Residual anastomoses in twin-twin transfusion syndrome after laser: the Solomon randomized trial

Slaghekke, Femke; Lewi, Liesbeth; Middeldorp, Johanna M.; Weingertner, Anne Sophie; Klumper, Frans; DeKoninck, Philip; Devlieger, Roland; Lanna, M.; Deprest, Jan; Favre, R.; Oepkes, Dick; Lopriore, Enrico

doi:10.1016/j.ajog.2014.05.012

Cited by 81 publications

(82 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In the remaining 31 cases, the placenta and fetal membranes were examined after delivery to identify the recipient sac, donor sac, and intervening membranes. The recipient side of the sac was determined based on the side of the placenta where laser photocoagulation was performed, the larger size of the sac and of the placental surface (37). The fetoscopic entry site was identified by careful macroscopic survey of the fetal membranes.…”

Section: Articlesmentioning

confidence: 99%

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

et al. 2015

View full text Add to dashboard Cite

Background: Preterm premature rupture of membranes remains a major complication after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). We studied the histologic changes of fetal membranes post-FLS and investigated a possible impact of amniotic fluid (AF) dilution. Methods: Fetal membranes of 31 pregnancies that underwent FLS for TTTS were investigated histologically at delivery at different sites: trocar site of recipient sac and at distance, donor sac, and inter-twin membrane. results: The trocar insertion site on the recipient sac showed no signs of histologic hallmarks of healing. Wide-spread alteration in collagen organization and higher apoptotic index in the amnion of the recipient sac which were absent in donor's and reference membranes. To explain the mechanisms, we analyzed the AF composition of recipient sacs from TTTS pregnancies vs. GA-matched healthy singleton controls and found glucose, protein and lactate dehydrogenase activity were all significantly lower in TTTS sacs consistent with over-dilution of recipient's AF (~2-fold). In-vitro exposure of healthy amniochorion to analogous dilutional stress conditions recapitulated the histologic changes and induced apoptosis and autophagy. conclusion: Alteration in structural integrity of the recipient's amniochorion, possibly in response to dilution stress, along with ineffective repair mechanisms may explain the increased incidence of preterm birth post-FLS.d espite the success of fetoscopic laser surgery (FLS) for the treatment of severe twin-twin transfusion (TTTS), preterm delivery with or without preterm premature rupture of membranes (PPROM) remains a major complication (1-4). The average gestational age at delivery after procedure ranges between 29 to 33 wk (1,5). Aside from the cost of caring for the premature infants, preterm delivery is directly associated with long-term neurological deficits in TTTS (4,6), undermining the complete benefits of such intervention. PPROM which affects 20-32% of cases is the most important risk factor leading to preterm delivery (2,7-10).Considered a minimally invasive procedure, FLS necessitates the insertion of a trocar into the amniotic cavity of the recipient twin to allow for insertion of the fetoscope (through a cannula which stays in place throughout the procedure) (11). A laser is used to seal the abnormal blood vessel anastomoses between the monochorionic twin placentas. Lastly, the surgeon performs an amnioreduction to relieve the recipient's polyhydramnios by draining the excess amniotic fluid (AF) through the cannula before removing it. During the procedure to allow proper visualization due to the inadvertent loss of amniotic fluid through cannula port or due to cloudy AF, it is customary for the surgeon to remove a volume of AF and replace it via amnioinfusion with a solution of Lactated Ringer's (LR).Fetal membranes are the outermost layer of fetal compartment in apposition to maternal decidua. The amniotic layer of the fetal membranes is made up of a lining of cuboidal epithe...

show abstract

Section: Articlesmentioning

confidence: 99%

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

et al. 2015

View full text Add to dashboard Cite

show abstract

“…The intention was to complete the dichorionisation with the Solomon technique to minimise the risk of twin anaemia-polycythaemia sequence (TAPS). (44) Amniotic fl uid was aspirated from the recipient sac under constant ultrasonography monitoring until the deepest fl uid pocket did not exceed 4 cm. The fetoscope and operating trocar were removed from the maternal abdomen and the skin incision was closed with a mattress suture.…”

Section: Methodsmentioning

confidence: 99%

Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience

Gosavi

Vijayakumar

et al. 2017

smedj

View full text Add to dashboard Cite

INTRODUCTION Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units. METHODSFive pregnancies with fetal complications were identifi ed for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision.RESULTS All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise.DISCUSSION Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefi t other small units committed to providing these services.

show abstract

“…For this study, we excluded placentas with severe placental maceration due to fetal demise of one or more infants. Part of the placental data used in this study has been used in previous reports [3,5,6,11] . The study was approved by the Leiden University Medical Centre Medical Ethics Committee.…”

Section: Methodsmentioning

confidence: 99%

“…The aim of fetoscopic laser coagulation is to achieve two separate circulations by coagulating all intertwin vascular anastomoses. Anastomoses may however be missed during fetoscopic surgery, causing severe postoperative complications such as recurrent TTS and twin anemia polycythemia sequence (TAPS) [3][4][5] . The incidence of these residual anastomoses (RA) varies greatly Th is article is licensed under the Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense).…”

Section: Introductionmentioning

confidence: 99%

Incidence of and Risk Factors for Residual Anastomoses in Twin-Twin Transfusion Syndrome Treated with Laser Surgery: A 15-Year Single-Center Experience

et al. 2018

View full text Add to dashboard Cite

Objectives:To evaluate the incidence of residual anastomoses (RA) after laser therapy for twin-twin transfusion syndrome (TTS) and investigate risk factors for incomplete laser surgery. Material and Methods: All available TTS placentas treated with laser at our center between 2002 and 2016 were injected with color dye to assess the presence of RA. We evaluated the incidence of RA over the past 15 years by dividing the cohort into three time periods, and studied the association with risk factors and neonatal outcome. Results: Overall, RA were detected in 21.0% (78/371) of placentas. The incidence of RA decreased from 38.8% (26/67) in the initial period to 11.7% (16/137) in the most recent period ( p < 0.001). On multivariate analysis, several risk factors were independently associated with the risk of RA, including Solomon laser technique (odds ratio [OR] 0.17, 95% CI 0.09-0.33) and estimation of surgical success (OR 19.28,).Premature delivery and neonatal morbidity occurred more often in TTS cases with RA. Conclusions: The incidence of RA after laser therapy for TTS decreased significantly in the past 15 years and is now below 15% due to the use of the Solomon technique.

show abstract

Residual anastomoses in twin-twin transfusion syndrome after laser: the Solomon randomized trial

Cited by 81 publications

References 24 publications

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience

Incidence of and Risk Factors for Residual Anastomoses in Twin-Twin Transfusion Syndrome Treated with Laser Surgery: A 15-Year Single-Center Experience

Contact Info

Product

Resources

About