Laser Treatment of Twin–to–Twin Transfusion Syndrome

Objective: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin–twin transfusion syndrome (TTTS). However, two important controversies are apparent in the literature: (a) a gap between concept and performance, and (b) controversy regarding whether all the anastomoses can be identified endoscopically and whether blind lasering of healthy placenta is justified. The purpose of this article is: (a) to address the potential source of the gap between concept and performance by analyzing the fundamental steps needed to successfully accomplish the surgery, and (b) to discuss the resulting competency benchmarks reported with the different surgical techniques. Materials and Methods: Laser surgery for TTTS can be broken down into two fundamental steps: (1) endoscopic identification of the placental vascular anastomoses, (2) laser ablation of the anastomoses. The two steps are not synonymous: (a) regarding the endoscopic identification of the anastomoses, the non-selective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies and lasers only placental vascular anastomoses. The Solomon technique is based on the theory that not all anastomoses are endoscopically visible and thus involves lasering healthy areas of the placenta between lasered anastomoses, (b) regarding the actual laser ablation of the anastomoses, successful completion of the surgery (i.e., lasering all the anastomoses) can be measured by the rate of persistent or reverse TTTS (PRTTTS) and how often a selective technique can be achieved. Articles representing the different techniques are discussed. Results: The non-selective technique is associated with the lowest double survival rate (35%), compared with 60–75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of residual patent placental vascular anastomoses, compared to 3.5–5% for the selective technique (p < .05). Both the Solomon and the selective technique are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the selective technique (99%) compared with the Solomon (80%) or the ‘standard’ (60%) techniques (p < .05). A surgical performance index is proposed. Conclusion: The Quintero selective technique was associated with the highest rate of successful ablation and lowest rate of PRTTTS. The Solomon technique represents a historical backward movement in the identification of placental vascular anastomoses and is associated with higher rate of residual patent vascular communications. The reported outcomes of the Quintero selective technique do not lend support to the existence of invisible anastomoses or justify lasering healthy placental tissue.

Download Full-text

Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin–Twin Transfusion Syndrome

Twin Research and Human Genetics ◽

10.1017/thg.2020.94 ◽

2021 ◽

Vol 24 (1) ◽

pp. 42-48

Author(s):

Seiji Kanazawa ◽

Katsusuke Ozawa ◽

Jin Muromoto ◽

Rika Sugibayashi ◽

Yuka Wada ◽

...

Keyword(s):

Adverse Events ◽

Laser Surgery ◽

Placental Abruption ◽

Laser Energy ◽

Significant Risk ◽

Incidence Rates ◽

Risk Profiling ◽

Perinatal Management ◽

Solomon Technique ◽

Selective Technique

AbstractWe evaluated the outcomes and adverse events after fetoscopic laser surgery (FLS) for twin–twin transfusion syndrome (TTTS) using the Solomon technique in comparison to the selective technique. A retrospective analysis of a single-center consecutive cohort of FLS-treated TTTS using the selective (January 2010 to July 2014) and Solomon (August 2014 to December 2017) techniques was performed. Among 395 cases, 227 underwent selective coagulation and 168 underwent the Solomon technique. The incidence rates of recurrent TTTS (Solomon vs. selective: 0% vs. .9%, p = .510) and twin anemia–polycythemia sequence (.6% vs. .4%, p = .670) were very low in both groups. The incidence rates of placental abruption (Solomon vs. selective: 10.7% vs. 3.5%, p = .007) and preterm premature rupture of the membranes (pPROM) with subsequent delivery before 32 weeks (20.2% vs. 7.1%, p < .001) were higher in the Solomon group. The median birth recipient weight was significantly smaller in the Solomon group (1790 g vs. 1933 g, p = .049). The rate of survival of at least one twin was significantly higher in the Solomon group (98.2% vs. 93.8%, p = .046). The Solomon technique and total laser energy were significant risk factors for pPROM (odds ratio: 2.64, 1.07, 95% CI [1.32, 5.28], [1.01, 1.13], p = .006, p = .014, respectively). These findings suggest that the Solomon technique led to superior survival outcomes but increased risks of placental abruption, pPROM and fetal growth impairment. Total laser energy was associated with the occurrence of pPROM. Close attention to adverse events is required for perinatal management after FLS to treat TTTS using the Solomon technique.

