland; Deprest, Jan; Kontopoulos, Eftichia V.; Quintero, Rubén A.; Chmait, Ramen H.; Smoleniec, J. S.; Otaño, Lucas; Oepkes, Dick

doi:10.1002/uog.14761

Cited by 19 publications

(35 citation statements)

References 17 publications

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“…A recent Delphi study outlined the multitude of steps needed to perform the surgery. Most authors agreed on the basic surgical goal (the purpose of the Delphi survey), including the ablation of all of the placental vascular anastomoses along the vascular equator, without injuring healthy placenta or non-anastomotic vessels (Peeters et al, 2015). The question is: How often can these goals be accomplished while overcoming the various challenges mentioned above?…”

Section: Connecting the Dots: The 'Solomon' Techniquementioning

confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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Objective: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin-twin transfusion syndrome (TTTS). However, two important controversies are apparent in the literature: (a) a gap between concept and performance, and (b) controversy regarding whether all the anastomoses can be identified endoscopically and whether blind lasering of healthy placenta is justified. The purpose of this article is: (a) to address the potential source of the gap between concept and performance by analyzing the fundamental steps needed to successfully accomplish the surgery, and (b) to discuss the resulting competency benchmarks reported with the different surgical techniques. Materials and Methods: Laser surgery for TTTS can be broken down into two fundamental steps: (1) endoscopic identification of the placental vascular anastomoses, (2) laser ablation of the anastomoses. The two steps are not synonymous: (a) regarding the endoscopic identification of the anastomoses, the non-selective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies and lasers only placental vascular anastomoses. The Solomon technique is based on the theory that not all anastomoses are endoscopically visible and thus involves lasering healthy areas of the placenta between lasered anastomoses, (b) regarding the actual laser ablation of the anastomoses, successful completion of the surgery (i.e., lasering all the anastomoses) can be measured by the rate of persistent or reverse TTTS (PRTTTS) and how often a selective technique can be achieved. Articles representing the different techniques are discussed. Results: The non-selective technique is associated with the lowest double survival rate (35%), compared with 60-75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of residual patent placental vascular anastomoses, compared to 3.5-5% for the selective technique (p < .05). Both the Solomon and the selective technique are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the selective technique (99%) compared with the Solomon (80%) or the 'standard' (60%) techniques (p < .05). A surgical performance index is proposed. Conclusion: The Quintero selective technique was associated with the highest rate of successful ablation and lowest rate of PRTTTS. The Solomon technique represents a historical backward movement in the identification of placental vascular anastomoses and is associated with higher rate of residual patent vascular communications. The reported outcomes of the Quintero selective technique do not lend support to the existence of invisible anastomoses or justify lasering healthy placental tissue.

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Section: Connecting the Dots: The 'Solomon' Techniquementioning

confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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“…), none had previously performed the fetoscopic laser procedure for TTTS. In the group of experts, 5/11 (45%) had performed > 100 procedures with a median of 10 procedures (range, [8][9][10][11][12][13][14][15][16][17][18][19][20] annually. The demographics of the participants are shown in Table 1.…”

Section: Resultsmentioning

confidence: 99%

“…In the first part of the project, we determined the essential steps of treatment to develop an assessment instrument 9 . In the current part of the project, this instrument was validated using a silicone simulator involving the complete laser procedure.…”

Section: Participants and Study Designmentioning

confidence: 99%

“…and J.A. ), using the assessment instrument created by the Delphi consensus 9 . This list of essential steps was modified into a checklist adjusted to the simulated scenario.…”

Section: Assessmentmentioning

confidence: 99%

“…We previously reported on a list of steps judged essential to the laser procedure based on the Delphi methods 9 . These steps were consensus based by a sample of international experts, making the final tool representative of international, rather than local, practice.…”

Section: Introductionmentioning

confidence: 99%

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Operator competence in fetoscopic laser surgery for twin–twin transfusion syndrome: validation of a procedure‐specific evaluation tool

Peeters

Bustraan²,

Middeldorp

et al. 2016

Ultrasound in Obstet & Gyne

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Magnetically Guided Laser Surgery for the Treatment of Twin‐to‐Twin Transfusion Syndrome

Lussi

Gervasoni

Mattille

et al. 2022

Advanced Intelligent Systems

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In the past 40 years, the percentage of twin pregnancies has increased by almost a third as a result of a rise in medically assisted reproduction and delayed childbearing. [1] Of the 1.6 million twin pairs born around the globe every year, %15% are monochorionic (MC), i.e., they share the same placenta. [2] These pregnancies present more frequent complications than dichorionic twins that develop with separate placentas. [3] One of these complications arises from vascular anastomoses that connect the blood circulation systems of both fetuses to the placenta. Twin-to-twin transfusion syndrome (TTTS) affects 10-15% of MC multiple pregnancies and is characterized by a chronic, imbalanced blood flow from the donor to the recipient twin, which results in a disproportionate nutrient supply. [4] If left untreated, the consequences of TTTS are severe, leading to a mid-trimester mortality rate of up to 95%. [5] State-of-the-art treatment of TTTS involves fetoscopic laser coagulation of the placental anastomoses. Under ultrasound guidance, the surgeon identifies a safe entry site in the maternal abdomen from which a fetoscope is inserted through a trocar (typically 2.2-4 mm in diameter; 7-12 French [6] ) into the recipient's amniotic sac. The fetoscope consists of a camera and a working channel to deliver laser light through an optical fiber at the desired location. Before the surgeon ablates the vessels, the vascular architecture is scrutinized and the connecting vessels are identified. Subsequently, all identified anastomoses are coagulated with a neodymium-doped yttrium aluminum garnet (Nd:YAG) or diode laser such that the MC circulation is converted into two independent vascular systems. [7] To ensure no small vessels are missed, the laser is repeatedly fired along a line connecting all the coagulation points from one placental border to the other (known as the Solomon technique). [5,8,9] Mortality rates still range from 20% to 48% after this surgical procedure and significant complications are reported in 6-18% of surviving newborns. [10] Neurological damage to the fetus is also more likely to occur in technically difficult cases. [8] As the procedure is demanding, outcomes are also dependent on the surgeon experience. [7,10] Cases with anterior placentas (i.e., located on the abdominal side of the uterus) constitute a major challenge, even for experienced surgeons. Good access and visualization of anterior placentas are difficult with rigid endoscopes. [11] This can prevent complete coagulation, which,

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Identification of essential steps in laser procedure for twin–twin transfusion syndrome using the Delphi methodology: SILICONE study

Abstract: Objective To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists. Methods

Cited by 19 publications

References 17 publications

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Operator competence in fetoscopic laser surgery for twin–twin transfusion syndrome: validation of a procedure‐specific evaluation tool

Magnetically Guided Laser Surgery for the Treatment of Twin‐to‐Twin Transfusion Syndrome

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