Laser therapy for twin‐to‐twin transfusion syndrome (TTTS)

Chalouhi, G. E.; Essaoui, M.; Stirnemann, J.; Quibel, T.; Deloison, B.; Salomon, Laurent; Ville, Y.

doi:10.1002/pd.2803

Cited by 94 publications

(81 citation statements)

References 98 publications

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“…In comparison, the rate of residual patent placental vascular anastomoses after SLPCV by our group, using similar technique and technology, has consistently been less than 5%, with no anemia after demise of the co-twin, and an incidence of reverse or persistent TTTS of only 1-1.5% (USFetus Consortium; . In view of the relatively high incidence of residual patent placental vascular anastomoses seen by some groups, some authors proposed 'connecting the dots' between photocoagulated areas on the surface of the placenta (Chalouhi et al, 2011). The premise behind this idea was that by lasering areas between laser-ablated placental vascular anastomoses, such 'blind lasering' would capture 'anastomoses' that would otherwise be missed (i.e., 'not visible'; Lewi et al, 2006).…”

Section: Connecting the Dots: The 'Solomon' Techniquementioning

confidence: 99%

“…Such authors believed that, in fact, not all of the placental vascular anastomoses can be identified endoscopically (Lewi et al, 2006), and that therefore, ablating only the visible ones using the selective technique could miss vascular anastomoses and explain their high rate of residual patent placental vascular anastomoses. The resulting surgical technique of 'connecting the dots' was dubbed 'the Solomon technique' (Chalouhi et al, 2011), in reference to the biblical passage where, in order to resolve a dispute between two alleging mothers of a child, King Solomon proposed to cut the baby in half (1 Kings 3:16-28, NIV). The analogy, therefore, is that by lasering the areas of the placenta between endoscopically identified and laser-ablated vascular anastomoses, the placenta would be 'cut in half' .…”

Section: Connecting the Dots: The 'Solomon' Techniquementioning

confidence: 99%

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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%

Section: Connecting the Dots: The 'Solomon' Techniquementioning

confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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“…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.…”

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confidence: 99%

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

et al. 2015

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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...

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“…Membrane folding or intertwin disparity in fetal growth, nuchal translucency thickness or amniotic fluid volumes are early signs of the possible development of TTTS and indicate the need for increased ultrasound surveillance of monochorionic pregnancies. This syndrome can also be suspected by acute maternal symptoms related to polyhydramnios (uterine distension, uterine contractions, dyspnea) (Chalouhi et al, 2011). The diagnosis relies upon strict ultrasound criteria as defined in the Eurofetus trial (Senat et al, 2004) and consist of a polyuric polyhydramnios in the recipient twin with a deepest vertical pool of at least 8.0 cm at or before 20 weeks of gestation or 10.0 cm after 20 weeks of gestation together with a distended fetal bladder, with oliguric oligohydramnios in the donor twin, showing a deepest vertical pool of at most 2.0 cm.…”

Section: Twin-to-twin Transfusion Syndrome (Ttts)mentioning

confidence: 99%

“…It is a hemodynamic, and probably hormonal, discordance secondary to imbalanced blood flow through the vascular anastomoses (Hubinont et Fisk, 1990) (Chalouhi et al, 2011). The natural history of untreated TTTS leads to intra-or perinatal death in 90% of cases (Robyr et al, 2006).…”

Section: Twin-to-twin Transfusion Syndrome (Ttts)mentioning

confidence: 99%