Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate
ABSTRACT Objective To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting. Methods Between January 1...
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| Veröffentlicht in: | Ultrasound in obstetrics & gynecology 2017-12, Vol.50 (6), p.728-735 |
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| creator | Diehl, W. Diemert, A. Grasso, D. Sehner, S. Wegscheider, K. Hecher, K. |
| description | ABSTRACT
Objective
To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting.
Methods
Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates.
Results
The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double‐twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double‐twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands‐on and performed 174 of the last 400 procedures.
Conclusions
We report the largest single‐center experience of laser coagulation in TTTS. We observed a continuous increase in double‐twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high‐volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
La coagulación fetoscópica láser en 1020 embarazos con síndrome de transfusión feto fetal demuestra una mejoría |
| doi_str_mv | 10.1002/uog.17520 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1896037412</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1984816555</sourcerecordid><originalsourceid>FETCH-LOGICAL-c3880-620205e6a4cbc45ae260a24eeab115fe38238c4f8f40c92202e58d4147a8cd603</originalsourceid><addsrcrecordid>eNp1kc1q3DAUhUVpaSZJF32BIuimXTiRZEmWlyU0PxDIJlkLjXw9VbClqWTNMLs8QSj0DfMklTNJF4Wu7kLf-TjoIPSRkhNKCDvNYXVCG8HIG7SgXLYVaYh4ixaklaRqZMsO0GFK94QQyWv5Hh0wxZum5mKBHs9hCsmGtbN4MAkitsGs8mAmFzx2HlPCCF5HWHnjrYOEt276gaet808Pv-eDp2h86nOaA2nnuxhGwB2MwafyNJWIG9cxbGAEP83KLuTlAE8Pv57jKceN25gBz-wxetebIcGHl3uE7s6_355dVtc3F1dn364rWytFKslKKwHScLu0XBhgkhjGAcySUtFDrVitLO9Vz4ltWaFBqI5T3hhlO0nqI_Rl7y3FfmZIkx5dsjAMxkPISVNVvq5uOGUF_fwPeh9y9KWdpq3iikohRKG-7ikbQ0oRer2ObjRxpynR80i6jKSfRyrspxdjXo7Q_SVfVynA6R7YugF2_zfpu5uLvfIPXoqf6A</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1984816555</pqid></control><display><type>article</type><title>Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate</title><source>Wiley Free Content</source><source>MEDLINE</source><source>Wiley Online Library Journals Frontfile Complete</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><creator>Diehl, W. ; Diemert, A. ; Grasso, D. ; Sehner, S. ; Wegscheider, K. ; Hecher, K.</creator><creatorcontrib>Diehl, W. ; Diemert, A. ; Grasso, D. ; Sehner, S. ; Wegscheider, K. ; Hecher, K.</creatorcontrib><description>ABSTRACT
Objective
To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting.
Methods
Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates.
Results
The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double‐twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double‐twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands‐on and performed 174 of the last 400 procedures.
Conclusions
We report the largest single‐center experience of laser coagulation in TTTS. We observed a continuous increase in double‐twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high‐volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
La coagulación fetoscópica láser en 1020 embarazos con síndrome de transfusión feto fetal demuestra una mejoría en la tasa de supervivencia de gemelos
Objetivo
Investigar la experiencia creciente y la curva de aprendizaje de la coagulación fetoscópica láser de anastomosis vasculares placentarias en el síndrome de transfusión feto fetal (TTTS, por sus siglas en inglés) de carácter severo a mitad de trimestre y su influencia en el resultado perinatal en el contexto de un solo centro.
Métodos
Entre enero de 1995 y marzo de 2013 se realizó terapia con láser en 1020 embarazos consecutivos con TTTS entre las semanas de gestación 15.1 y 27.4. Se comparó el resultado perinatal en bloques de cinco grupos secuenciales de 200 casos, teniendo en cuenta varias covariables con el fin de hacer ajustes según la mezcla de casos, y para demostrar las curvas de aprendizaje y las tasas de éxito.
