The effect of surgeon experience on outcomes of fetoscopic laser coagulation of placental anastomoses in twin-to-twin transfusion syndrome


Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access

Abstract

Relevance. Fetoscopic laser coagulation (FLC) of placental anastomoses is the only pathogenetically oriented treatment of twin-to-twin transfusion syndrome (TTTS). Aim. To investigate the effect of the learning curve for TTTS on treatment outcomes and the incidence of postoperative complications. Material and methods. This retrospective study included 126 patients with monochorionic diamniotic twins who underwent fetoscopic laser coagulation of placental anastomoses for TTTS at the V.I. Kulakov NMRC for OG&P in 2014-2019. The patients were divided into three equal groups of 42 women each. Groups 1, 2, and 3 included pregnant women who underwent FLC in 2014-2016, 2017-2018, and 2018-2019, respectively. The study investigated the effect of the learning curve on fetal survival and complication rates. Statistical analysis was performed using the D’Agostino-Pearson test, the Mann-Whitney U-test, and the Kruskal-Wallis test. Differences were considered statistically significant atp <0.05. Results. Increasing surgeon caseload for FLC was associated with higher overall (from 61.9% to 88.1%) and both twins’ survival rates (from 38.1% to 59.5%). Postoperative complication rates reduced from 64.3% to 52.4%. The incidence of neonatal morbidity and mortality decreased along with an increasing number of FLCs performed. We achieved satisfactory FLC results for overall survival (at least 73%) after performing 34 procedures, and 80 procedures for the survival of both twins (at least 55%). Conclusion. The accumulation of experience and concentration of fetal surgery at a high-volume provider contributes to better overall and both twins’ survival with a concomitant reduction in the incidence of postoperative complications. FLC and other in utero surgical procedures should be concentrated at highly specialized high-volume centers with high patients’ flow.

Full Text

Restricted Access

About the authors

Kristina A. Gladkova

V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of Minzdrav of Russia

Email: k_gladkova@oparina4.ru
M.D., Ph.D., Senior Researcher at the Department of Fetal Medicine, Institute of Obstetrics, Head of the 1st Obstetric Department of Pathology of Pregnancy

Kirill V. Kostyukov

V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of Minzdrav of Russia

Email: kostyukov_k@yahoo.com
M.D., Ph.D., Senior Researcher at the Department of Fetal Medicine, Institute of Obstetrics, Physician at the Unit of Functional and Ultrasound Diagnostics, Department of Diagnostic Imaging

