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Natarajan L, Gosavi AT, Wataganara T, Su LL, Amin Z, Leung TY, Choolani M, Biswas A, Mattar CNZ. Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation. Singapore Med J 2022; 63:274-282. [PMID: 36043312 PMCID: PMC9297184 DOI: 10.11622/smedj.2020137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload. METHODS We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance. RESULTS 9 patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). ≥ 1 twin was live-born in 88.9% of cases, while postnatal survival to six months of ≥ 1 twin occurred in 77.8% of cases. CONCLUSION Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.
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Affiliation(s)
- Lalitha Natarajan
- Fetal Medicine Unit, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Arundhati T Gosavi
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tuangsit Wataganara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zubair Amin
- Department of Neonatology, National University Health System, Singapore
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Citra NZ Mattar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Torrents-Barrena J, Piella G, Valenzuela-Alcaraz B, Gratacos E, Eixarch E, Ceresa M, Gonzalez Ballester MA. TTTS-STgan: Stacked Generative Adversarial Networks for TTTS Fetal Surgery Planning Based on 3D Ultrasound. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:3595-3606. [PMID: 32746107 DOI: 10.1109/tmi.2020.3001028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is characterized by an unbalanced blood transfer through placental abnormal vascular connections. Prenatal ultrasound (US) is the imaging technique to monitor monochorionic pregnancies and diagnose TTTS. Fetoscopic laser photocoagulation is an elective treatment to coagulate placental communications between both twins. To locate the anomalous connections ahead of surgery, preoperative planning is crucial. In this context, we propose a novel multi-task stacked generative adversarial framework to jointly learn synthetic fetal US generation, multi-class segmentation of the placenta, its inner acoustic shadows and peripheral vasculature, and placenta shadowing removal. Specifically, the designed architecture is able to learn anatomical relationships and global US image characteristics. In addition, we also extract for the first time the umbilical cord insertion on the placenta surface from 3D HD-flow US images. The database consisted of 70 US volumes including singleton, mono- and dichorionic twins at 17-37 gestational weeks. Our experiments show that 71.8% of the synthesized US slices were categorized as realistic by clinicians, and that the multi-class segmentation achieved Dice scores of 0.82 ± 0.13, 0.71 ± 0.09, and 0.72 ± 0.09, for placenta, acoustic shadows, and vasculature, respectively. Moreover, fetal surgeons classified 70.2% of our completed placenta shadows as satisfactory texture reconstructions. The umbilical cord was successfully detected on 85.45% of the volumes. The framework developed could be implemented in a TTTS fetal surgery planning software to improve the intrauterine scene understanding and facilitate the location of the optimum fetoscope entry point.
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Elbanna WSS, Oun IA, Ellatif EMA, Hablas WR, El Shaikh WI, Wafa YA. Evaluation of Fetoscopy Role in Fetal Surgery and Fetal Medicine. OPEN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2018; 08:946-957. [DOI: 10.4236/ojog.2018.811096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Tan KH. Progress in obstetrics and gynaecology - evidence-based practices and practice-based evidence reviews. Singapore Med J 2017. [PMID: 28642959 DOI: 10.11622/smedj.2017047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kok Hian Tan
- Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
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Galluzo RN, Franco MJ, Faust LW, Dacorégio KS, Braga JRDS, Werner Junior H, Araujo Júnior E. Virtual three-dimensional placentoscopy: a new approach to assess residual anastomoses following laser photocoagulation in twin-to-twin transfusion syndrome. J Matern Fetal Neonatal Med 2017; 31:518-520. [DOI: 10.1080/14767058.2017.1286321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Roberto Noya Galluzo
- Department of Radiology, SONITEC – Imaging Medical Diagnostic, Florianopolis, SC, Brazil
| | - Mario Júlio Franco
- Department of Obstetrics and Gynecology, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Leila Wessler Faust
- Department of Obstetrics and Gynecology, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Karine Souza Dacorégio
- Department of Obstetrics and Gynecology, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Jair Roberto da Silva Braga
- Department of Obstetrics and Gynecology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Heron Werner Junior
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI), Rio de Janeiro, RJ, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine – Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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