Resultados
El porcentaje de embarazos con supervivencia de ambos fetos aumentó del 50,0% (n=100) en los primeros 200 casos al 69,5% (n=153) en los últimos 220 casos (P=0,018 para la tendencia) y la tasa de supervivencia general para ambos fetos en la serie completa de 1019 casos con resultado conocido fue del 63,3% (n=645). La tasa de supervivencia de al menos un feto aumentó del 80,5% (161/200) en el primer grupo al 91,8% (202/220) en el último grupo (P=0,072 para la tendencia) y la tasa de supervivencia general de al menos un feto en la serie completa fue del 86,7% (883/1019). En la población total, la edad de gestación media al momento del parto con al menos un neonato vivo fue de 33,7 ± 3,2 semanas, con un intervalo promedio de 12,9 ± 4,0 semanas entre la intervención y el parto. Entre los primeros dos grupos, 124 embarazos tenían placenta anterior y fueron tratados con un fetoscopio de 0°. Estos casos tuvieron el peor resultado en general, con una tasa de supervivencia de gemelos del 44,4% (55/124), que aumentó al 65,1% (207/318; P=0,001) después de la introducción de un fetoscopio de 30° para casos con placenta anterior. La tasa de éxito para la supervivencia de gemelos alcanzó un nivel estable del 69% al alcanzar los 600 procedimientos, siendo ésta tasa igualada por una nueva persona que recibió capacitación práctica y realizó 174 de los últimos 400 procedimientos.
Conclusiones
Se reporta la mayor experiencia hasta la fecha en un solo centro en cuanto a coagulación con láser en TTTS. Se observó un aumento continuo en la tasa de supervivencia de gemelos debido a la experiencia cada vez mayor en función de la curva de aprendizaje y los avances en los instrumentos y técnicas fetoscópicas. Estos datos proporcionan argumentos sólidos para la centralización de la cirugía intrauterina mínimamente invasiva en centros especializados de alto volumen.
摘要
采用胎儿镜下激光凝固治疗1020例双胎输血综合征妊娠能够提高双胎存活率
目的
单中心研究采用胎儿镜下激光凝固胎盘吻合血管术治疗重度孕中期双胎输血综合征(twin–twin transfusion syndrome,TTTS)的成长经验和学习曲线以及其对围产结局的影响。
方法
1995年1月至2013年3月间,我们采用激光手术治疗1020例孕15.1~27.4周的连续TTTS孕妇。比较5个序贯组(每组200例)的围产结局,考虑几个协变量,以校正病例混合,来证实学习曲线和成功率。
结果
双胎存活的妊娠比例从前200例的50.0%(n=100)升高至最后220例的69.5%(n=153)(趋势P值=0.018),已知结局的全部1019例中双胎总存活率为63.3%(n=645)。至少一胎存活率从第一组的80.5%(161/200)升高至最后一组的91.8%(202/220)(趋势P值=0.072),全部病例中至少一胎存活率为86.7%(883/1019)。总人群中,至少一胎活产的孕妇平均分娩孕周为33.7 ± 3.2周,治疗与分娩平均间隔2.9 ± 4.0周。前两组中,124例妊娠为前置胎盘,接受0°胎儿镜治疗。这些病例的总体结局最差,双胎存活率为44.4%(55/124),采用30°胎儿镜治疗前置胎盘病例后,双胎存活率升高至65.1%(207/318;P=0.001)。治疗600例后双胎存活治疗成功率达到平稳,为69%,与接受实践培训的新操作者对后400例中174例进行治疗取得的成功率相似。
结论
我们报道了采用激活凝固治疗TTTS的最大单中心经验。我们发现,根据学习曲线取得越来越多的经验以及胎儿镜仪器和技术的成熟,双胎存活率持续升高。这些结果为在专科、患者量大的医疗中心集中进行微创宫内手术提供了有力证据。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.
