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Paediatrics
Published in David A Lisle, Imaging for Students, 2012
With the widespread use of obstetric US, oesophageal atresia and tracheo-oesophageal fistula (TOF) may be suspected prenatally. Findings on obstetric US may include polyhydramnios and absence of a normal fluid-filled fetal stomach.
Fetal surgery: how recent technological advancements are extending its applications
Published in Expert Review of Medical Devices, 2019
The first example is the use of fetoscopy to map and guide the fulguration of placental anastomoses in twin-to-twin transfusion syndrome (TTTS) [2]. TTTS occurs in 10–20% of monochorionic pregnancies with the natural history showing a mortality rate of near 90%. In TTTS, abnormal vascular communications lead to an unbalanced blood flow from one twin (the donor) to the other twin (the recipient) [2]. This can cause anuria, oligohydramnios and poor fetal growth in the donor twin due to hypovolemia, as well as polyuria, polyhydramnios, heart failure, and hydrops in the recipient twin due to hypervolemia. Fetoscopic selective laser coagulation (FSLC) of the placental anastomoses has become the standard-of-care treatment in severe TTTS [2]. Essentially, a 1-3 mm endoscope is introduced into the polyhydramniotic sac of the recipient twin and a laser fiber is used to cauterize the placental anastomoses. Originally, the photocoagulation of the anastomoses was done in a non-selective laser ablation of placental anastomoses, meaning that all vessels crossing the intertwin membranes were targeted by the laser [3]. However, research indicated that non-selective photocoagulation of placental anastomoses was associated with higher frequency of donor twin demise [3]. Therefore, a selective laser ablation was developed that endoscopically identifies all anastomoses and occludes only such connections avoiding ablating important vessels to the twins that are not causing TTTS. Residual anastomosis leading to twin anemia polycythemia sequence (TAPS) and recurrent TTTS were found to be an issue with this technique in up to 33% of cases. In order to minimize the risk of residual anastomoses that are invisible to the naked eye, the Solomon technique was introduced. After selectively ablating the anastomoses, we ablate the area between the anastomoses making a line on the placental vascular equator, with the objective of occluding small anastomoses that are usually not seen through fetoscope. The Solomon technique is different than the non-selective technique initially described since we follow the placental vascular equator where the anastomoses are really located, preserving important vessels to both twins. Solomonization not only coagulates all identified anastomotic vessels, but it also creates a continuous line of coagulation on the chorionic plate [3]. Recent studies demonstrated that this approach significantly reduces the incidence of TAPS and recurrent TTTS in comparison to the selective laser method and may improve survival and neonatal outcome [3]. Fortunately, because of the technological advancements, outcomes for fetoscopic laser surgery have significantly improved over the past 25 years, with up to 70% overall double survival and >80% single survival rates [1]. Flexible mini-telescopes have recently been applied to allow for better visualization of the vascular equator in anterior placentas, especially in cases where anastomoses are close to the insertion site of the fetoscope [3].