References

  1. Костюков К.В., Гладкова К.А. Диагностика фето-фетального трансфузи-онного синдрома, синдрома анемии-полицитемии при монохориальной многоплодной беременности. Акушерство и гинекология. 2016; 1: 10-5. [Kostyukov K.V., Gladkova K.A. Diagnosis of twin-twin transfusion syndrome, anemia-polycythemia sequence in monochorionic diamniotic twins. Obstetrics and gynecology. 2016; 1: 10-5. (in Russian)]. https://dx.doi.org/10.18565/ aig.2016.1.10-15
  2. Roberts D, Neilson J.P., Weindling A.M. Interventions for twin-twin transfusion syndrome: a Cochrane review. Ultrasound Obstet. Gynecol. 2008; 31(6): 701 11. https://dx.doi.org/10.1002/uog.5328
  3. Morris R.K., Selman T.J., Harbidge A., Martin W.L., Kilby M.D. Fetoscopic laser coagulation for severe twin-to-twin transfusion syndrome: factors influencing perinatal outcome, learning curve of the procedure and lessons for new centres. BJOG. 2010; 117(11): 1350-7. https://dx.doi.org/10.1111/j.1471-0528.2010.02680.x.
  4. Diehl W., Diemert A., Glosemeyer P., Wegscheider K. 0P06.02: Development of survival rates after intrauterine therapy for severe mid-trimester twin-twin transfusion syndrome: experience with 600 cases. Ultrasound Obstet. Gynecol. 2012; 36(Suppl. 1): 67.
  5. Quintero R.A., Morales W.J., Allen M.H., Bornick P.W., Johnson P.K., Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. 1999; 19(8, Pt1): 550-5. https://dx.doi.org/10.1038/sj.jp.7200292.
  6. Rossi A.C., D’Addario V Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: a metaanalysis and review of literature. Am. J. Obstet. Gynecol. 2008; 198(2): 147-52. https://dx.doi.org/10.1016/j. ajog.2007.09.043.
  7. Бугеренко А.Е., Курцер М.А., Сичинава Л.Г., Суханова Д.И. Синдром фетофетальной трансфузии. Фетоскопическая лазерная коагуляция анастомозов. Акушерство и гинекология. 2013; 10: 40-5. [Bugerenko A.E., Kurtser M.A., Sichinava L.G., Sukhanova D.I. Twin-twin transfusion syndrome. Fetoscopic laser coagulation of anastomoses. Obstetrics and gynecology. 2013; 10: 40-5. (in Russian)].
  8. Ruano R., Rodo C., Peiro J.L., Shamshirsaz A.A., Haeri S., Nomura M.L. et al. Fetoscopic laser ablation of the placental anastomoses in twin-twin transfusion syndrome using the ‘Solomon technique’. Ultrasound Obstet. Gynecol. 2013; 42(4): 434-9. https://dx.doi.org/10.1002/ uog.12492.
  9. Yamamoto M, El Murr L, Robyr R., Leleu F., Takahashi Y., Ville Y. Incidence and impact of perioperative complications in 175 fetoscopy-guided laser coagulation of chorionic plate anastomoses in Feto-Fetal Transfusion Syndrome before 26 weeks of gestation. Am. J. Obstet. Gynecol. 2005; 193(3, Pt 2): 1110-6. https://dx.doi.org/10.1016/j.ajog.2005.07.003.
  10. Chmait R.H., Kontopoulos E.V., Korst L.M., Llanes A., Petisco I., Quintero R.A. Stage-based outcomes of 682 consecutive cases of twin-twin transfusion syndrome treated with laser surgery: the USFetus experience. Am. J. Obstet. Gynecol. 2011; 204(5): 393. e1-6. https://dx.doi.org/10.1016/j.ajog.2011.02.001.
  11. Ahmed S., Luks F.I., O’Brien B.M., Muratore C.S., Carr S.R. Influence of experience, case load, and stage distribution on outcome of endoscopic laser surgery for TTTS - a review. Prenat. Diagn. 2010; 30(4): 314-9. https://dx.doi. org/10.1002/pd.2454.
  12. Akkermans J., Peeters S.H.P., Klumper F.J., Lopriore E., Middeldorp J.M., Oepkes D. Twenty-five years of fetoscopic laser coagulation in twin-twin transfusion syndrome: a systematic review. Fetal Diagn. Ther. 2015; 38(4): 24153. https://dx.doi.org/10.1159/000437053.
  13. Papanna R., Biau D.J., Mann L.K., Johnson A., Moise K.J.Jr. Use of the Learning Curve - Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am. J. Obstet. Gynecol. 2011; 204(3): 218. e1-9. https://dx.doi.org/10.1016/j.ajog.2010.10.910.
  14. Peeters S.H.P., Van Zwet E.W., Oepkes D., Lopriore E., Klumper F.J., Middeldorp J.M. Learning curve for fetoscopic laser surgery using cumulative sum analysis. Acta Obstet. Gynecol. Scand 2014; 93(7): 705-11. https://dx.doi. org/10.1111/aogs.12402.
  15. van Klink J.M., Koopman H.M., van Zwet E.W., Middeldorp J.M., Walther F.J., Oepkes D., Lopriore E. Improvement in neurodevelopmental outcome in survivors of twin - twin transfusion syndrome treated with laser surgery. Am. J. Obstet. Gynecol. 2014; 210(6): 540. e1-7. https://dx.doi.org/10.1016/j. ajog.2014.01.002.
  16. Slaghekke F., Lopriore E., Lewi L., Middeldorp J.M., van Zwet E.W., Weingertner A.S. et al. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial. Lancet. 2014; 383(9935): 2144-51. https:// dx.doi.org/10.1016/S0140-6736(13)62419-8.

Supplementary files

Supplementary Files
Action
1. JATS XML
Download

Copyright (c) 2020 Bionika Media