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The Pediatric Surgeons’ Contribution to In Utero Treatment of Twin-to-Twin Transfusion Syndrome

Luks, François I. MD, PhD*†; Carr, Stephen R. MD‡†; Muratore, Christopher S. MD*†; O'Brien, Barbara M. MD‡†; Tracy, Thomas F. Jr MD*

doi: 10.1097/SLA.0b013e3181b45794
Original Articles

Objective: To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination of endoscopic fetal surgery-specific techniques and surgical restraint.

Summary Background Data: TTTS is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of placental vessels (LASER) causes premature rupture of membranes (PROM) in 10% to 20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of ≥1 twin of 75% to 80%.

Methods: We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe TTTS. Pregnancies with TTTS (stages I–IV) managed in the last 8 years were reviewed. LASER was offered in stage III/IV only.

Results: Ninety-eight cases of TTTS were managed in a pediatric surgery/maternal-fetal medicine collaborative Fetal Treatment Program—39 were observed (40%) and 59 underwent LASER (60%). Survival of ≥ twin was seen in 82.7%, and overall survival was 69.4%. These survival rates are similar to, or better than, other comparable series with similar stage distribution (low:high stage ratio 1:1) in which all patients underwent LASER. PROM rate was 4%.

Conclusions: Reserving LASER treatment for severe TTTS results in outcomes similar to, or better than, LASER for all stages. Applying fetal surgery-specific endoscopic techniques, including port-site sealing, reduces postoperative complications.

We present our experience with 98 patients with twin-to-twin transfusion syndrome, where a combination of surgical techniques and surgical restraint leads to fewer in utero interventions, fewer complications in those undergoing procedures and success rates similar to other all operative series.

From the *Division of Pediatric Surgery, †Program in Fetal Medicine, and ‡Division of Maternal-Fetal Medicine, Alpert Medical School of Brown University, Providence, RI.

Presented at the 2009 Annual Meeting of the American Surgical Association.

Reprints: François I. Luks, MD, PhD, Division of Pediatric Surgery, 2, Dudley Street, Suite 180, Providence, RI 02905. E-mail: Francois_Luks@brown.edu.

© 2009 Lippincott Williams & Wilkins, Inc.