This article has been selected for Journal Club. Click here to view slides and discussion points.</description><identifier>ISSN: 0960-7692</identifier><identifier>EISSN: 1469-0705</identifier><identifier>DOI: 10.1002/uog.17520</identifier><identifier>PMID: 28477345</identifier><language>eng</language><publisher>Chichester, UK: John Wiley & Sons, Ltd</publisher><subject>Adult ; Anastomosis ; Coagulation ; Completeness ; Feasibility Studies ; Female ; Fetofetal Transfusion - mortality ; Fetofetal Transfusion - surgery ; Fetoscopy - education ; Fetoscopy - mortality ; Fetuses ; Gestation ; Gestational Age ; Humans ; Infant, Newborn ; laser coagulation ; Laser Coagulation - education ; Laser Coagulation - mortality ; Lasers ; Learning ; Learning Curve ; Learning curves ; monochorionic twins ; Placenta ; Placenta - blood supply ; Pregnancy ; Pregnancy Outcome ; Pregnancy, Twin ; Surgery ; Survival ; Survival Rate ; Transfusion ; Translations ; TTTS ; Twins</subject><ispartof>Ultrasound in obstetrics & gynecology, 2017-12, Vol.50 (6), p.728-735</ispartof><rights>Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.</rights><rights>Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3880-620205e6a4cbc45ae260a24eeab115fe38238c4f8f40c92202e58d4147a8cd603</citedby><cites>FETCH-LOGICAL-c3880-620205e6a4cbc45ae260a24eeab115fe38238c4f8f40c92202e58d4147a8cd603</cites><orcidid>0000-0002-3172-1164</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1002%2Fuog.17520$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1002%2Fuog.17520$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,776,780,1411,1427,27903,27904,45553,45554,46387,46811</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28477345$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Diehl, W.</creatorcontrib><creatorcontrib>Diemert, A.</creatorcontrib><creatorcontrib>Grasso, D.</creatorcontrib><creatorcontrib>Sehner, S.</creatorcontrib><creatorcontrib>Wegscheider, K.</creatorcontrib><creatorcontrib>Hecher, K.</creatorcontrib><title>Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate</title><title>Ultrasound in obstetrics & gynecology</title><addtitle>Ultrasound Obstet Gynecol</addtitle><description>ABSTRACT
Objective
To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting.
Methods
Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates.
Results
The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double‐twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double‐twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands‐on and performed 174 of the last 400 procedures.
Conclusions
We report the largest single‐center experience of laser coagulation in TTTS. We observed a continuous increase in double‐twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high‐volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
La coagulación fetoscópica láser en 1020 embarazos con síndrome de transfusión feto fetal demuestra una mejoría en la tasa de supervivencia de gemelos
Objetivo
Investigar la experiencia creciente y la curva de aprendizaje de la coagulación fetoscópica láser de anastomosis vasculares placentarias en el síndrome de transfusión feto fetal (TTTS, por sus siglas en inglés) de carácter severo a mitad de trimestre y su influencia en el resultado perinatal en el contexto de un solo centro.
Métodos
Entre enero de 1995 y marzo de 2013 se realizó terapia con láser en 1020 embarazos consecutivos con TTTS entre las semanas de gestación 15.1 y 27.4. Se comparó el resultado perinatal en bloques de cinco grupos secuenciales de 200 casos, teniendo en cuenta varias covariables con el fin de hacer ajustes según la mezcla de casos, y para demostrar las curvas de aprendizaje y las tasas de éxito.
Resultados
El porcentaje de embarazos con supervivencia de ambos fetos aumentó del 50,0% (n=100) en los primeros 200 casos al 69,5% (n=153) en los últimos 220 casos (P=0,018 para la tendencia) y la tasa de supervivencia general para ambos fetos en la serie completa de 1019 casos con resultado conocido fue del 63,3% (n=645). La tasa de supervivencia de al menos un feto aumentó del 80,5% (161/200) en el primer grupo al 91,8% (202/220) en el último grupo (P=0,072 para la tendencia) y la tasa de supervivencia general de al menos un feto en la serie completa fue del 86,7% (883/1019). En la población total, la edad de gestación media al momento del parto con al menos un neonato vivo fue de 33,7 ± 3,2 semanas, con un intervalo promedio de 12,9 ± 4,0 semanas entre la intervención y el parto. Entre los primeros dos grupos, 124 embarazos tenían placenta anterior y fueron tratados con un fetoscopio de 0°. Estos casos tuvieron el peor resultado en general, con una tasa de supervivencia de gemelos del 44,4% (55/124), que aumentó al 65,1% (207/318; P=0,001) después de la introducción de un fetoscopio de 30° para casos con placenta anterior. La tasa de éxito para la supervivencia de gemelos alcanzó un nivel estable del 69% al alcanzar los 600 procedimientos, siendo ésta tasa igualada por una nueva persona que recibió capacitación práctica y realizó 174 de los últimos 400 procedimientos.
Conclusiones
Se reporta la mayor experiencia hasta la fecha en un solo centro en cuanto a coagulación con láser en TTTS. Se observó un aumento continuo en la tasa de supervivencia de gemelos debido a la experiencia cada vez mayor en función de la curva de aprendizaje y los avances en los instrumentos y técnicas fetoscópicas. Estos datos proporcionan argumentos sólidos para la centralización de la cirugía intrauterina mínimamente invasiva en centros especializados de alto volumen.