Download Full-text

How do laser ablation and conization compare with each other or alternative surgical techniques in women with cervical intraepithelial neoplasia?

Cochrane Clinical Answers ◽

10.1002/cca.1054 ◽

2016 ◽

Author(s):

Jane Burch ◽

Simone Mocellin

Keyword(s):

Laser Ablation ◽

Cervical Intraepithelial Neoplasia ◽

Surgical Techniques ◽

Intraepithelial Neoplasia

Download Full-text

Optimizing controlled laser cutting of hard tissue (bone)

at - Automatisierungstechnik ◽

10.1515/auto-2018-0072 ◽

2018 ◽

Vol 66 (12) ◽

pp. 1072-1082 ◽

Cited By ~ 4

Author(s):

Lina M. Beltran Bernal ◽

Iris T. Schmidt ◽

Nikola Vulin ◽

Jonas Widmer ◽

Jess G. Snedeker ◽

...

Keyword(s):

Laser Ablation ◽

Laser Cutting ◽

Laser Surgery ◽

Healing Process ◽

Ablation Rate ◽

Movement Speed ◽

Lateral Movement ◽

Hard Tissue ◽

Robot Assisted ◽

Bone Surgery

Abstract Conventional bone surgery leads to unwanted damage to the surrounding tissues and a slow healing process for the patients. Additionally, physicians are not able to perform free cutting shapes due to the limitations of available systems. These issues can be overcome by robot-assisted contactless laser surgery since it provides less mechanical stress, allows precise functional cuts, and leads to faster healing. The remaining drawback of laser surgery is the low ablation rate that is not yet competitive with conventional mechanical piezo-osteotomes. Therefore, we aim at maximizing the efficiency in hard tissue laser ablation by optimizing the lateral movement speed for different irrigation conditions. The results of this study show a non-linear relationship between cutting rates, speeds, and depths that should be critically considered for integration in robotic laser surgery.

Download Full-text

Autonomy in the Operating Room: A Multicenter Study of Gender Disparities During Surgical Training

Journal of Graduate Medical Education ◽

10.4300/jgme-d-21-00217.1 ◽

2021 ◽

Vol 13 (5) ◽

pp. 666-672

Author(s):

Jenny X. Chen ◽

Edward H. Chang ◽

Francis Deng ◽

Shari Meyerson ◽

Brian George ◽

...

Keyword(s):

Surgical Training ◽

Gender Disparities ◽

Training Level ◽

Surgical Performance ◽

Surgical Trainees ◽

Significant Difference ◽

Multivariable Regression ◽

Operative Performance ◽

And Performance ◽

Multivariable Regression Models

ABSTRACT Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. Results A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = −0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P < .001; performance B = −0.0704, P < .001). Conclusions While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

Download Full-text

Surgical Techniques: Vaginal 6.3.2.2 Laser Surgery on the Vulva and Vagina

Atlas of Gynecologic Surgery ◽

10.1055/b-0034-91305 ◽

2014 ◽

Keyword(s):

Laser Surgery ◽

Surgical Techniques

Download Full-text

Managing Benign and Malignant Oral Lesions with Carbon Dioxide Laser: Indications, Techniques, and Outcomes for Outpatient Surgery

The Surgery Journal ◽

10.1055/s-0039-1694735 ◽

2019 ◽

Vol 05 (03) ◽

pp. e69-e75

Author(s):

Alberto Maria Saibene ◽

Cecilia Rosso ◽

Paolo Castellarin ◽

Federica Vultaggio ◽

Carlotta Pipolo ◽

...

Keyword(s):

