title: Neurodevelopmental outcome at 2 years in twin-twin transfusion syndrome survivors randomized for the Solomon trial.
abstract: BACKGROUND
  The preferred treatment for twin-twin transfusion syndrome is fetoscopic laser coagulation of inter-twin vascular anastomoses on the monochorionic placenta. Severe postoperative complications can occur when inter-twin vascular anastomoses remain patent including twin-anemia polycythemia sequence or recurrent twin-twin transfusion syndrome. To minimize the occurrence of residual anastomoses, a modified laser surgery technique, the Solomon technique, was developed in which the entire vascular equator is coagulated. In the Solomon randomized controlled trial (NTR1245), the Solomon technique was associated with a significant reduction in twin-anemia polycythemia sequence and recurrence of twin-twin transfusion syndrome when compared with the standard laser surgery technique. Although a significant improvement in perinatal outcome was shown after the Solomon technique, the clinical importance should also be ascertained with long-term follow-up evaluation of the surviving children.
  
  
  OBJECTIVE
  The purpose of this study was to compare the long-term neurodevelopmental outcome in surviving children with twin-twin transfusion syndrome who were included in the Solomon randomized trial and treated with either the Solomon technique or standard laser surgery technique.
  
  
  METHODS
  Routine standardized follow-up evaluation in survivors, at least 2 years after the estimated date of delivery, was performed at 2 of the 5 centers that participated in the Solomon trial: Buzzi Hospital Milan (Italy) and Leiden University Medical Center (The Netherlands). The primary outcome of this follow-up study was survival without long-term neurodevelopmental impairment at age 2 years. Neurodevelopmental impairment was defined as cerebral palsy, cognitive and/or motor development score of <85, bilateral blindness, or deafness. Cognitive and motor development was evaluated with the use of Bayley-III. All analyses per fetus, neonate, or child were conducted with the generalized estimated equation module to account for the effect that observations between co-twins are not independent.
  
  
  RESULTS
  The primary outcome (survival without neurodevelopmental impairment) was detected in 95 of 141 cases (67%) in the Solomon group and in 99 of 146 cases (68%) in the standard group (P = .92). Neurodevelopmental impairment in long-term survivors who were included for follow-up evaluation was detected in 12 of 107 cases (11%) in the Solomon and in 10 of 109 cases (9%) in the standard group (P = .61). Neurodevelopmental impairment was due to cerebral palsy in 1 case (1%; spastic unilateral) in the Solomon group and in 2 cases (2%; spastic unilateral and spastic bilateral) in the standard group (P = .58). Cognitive development <85 cases was detected in 2 of 105 children (2%) in the Solomon group and in 6 of 106 children (6%) in the standard group (P = .23). Motor development <85 occurred in 8 of 103 children (8%) in the Solomon group and 3 of 104 children (3%) in the standard group (P = .23).
  
  
  CONCLUSIONS
  We found no difference in survival without neurodevelopmental impairment between the Solomon and standard laser techniques. In view of the reduction of short-term complications and the absence of increased adverse long-term effects, these data support the use of the Solomon technique in the treatment of twin-twin transfusion syndrome.
authors: Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: j.m.m.van_klink@lumc.nl.
authors: Jeanine M M
authors: JM
authors: van Klink
authors: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
authors: Femke
authors: F
authors: Slaghekke
authors: Department of Pediatrics, Neurology Unit, Fetal Therapy Unit, V Buzzi Children's Hospital, Milan, Italy.
authors: Marina A
authors: MA
authors: Balestriero
authors: Department of Pediatrics, Neurology Unit, Fetal Therapy Unit, V Buzzi Children's Hospital, Milan, Italy.
authors: Barbara
authors: B
authors: Scelsa
authors: Division of Neonatology, Fetal Therapy Unit, V Buzzi Children's Hospital, Milan, Italy.
authors: Paola
authors: P
authors: Introvini
authors: Department of Obstetrics, Fetal Therapy Unit, V Buzzi Children's Hospital, Milan, Italy.
authors: Mariangela
authors: M
authors: Rustico
authors: Department of Obstetrics, Fetal Therapy Unit, V Buzzi Children's Hospital, Milan, Italy.
authors: Stefano
authors: S
authors: Faiola
authors: Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.
authors: Monique
authors: M
authors: Rijken
authors: Department of Clinical Psychology, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands.
authors: Hendrik M
authors: HM
authors: Koopman
authors: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
authors: Johanna M
authors: JM
authors: Middeldorp
authors: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
authors: Dick
authors: D
authors: Oepkes
authors: Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.
authors: Enrico
authors: E
authors: Lopriore
mesh_terms: D001557:Benzenesulfonates; D001766:Blindness / Q000209:etiology; D002547:Cerebral Palsy / Q000209:etiology; D002675:Child, Preschool; D003638:Deafness / Q000209:etiology; D005260:Female; D005330:Fetofetal Transfusion / Q000150:complications* / Q000601:surgery*; D005332:Fetoscopy / Q000295:instrumentation / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008607:Intellectual Disability / Q000209:etiology; D053685:Laser Therapy / Q000379:methods*; D008297:Male; D019957:Motor Skills Disorders / Q000209:etiology; D065886:Neurodevelopmental Disorders / Q000209:etiology*; D011247:Pregnancy
chemical_list: D001557:Benzenesulfonates; C046836:thimerfonate
keywords: Solomon; laser surgery; neurodevelopmental outcome; twin-twin transfusion syndrome