摘要
采用胎儿镜下激光凝固治疗1020例双胎输血综合征妊娠能够提高双胎存活率
目的
单中心研究采用胎儿镜下激光凝固胎盘吻合血管术治疗重度孕中期双胎输血综合征(twin–twin transfusion syndrome,TTTS)的成长经验和学习曲线以及其对围产结局的影响。
方法
1995年1月至2013年3月间,我们采用激光手术治疗1020例孕15.1~27.4周的连续TTTS孕妇。比较5个序贯组(每组200例)的围产结局,考虑几个协变量,以校正病例混合,来证实学习曲线和成功率。
结果
双胎存活的妊娠比例从前200例的50.0%(n=100)升高至最后220例的69.5%(n=153)(趋势P值=0.018),已知结局的全部1019例中双胎总存活率为63.3%(n=645)。至少一胎存活率从第一组的80.5%(161/200)升高至最后一组的91.8%(202/220)(趋势P值=0.072),全部病例中至少一胎存活率为86.7%(883/1019)。总人群中,至少一胎活产的孕妇平均分娩孕周为33.7 ± 3.2周,治疗与分娩平均间隔2.9 ± 4.0周。前两组中,124例妊娠为前置胎盘,接受0°胎儿镜治疗。这些病例的总体结局最差,双胎存活率为44.4%(55/124),采用30°胎儿镜治疗前置胎盘病例后,双胎存活率升高至65.1%(207/318;P=0.001)。治疗600例后双胎存活治疗成功率达到平稳,为69%,与接受实践培训的新操作者对后400例中174例进行治疗取得的成功率相似。
结论
我们报道了采用激活凝固治疗TTTS的最大单中心经验。我们发现,根据学习曲线取得越来越多的经验以及胎儿镜仪器和技术的成熟,双胎存活率持续升高。这些结果为在专科、患者量大的医疗中心集中进行微创宫内手术提供了有力证据。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.
This article has been selected for Journal Club. Click here to view slides and discussion points.</description><subject>Adult</subject><subject>Anastomosis</subject><subject>Coagulation</subject><subject>Completeness</subject><subject>Feasibility Studies</subject><subject>Female</subject><subject>Fetofetal Transfusion - mortality</subject><subject>Fetofetal Transfusion - surgery</subject><subject>Fetoscopy - education</subject><subject>Fetoscopy - mortality</subject><subject>Fetuses</subject><subject>Gestation</subject><subject>Gestational Age</subject><subject>Humans</subject><subject>Infant, Newborn</subject><subject>laser coagulation</subject><subject>Laser Coagulation - education</subject><subject>Laser Coagulation - mortality</subject><subject>Lasers</subject><subject>Learning</subject><subject>Learning Curve</subject><subject>Learning curves</subject><subject>monochorionic twins</subject><subject>Placenta</subject><subject>Placenta - blood supply</subject><subject>Pregnancy</subject><subject>Pregnancy Outcome</subject><subject>Pregnancy, Twin</subject><subject>Surgery</subject><subject>Survival</subject><subject>Survival Rate</subject><subject>Transfusion</subject><subject>Translations</subject><subject>TTTS</subject><subject>Twins</subject><issn>0960-7692</issn><issn>1469-0705</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1kc1q3DAUhUVpaSZJF32BIuimXTiRZEmWlyU0PxDIJlkLjXw9VbClqWTNMLs8QSj0DfMklTNJF4Wu7kLf-TjoIPSRkhNKCDvNYXVCG8HIG7SgXLYVaYh4ixaklaRqZMsO0GFK94QQyWv5Hh0wxZum5mKBHs9hCsmGtbN4MAkitsGs8mAmFzx2HlPCCF5HWHnjrYOEt276gaet808Pv-eDp2h86nOaA2nnuxhGwB2MwafyNJWIG9cxbGAEP83KLuTlAE8Pv57jKceN25gBz-wxetebIcGHl3uE7s6_355dVtc3F1dn364rWytFKslKKwHScLu0XBhgkhjGAcySUtFDrVitLO9Vz4ltWaFBqI5T3hhlO0nqI_Rl7y3FfmZIkx5dsjAMxkPISVNVvq5uOGUF_fwPeh9y9KWdpq3iikohRKG-7ikbQ0oRer2ObjRxpynR80i6jKSfRyrspxdjXo7Q_SVfVynA6R7YugF2_zfpu5uLvfIPXoqf6A</recordid><startdate>201712</startdate><enddate>201712</enddate><creator>Diehl, W.</creator><creator>Diemert, A.</creator><creator>Grasso, D.</creator><creator>Sehner, S.</creator><creator>Wegscheider, K.</creator><creator>Hecher, K.</creator><general>John Wiley & Sons, Ltd</general><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QO</scope><scope>8FD</scope><scope>FR3</scope><scope>K9.</scope><scope>P64</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-3172-1164</orcidid></search><sort><creationdate>201712</creationdate><title>Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate</title><author>Diehl, W. ; Diemert, A. ; Grasso, D. ; Sehner, S. ; Wegscheider, K. ; Hecher, K.