胎儿镜激光凝固术治疗双胎输血综合征的发展

doi:10.12280/gjfckx.20230183

摘要/Abstract

摘要：

胎儿镜激光凝固术（fetoscopic laser coagulation，FLC）已广泛应用于临床上治疗双胎输血综合征（twin to twin transfusion syndrome，TTTS）Ⅱ~Ⅳ期患者，并取得了一定的成效，TTTS围产儿存活率显著提高，存活胎儿神经系统发病率显著降低，同时因其可直视下操作、切口小、母体出血少和对妊娠干扰小等优点，在胎儿医学微创领域得到广泛认可及开展。但是由于FLC技术要求术者具备较高操作技术及内窥镜、激光等特殊设备的局限性，限制了FLC技术取得更好的成效，TTTS患者接受FLC治疗后仍要面临着较严重的围手术期并发症、术后复发及再次手术的风险。通过回顾国内外FLC在TTTS治疗中的应用进展，阐述FLC技术的发展、操作方法、不足及未来发展方向，以期为后续胎儿医学发展提供一定的参考。

关键词: 胎儿镜, 激光凝固术, 双胎输血综合征, 妊娠并发症, 胎儿医学

Abstract:

Fetoscopic laser coagulation (FLC) has been widely used in clinical treatment of patients with twin to twin transfusion syndrome (TTTS) by Ⅱ-Ⅳ stage and has achieved certain results. The perinatal survival rate of TTTS is significantly improved, and the incidence rate of the surviving fetal nervous system is significantly reduced. Meanwhile, it is widely recognized and carried out in the field of minimally invasive fetal medicine because of its advantages such as direct vision operation, small incision, less maternal blood loss, and less interference to pregnancy. However, due to the limitations of FLC technology, which requires a high level of operator skill and special equipment such as their own endoscope and laser, FLC technology can not achieve better results. Pregnant women who receive FLC treatment still face serious perioperative complications, postoperative recurrence, and the risk of reoperation. This article reviews the application and research progress of FLC in TTTS treatment both domestically and internationally, comprehensively elaborates on the development history, operational methods, shortcomings, and future development direction of FLC technology, in order to provide certain reference for the future development of fetal medicine.

Key words: Fetoscopes, Laser coagulation, Fetofetal transfusion, Pregnancy complications, Fetal medicine

李渝波, 李俊男. 胎儿镜激光凝固术治疗双胎输血综合征的发展[J]. 国际妇产科学杂志, 2023, 50(5): 486-491.

LI Yu-bo, LI Jun-nan. Development of Fetoscopic Laser Coagulation for Twin to Twin Transfusion Syndrome[J]. Journal of International Obstetrics and Gynecology, 2023, 50(5): 486-491.

