Reply

Abstract

We note the comments made by Moise and colleagues regarding our study, ‘Fetoscopic laser ablation of placental anastomoses in twin–twin transfusion syndrome using ‘Solomon technique’, published in this journal last year1, and welcome the opportunity to provide further information about our study. Moise et al. stated that their esteemed colleagues at Leiden University (Enrico Lopriore et al.) described the Solomon method 3 years earlier than did Chalouhi et al.. We would like to point out that there was never a claim of primacy regarding the Chalouhi et al. study2 made in our article. Enrico Lopriore et al.3 may well have been the first to use the term. Moise et al. make the statement that: ‘Most laser centers in such large countries as the USA and Brazil serve a large referral population base with great geographic distribution. As such, complete perinatal follow-up is difficult.’ While we cannot make sweeping statements about the type of follow-up offered by their center or that offered by ‘most laser centers in large countries’, we do pride ourselves on our own efforts to obtain this information for our patients, regardless of their geographic origin. While it may be difficult, it can certainly be done, and we follow all our post-laser patients closely with Doppler studies after surgery, in some cases performed by the referring physicians, and in others (more local) by ourselves. In the patients involved in our study none was lost to follow-up. As requested, in Table 1, we have provided further information about the six cases that developed twin anemia-polycythemia sequence (TAPS). The ‘Solomon technique’ was not performed in any of these patients. As demonstrated in Table 1, all had Doppler studies confirming the diagnosis of TAPS4. Three of these patients had an anterior placenta and three had a posterior placenta. Intrauterine fetal blood transfusion was performed in one case (Case 1). In four of the six cases, the TAPS was diagnosed late and all four were delivered by preterm Cesarean section. One patient had twin demise in utero and the classic features of anemia and plethora were confirmed at delivery but no hemoglobin values could be obtained. The remaining five twin sets had postnatal confirmation of an intertwin hemoglobin difference > than 8 g/dL. Regarding the number of ‘unsuccessful’ cases of complete ‘Solomonization’, we did not receive all of the placentae for pathological examination and so cannot be sure. This was, unfortunately, one of the limitations of our study. Moise et al. stated that: ‘The dual neonatal survival rate in the control group was 46%, a rate that is lower than that reported by other experienced centers’. We note that Moise and his colleagues have not supplied us with their dual fetal survival prior to their adoption of the Solomon technique, but we are reasonably sure that it was very similar to that reported in our paper, and that reported by another USA center (50.7%)5. The surgeons who operated on the cases in our study were experienced and were not new to laser surgery6. Thus, we feel that the improvement in dual survival that we, and others7, have shown following adoption of the Solomon technique is most probably due to the benefits of the technique itself, and not due to increasing experience of the operators. In fact, the results of one of our trainees, who learned to perform laser therapy using only the Solomon technique, show dual survival of 70% (14/20) for his first 20 cases (pers. comm.), which suggests that good results are possible even during the learning curve using this technique. His cases were all performed after July 2012. This result compares favorably with that reported by the experienced operators in Moise's group (75%)8. Given that our study was not a randomized controlled trial, and that the two techniques were employed sequentially in our study, the question is still valid, and is one that, hopefully, will be answered soon by the randomized controlled trial that is underway. R. Ruano*†, C. Rodo‡, J. L. Peiro‡, A. A. Shamshirsaz†, S. Haeri†, M. L. Nomura§, E. M. A. Salustiano§, K. K. De Andrade§, H. Sangi-Haghpeykar†, E. Carreras‡ and M. A. Belfort† †Baylor College of Medicine and Texas Children's Hospital, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Houston, TX, USA; ‡Hospital Universitari Vall d'Hebron and University Autonoma de Barcelona, Fetal Surgery Program, Barcelona, Spain; §Maternal-Fetal Institute in Campinas, Campinas, Brazil *Correspondence. Pavilion for Women – Texas Children's Fetal Center, 6651 Main Street, Suite F1020, Houston, TX 77030, USA (e-mail: ruano@bcm.edu; rodrigoruano@hotmail.com)