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3880-620205e6a4cbc45ae260a24eeab115fe38238c4f8f40c92202e58d4147a8cd603</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Adult</topic><topic>Anastomosis</topic><topic>Coagulation</topic><topic>Completeness</topic><topic>Feasibility Studies</topic><topic>Female</topic><topic>Fetofetal Transfusion - mortality</topic><topic>Fetofetal Transfusion - surgery</topic><topic>Fetoscopy - education</topic><topic>Fetoscopy - mortality</topic><topic>Fetuses</topic><topic>Gestation</topic><topic>Gestational Age</topic><topic>Humans</topic><topic>Infant, Newborn</topic><topic>laser coagulation</topic><topic>Laser Coagulation - education</topic><topic>Laser Coagulation - mortality</topic><topic>Lasers</topic><topic>Learning</topic><topic>Learning Curve</topic><topic>Learning curves</topic><topic>monochorionic twins</topic><topic>Placenta</topic><topic>Placenta - blood supply</topic><topic>Pregnancy</topic><topic>Pregnancy Outcome</topic><topic>Pregnancy, Twin</topic><topic>Surgery</topic><topic>Survival</topic><topic>Survival Rate</topic><topic>Transfusion</topic><topic>Translations</topic><topic>TTTS</topic><topic>Twins</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Diehl, W.</creatorcontrib><creatorcontrib>Diemert, A.</creatorcontrib><creatorcontrib>Grasso, D.</creatorcontrib><creatorcontrib>Sehner, S.</creatorcontrib><creatorcontrib>Wegscheider, K.</creatorcontrib><creatorcontrib>Hecher, K.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Biotechnology Research Abstracts</collection><collection>Technology Research Database</collection><collection>Engineering Research Database</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>Ultrasound in obstetrics & gynecology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Diehl, W.</au><au>Diemert, A.</au><au>Grasso, D.</au><au>Sehner, S.</au><au>Wegscheider, K.</au><au>Hecher, K.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate</atitle><jtitle>Ultrasound in obstetrics & gynecology</jtitle><addtitle>Ultrasound Obstet Gynecol</addtitle><date>2017-12</date><risdate>2017</risdate><volume>50</volume><issue>6</issue><spage>728</spage><epage>735</epage><pages>728-735</pages><issn>0960-7692</issn><eissn>1469-0705</eissn><abstract>ABSTRACT
Objective
To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting.
Methods
Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates.
Results
The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double‐twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double‐twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands‐on and performed 174 of the last 400 procedures.
Conclusions
We report the largest single‐center experience of laser coagulation in TTTS. We observed a continuous increase in double‐twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high‐volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
La coagulación fetoscópica láser en 1020 embarazos con síndrome de transfusión feto fetal demuestra una mejoría en la tasa de supervivencia de gemelos
Objetivo
Investigar la experiencia creciente y la curva de aprendizaje de la coagulación fetoscópica láser de anastomosis vasculares placentarias en el síndrome de transfusión feto fetal (TTTS, por sus siglas en inglés) de carácter severo a mitad de trimestre y su influencia en el resultado perinatal en el contexto de un solo centro.
Métodos
Entre enero de 1995 y marzo de 2013 se realizó terapia con láser en 1020 embarazos consecutivos con TTTS entre las semanas de gestación 15.1 y 27.4. Se comparó el resultado perinatal en bloques de cinco grupos secuenciales de 200 casos, teniendo en cuenta varias covariables con el fin de hacer ajustes según la mezcla de casos, y para demostrar las curvas de aprendizaje y las tasas de éxito.