参考文献 30

[1]	Van Mieghem T, Abbasi N, Shinar S, et al. Monochorionic monoamniotic twin pregnancies[J]. Am J Obstet Gynecol MFM, 2022, 4(2S):100520. doi: 10.1016/j.ajogmf.2021.100520.
[2]	Saito M, Tokunaka M, Takita H, et al. Impact of first trimester determination of abnormal cord insertion on twin-to-twin transfusion syndrome and other adverse outcomes in monochorionic diamniotic twins: A retrospective cohort study[J]. Prenat Diagn, 2020, 40(4):507-513. doi: 10.1002/pd.5633.
[3]	Bamberg C, Hecher K. Update on twin-to-twin transfusion syndrome[J]. Best Pract Res Clin Obstet Gynaecol, 2019, 58:55-65. doi: 10.1016/j.bpobgyn.2018.12.011. pmid: 30850326
[4]	Murgano D, Khalil A, Prefumo F, et al. Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis[J]. Ultrasound Obstet Gynecol, 2020, 55(3):310-317. doi: 10.1002/uog.21889. pmid: 31595578
[5]	D′Antonio F, Benlioglu C, Sileo FG, et al. Perinatal outcomes of twin pregnancies affected by early twin-twin transfusion syndrome: A systematic review and meta-analysis[J]. Acta Obstet Gynecol Scand, 2020, 99(9):1121-1134. doi: 10.1111/aogs.13840.
[6]	Mustafa HJ, Krispin E, Tadbiri H, et al. Efficacy of long-term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin-to-twin transfusion syndrome: a collaborative cohort study[J]. BJOG, 2022, 129(4):597-606. doi: 10.1111/1471-0528.17017.
[7]	赵晓敏, 陈叙. 双胎输血综合征的预测和诊治进展[J]. 国际妇产科学杂志, 2021, 48(2):186-190. doi: 10.12280/gjfckx.20200676.
[8]	D′Antonio F, Herrera M, Oronzii L, et al. Solomon technique vs selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis of maternal and perinatal outcomes[J]. Ultrasound Obstet Gynecol, 2022, 60(6):731-738. doi: 10.1002/uog.26095.
[9]	Schou KV, Lando AV, Ekelund CK, et al. Long-Term Neurodevelopmental Outcome of Monochorionic Twins after Laser Therapy or Umbilical Cord Occlusion for Twin-Twin Transfusion Syndrome[J]. Fetal Diagn Ther, 2019, 46(1):20-27. doi: 10.1159/000491787. pmid: 30149379
[10]	Bamberg C, Diehl W, Diemert A, et al. Differentiation between TTTS Stages Ⅰ vs Ⅱ and ⅢI vs Ⅳ does not affect probability of double survival after laser therapy[J]. Ultrasound Obstet Gynecol, 2021, 58(2):201-206. doi: 10.1002/uog.23131.
[11]	Spruijt MS, Lopriore E, Steggerda SJ, et al. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond[J]. Expert Rev Hematol, 2020, 13(3):259-267. doi: 10.1080/17474086.2020.1720643. pmid: 31971028
[12]	De Lia JE, Cruikshank DP, Keye WR Jr. Fetoscopic neodymium:YAG laser occlusion of placental vessels in severe twin-twin transfusion syndrome[J]. Obstet Gynecol, 1990, 75(6):1046-1053. pmid: 2342732
[13]	De Lia JE, Kuhlmann RS. Twin-to-twin transfusion syndrome--30 years at the front[J]. Am J Perinatol, 2014, 31(Suppl 1):S7-S12. doi: 10.1055/s-0034-1376184.
[14]	Roberts D, Neilson JP, Kilby MD, et al. Interventions for the treatment of twin-twin transfusion syndrome[J]. Cochrane Database Syst Rev, 2014(1): CD002073. doi: 10.1002/14651858.
[15]	Quintero RA, Comas C, Bornick PW, et al. Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome[J]. Ultrasound Obstet Gynecol, 2000, 16(3):230-236. doi: 10.1046/j.1469-0705.2000.00265.x.
[16]	Di Mascio D, Khalil A, D′Amico A, et al. Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis[J]. Ultrasound Obstet Gynecol, 2020, 56(6):811-820. doi: 10.1002/uog.22054.
[17]	Shamshirsaz AA, Chmait RH, Stirnemann J, et al. Solomon versus selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: A systematic review and meta-analysis[J]. Prenat Diagn, 2023, 43(1):72-83. doi: 10.1002/pd.6246.
[18]	Quintero RA, Morales WJ, Mendoza G, et al. Selective photocoagulation of placental vessels in twin-twin transfusion syndrome: evolution of a surgical technique[J]. Obstet Gynecol Surv, 1998, 53(Suppl 12):S97-S103. doi: 10.1097/00006254-199812010-00001.
[19]	Loh M, Bhatia A, Tan KL, et al. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience[J]. Singapore Med J, 2020, 61(10):523-531. doi: 10.11622/smedj.2019107.
[20]	Murata S, Takano M, Kagawa Y, et al. The experience of modified sequential selective laser photocoagulation of communicating vessels technique for twin-twin transfusion syndrome[J]. J Matern Fetal Neonatal Med, 2018, 31(9):1137-1141. doi: 10.1080/14767058.2017.1311309. pmid: 28335669
[21]	Mustafa HJ, Javinani A, Goetzinger K, et al. Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome-cohort study, systematic review, and meta-analysis[J]. Am J Obstet Gynecol, 2022, 226(6):843.e1-843.e28. doi: 10.1016/j.ajog.2022.02.035.
[22]	Martínez JM, Bermúdez C, Becerra C, et al. The role of Doppler studies in predicting individual intrauterine fetal demise after laser therapy for twin-twin transfusion syndrome[J]. Ultrasound Obstet Gynecol, 2003, 22(3):246-251. doi: 10.1002/uog.215.
[23]	Quintero RA, Ishii K, Chmait RH, et al. Sequential selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome[J]. J Matern Fetal Neonatal Med, 2007, 20(10):763-768. doi: 10.1080/14767050701591827.
[24]	Akkermans J, Peeters SH, Klumper FJ, et al. Is the Sequential Laser Technique for Twin-to-Twin Transfusion Syndrome Truly Superior to the Standard Selective Technique? A Meta-Analysis[J]. Fetal Diagn Ther, 2015, 37(4):251-258. doi: 10.1159/000365212. pmid: 25139419
[25]	Kanazawa S, Ozawa K, Muromoto J, et al. Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin-Twin Transfusion Syndrome[J]. Twin Res Hum Genet, 2021, 24(1):42-48. doi: 10.1017/thg.2020.94. pmid: 33900164
[26]	Knijnenburg P, Lopriore E, Ge Y, et al. Placental Abruption after Fetoscopic Laser Surgery in Twin-Twin Transfusion Syndrome: The Role of the Solomon Technique[J]. Fetal Diagn Ther, 2021, 48(9):660-666. doi: 10.1159/000517800.
[27]	Fichera A, Azzaretto VV, Fratelli N, et al. Fetoscopic laser ablation therapy in monochorionic diamniotic twin pregnancies with twin-to-twin transfusion syndrome treated at a single centre over 10 years: a retrospective study[J]. J Perinat Med, 2022, 50(1):34-41. doi: 10.1515/jpm-2021-0058.
[28]	Ruano R, Rodo C, Peiro JL, et al. Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using ′Solomon technique′[J]. Ultrasound Obstet Gynecol, 2013, 42(4):434-439. doi: 10.1002/uog.12492. pmid: 23616360
[29]	Slaghekke F, Lopriore E, Lewi L, et al. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial[J]. Lancet, 2014, 383(9935):2144-2151. doi: 10.1016/S0140-6736(13)62419-8. pmid: 24613024
[30]	Miller JL, Block-Abraham DM, Blakemore KJ, et al. Preoperative Ultrasound Prediction of Essential Landmarks for Successful Fetoscopic Laser Treatment of Twin-Twin Transfusion Syndrome[J]. Fetal Diagn Ther, 2019, 45(5):295-301. doi: 10.1159/000489119. pmid: 29874646