The pediatric surgeons' contribution to in utero treatment of twin-to-twin transfusion syndrome.
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.


BACKGROUND
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.
Luks
François I
FI
Division of Pediatric Surgery, Alpert Medical School of Brown University, Providence, RI, USA. Francois_Luks@brown.edu
Carr
Stephen R
SR
Muratore
Christopher S
CS
O'Brien
Barbara M
BM
Tracy
Thomas F
TF
D000328:Adult; D000465:Algorithms; D016009:Chi-Square Distribution; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging / Q000601:surgery*; D005865:Gestational Age; D006801:Humans; D053685:Laser Therapy / Q000379:methods; D018579:Patient Selection; D011183:Postoperative Complications; D011247:Pregnancy; D011256:Pregnancy Outcome; D015996:Survival Rate; D016216:Ultrasonography, Prenatal