Resultados
El porcentaje de embarazos con supervivencia de ambos fetos aumentó del 50,0% (n=100) en los primeros 200 casos al 69,5% (n=153) en los últimos 220 casos (P=0,018 para la tendencia) y la tasa de supervivencia general para ambos fetos en la serie completa de 1019 casos con resultado conocido fue del 63,3% (n=645). La tasa de supervivencia de al menos un feto aumentó del 80,5% (161/200) en el primer grupo al 91,8% (202/220) en el último grupo (P=0,072 para la tendencia) y la tasa de supervivencia general de al menos un feto en la serie completa fue del 86,7% (883/1019). En la población total, la edad de gestación media al momento del parto con al menos un neonato vivo fue de 33,7 ± 3,2 semanas, con un intervalo promedio de 12,9 ± 4,0 semanas entre la intervención y el parto. Entre los primeros dos grupos, 124 embarazos tenían placenta anterior y fueron tratados con un fetoscopio de 0°. Estos casos tuvieron el peor resultado en general, con una tasa de supervivencia de gemelos del 44,4% (55/124), que aumentó al 65,1% (207/318; P=0,001) después de la introducción de un fetoscopio de 30° para casos con placenta anterior. La tasa de éxito para la supervivencia de gemelos alcanzó un nivel estable del 69% al alcanzar los 600 procedimientos, siendo ésta tasa igualada por una nueva persona que recibió capacitación práctica y realizó 174 de los últimos 400 procedimientos.
Conclusiones
Se reporta la mayor experiencia hasta la fecha en un solo centro en cuanto a coagulación con láser en TTTS. Se observó un aumento continuo en la tasa de supervivencia de gemelos debido a la experiencia cada vez mayor en función de la curva de aprendizaje y los avances en los instrumentos y técnicas fetoscópicas. Estos datos proporcionan argumentos sólidos para la centralización de la cirugía intrauterina mínimamente invasiva en centros especializados de alto volumen.
摘要
采用胎儿镜下激光凝固治疗1020例双胎输血综合征妊娠能够提高双胎存活率
目的
单中心研究采用胎儿镜下激光凝固胎盘吻合血管术治疗重度孕中期双胎输血综合征(twin–twin transfusion syndrome,TTTS)的成长经验和学习曲线以及其对围产结局的影响。
方法
1995年1月至2013年3月间,我们采用激光手术治疗1020例孕15.1~27.4周的连续TTTS孕妇。比较5个序贯组(每组200例)的围产结局,考虑几个协变量,以校正病例混合,来证实学习曲线和成功率。
结果
双胎存活的妊娠比例从前200例的50.0%(n=100)升高至最后220例的69.5%(n=153)(趋势P值=0.018),已知结局的全部1019例中双胎总存活率为63.3%(n=645)。至少一胎存活率从第一组的80.5%(161/200)升高至最后一组的91.8%(202/220)(趋势P值=0.072),全部病例中至少一胎存活率为86.7%(883/1019)。总人群中,至少一胎活产的孕妇平均分娩孕周为33.7 ± 3.2周,治疗与分娩平均间隔2.9 ± 4.0周。前两组中,124例妊娠为前置胎盘,接受0°胎儿镜治疗。这些病例的总体结局最差,双胎存活率为44.4%(55/124),采用30°胎儿镜治疗前置胎盘病例后,双胎存活率升高至65.1%(207/318;P=0.001)。治疗600例后双胎存活治疗成功率达到平稳,为69%,与接受实践培训的新操作者对后400例中174例进行治疗取得的成功率相似。
结论
我们报道了采用激活凝固治疗TTTS的最大单中心经验。我们发现,根据学习曲线取得越来越多的经验以及胎儿镜仪器和技术的成熟,双胎存活率持续升高。这些结果为在专科、患者量大的医疗中心集中进行微创宫内手术提供了有力证据。
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This article has been selected for Journal Club. Click here to view slides and discussion points.</abstract><cop>Chichester, UK</cop><pub>John Wiley & Sons, Ltd</pub><pmid>28477345</pmid><doi>10.1002/uog.17520</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0002-3172-1164</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0960-7692 |
| ispartof | Ultrasound in obstetrics & gynecology, 2017-12, Vol.50 (6), p.728-735 |
| issn | 0960-7692 1469-0705 |
| language | eng |
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| source | Wiley Free Content; MEDLINE; Wiley Online Library Journals Frontfile Complete; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals |
| subjects | Adult Anastomosis Coagulation Completeness Feasibility Studies Female Fetofetal Transfusion - mortality Fetofetal Transfusion - surgery Fetoscopy - education Fetoscopy - mortality Fetuses Gestation Gestational Age Humans Infant, Newborn laser coagulation Laser Coagulation - education Laser Coagulation - mortality Lasers Learning Learning Curve Learning curves monochorionic twins Placenta Placenta - blood supply Pregnancy Pregnancy Outcome Pregnancy, Twin Surgery Survival Survival Rate Transfusion Translations TTTS Twins |
| title | Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate |
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