Carbon Dioxide ◽

Co2 Laser ◽

Laser Surgery ◽

Carbon Dioxide Laser ◽

Outpatient Surgery ◽

Surgical Techniques ◽

Systematic Evaluation ◽

Oral Lesions ◽

Wide Range ◽

Malignant Lesions

Purpose Because of its affinity for water-based tissues, carbon dioxide (CO2) laser has become an instrument of choice for treating oral mucosa conditions, ranging from inflammatory to malignant lesions. The aim of this work is to systematically evaluate the outcomes of laser surgery over a wide range of lesions, while providing a solid and reproducible protocol for CO2 laser surgery in the outpatient management of oral lesion. Methods Seventy-eight patients underwent 92 laser outpatient procedures for treatment of a wide range of benign and malignant lesions. We performed 60 removals, 11 exeretic biopsies, 15 vaporizations, and 3 vaporization/removal combined. We analyzed laser parameters applied for each technique and provided a systematic evaluation of surgical results. Results No problems occurred intraoperatively in any of the patients. Five patients complained marginal pain, while 3 patients had postsurgery bleeding. All treatments were successful, with the notable exception of 3 relapsing verrucous proliferative leukoplakias and an infiltrating squamous cell carcinoma of the tongue requiring radicalization. We did not record any adverse reactions to drugs or lesions due to laser action. Concordance between clinical diagnosis and pathology results was at 94.8%. Conclusions Our data indicate that CO2 laser is a solid choice for outpatient treatment of oral lesions. This technique grants painless and almost bloodless treatment, with negligible recurrence rates. Providing a solid reference for laser settings and operative techniques could provide a foundation for further exploring this tool while offering the basis for a positive comparison between different surgical techniques and options.

Download Full-text

Quality improvement through public reporting: The surgeon scorecard – are we there yet?

Journal of Hospital Administration ◽

10.5430/jha.v7n4p27 ◽

2018 ◽

Vol 7 (4) ◽

pp. 27

Author(s):

Afshin A. Anoushiravani ◽

Zain Sayeed ◽

Muhammad T. Padela ◽

James E. Feng ◽

Paul Barach ◽

...

Keyword(s):

Clinical Performance ◽

Healthcare Providers ◽

Healthcare Organizations ◽

Surgical Performance ◽

Elective Surgical Procedures ◽

National Debate ◽

Patient Advocates ◽

And Performance ◽

Knee And Hip Arthroplasty ◽

The Impact

As national healthcare reform continues to place greater emphasis on providing high value care, measures designed to track clinical performance remain relatively overlooked. To that extent, several organizations have attempted to create objective grading systems to evaluate orthopaedic surgeon quality and performance. While attempting to address these issues, ProPublica’s Surgeon Scorecard has provoked national debate among patient advocates and healthcare providers. The methodology behind the Scorecard was developed at the Harvard School of Public Health with an aim to provide a more robust means of comparing surgical performance and outcomes for patients and healthcare organizations. Currently, the Scorecard assesses eight elective surgical procedures, including total knee and hip arthroplasty, through the use of the Medicare Claims Dataset. The impact of the Scorecard on orthopaedic practice has yet to be established. In this discussion, we analyze the Scorecard from the perspective of various stakeholders to identify its benefits and shortcomings, as well as offer direction for further improvement.

Download Full-text

Comparison of Solomon technique with selective laser ablation for twin-twin transfusion syndrome: a systematic review

Ultrasound in Obstetrics and Gynecology ◽

10.1002/uog.14813 ◽

2015 ◽

Vol 46 (5) ◽

pp. 526-533 ◽

Cited By ~ 13

Author(s):

R. K. Dhillon ◽

S. C. Hillman ◽

R. Pounds ◽

R. K. Morris ◽

M. D. Kilby

Keyword(s):

Systematic Review ◽

Laser Ablation ◽

Solomon Technique

Download Full-text

Reluctant Researchers

Australian Journal of Career Development ◽

10.1177/103841629600500209 ◽

1996 ◽

Vol 5 (2) ◽

pp. 28-33 ◽

Cited By ~ 1

Author(s):

Marilyn Prestage ◽

Anna Lichtenberg

Keyword(s):

Participation Rates ◽

Successful Completion ◽

Postgraduate Study ◽

Factors Influencing ◽

Potential Source ◽

Participation Of Women ◽

Postgraduate Studies ◽

Specific Factors ◽

Graduate Certificate ◽

Phd Programs

The aim of this study was to identify factors contributing to the low participation rates of women in research-based postgraduate study. Although it was acknowledged that there were increases in the participation of women in postgraduate studies, this was primarily at the Graduate Diploma and Graduate Certificate level. As these courses do not provide a direct entry point to Masters and PhD programs, a large potential source of research degree candidates is being lost. In recognition of the value of successful completion of an Honours degree as a foundation for research-based higher degree qualifications, the parameters of this project were narrowed in order to examine the specific factors influencing the enrolment of students in Honours programs.

Download Full-text