Endoscopic Laser Coagulation Research Articles

Development of Novel Balloon-Integrated Optical Catheter for Endoscopic and Circumferential Laser Application.

The current study aims to demonstrate the feasibility of a novel balloon-integrated optical catheter (BIOC) to achieve endoscopic laser application for circumferential coagulation of a tubular tissue structure. Both optical and thermal numerical simulations were developed to predict the propagation of laser light and a spatio-temporal distribution of temperature in tissue. Ex vivo esophagus tissue was tested with 980nm laser light at 30 W for 90s for quantitative evaluations. In vivo porcine models were used to validate the performance of BIOC for circumferential and endoscopic laser coagulation of esophagus in terms of acute tissue responses post-irradiation. Optical simulations confirmed that a diffusing applicator was able to generate a circumferential light distribution in a tubular tissue structure. Both numerical and experimental results presented that the maximum temperature elevation occurred at 3-5mm (muscle layer) below the mucosa surface after 90 s irradiation. In vivo tests confirmed the circumferential delivery of laser light to a deep muscle layer as well as no evidence of thermal damage to the esophageal mucosa. The proposed BIOC can be a feasible optical device to provide circumferential laser irradiation as well as endoscopic coagulation of tubular esophagus tissue for clinical applications.

Dual emission endoscopic laser vs argon plasma coagulation in treatment of gastrointestinal angiodysplasia: a single-center experience.

Dual emission endoscopic laser vs argon plasma coagulation in treatment of gastrointestinal angiodysplasia: a single-center experience.

Increased risk of placental abruption after solomon laser treatment of twin-twin transfusion syndrome

To evaluate the relative risk of placental abruption in monochorionic (MC) twin pregnancies complicated with twin-to-twin transfusion syndrome (TTTS) and treated with endoscopic laser coagulation of placental vessels (ELCPV).A retrospective analysis from January 2004 and December 2015 of 373 TTTS pregnancies, treated with selective ELCPV until January 2012 (287 cases), after which the Solomon technique was introduced (86 cases), compared with 243 normal MC pregnancies.A significant improvement in perinatal survival was observed after the introduction of the Solomon technique when compared to the selective procedure (77% vs 54%, p < 0.001).The rate of placental abruption was 1% (3/243) in normal MC pregnancies, 6% (21/373) in TTTS group, increased with Solomon technique (12/86, 14%, vs 9/287, 3%, p < 0.001).MC twin pregnancies treated with laser coagulation of placental vascular anastomoses could be at increased risk of placental abruption, especially when the Solomon technique is used.

Endoscopic Placental Laser Coagulation in Dichorionic and Monochorionic Triplet Pregnancies

Objective: To report the outcome of monochorionic (MC) and dichorionic (DC) triamniotic (TA) triplet pregnancies treated with endoscopic laser coagulation of the communicating placental vessels for severe feto-fetal transfusion syndrome (FFTS) and selective fetal growth restriction (sFGR). Methods: Laser surgery was performed at 18 (15-24) weeks' gestation in 11 MCTA and 33 DCTA pregnancies complicated by FFTS and 14 DCTA pregnancies complicated by sFGR. Data from our study and previous reports were pooled using meta-analytic techniques. Results: Survival of at least one baby and survival among all fetuses was 97.0 and 72.7% in DCTA pregnancies with FFTS, 78.6 and 52.4% in DCTA pregnancies with sFGR and 81.8 and 39.4% in MCTA pregnancies with FFTS. In the combined data from our study and previous reports, the pooled survival rates in 132 DCTA pregnancies with FFTS were 94.4 and 76.1%, and in 29 MCTA pregnancies with FFTS, they were 80.6 and 57.5%. Conclusions: Survival after laser surgery is higher in DC triplets with FFTS than in those with sFGR and in DC than in MC triplets with FFTS.

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

Postnatal survival after endoscopic equatorial laser for the treatment of twin-to-twin transfusion syndrome

Endoscopic laser coagulation of placental anastomoses is the first-line treatment for severe twin-to-twin transfusion syndrome. A recent randomized controlled trial reported that laser coagulation along the entire vascular equator was associated with a similar dual survival and survival of at least 1 twin compared with the group that was treated with the selective technique. In addition, there was a significantly lower incidence of postoperative recurrence of twin-to-twin transfusion syndrome and the development of twin anemia-polycythemia sequence in the equatorial group. The purpose of this study was to report on neonatal survival in twin-to-twin transfusion syndrome pregnancies that were treated with endoscopic laser therapy with the use of the equatorial technique and to examine the relationship between preoperative factors and twin loss. Endoscopic equatorial laser therapy was carried out as the primary treatment for twin-to-twin transfusion syndrome in all consecutive monochorionic diamniotic twin pregnancies that were referred at a single fetal surgery Center over a 4-year period. All visible placental anastomoses were coagulated; additional laser ablation of the placental tissue between the coagulated vessels was carried out. Pre-laser ultrasound data, periprocedural complications, pregnancy outcome, and postnatal survival at hospital discharge were recorded and analyzed. A total of 106 pregnancies were treated during the study period. Median gestational age at laser therapy was 19.7 weeks (range, 15.1-27.6 weeks). There was postoperative recurrence of twin-to-twin transfusion syndrome or the development of twin anemia-polycythemia sequence in 2 (1.9%) and 2 (1.9%) cases, respectively. The survival rates of both and at least 1 twin were 56.6% and 83.0%, respectively. Donor survival was significantly lower compared with the recipient co-twin (64.2% vs 75.5%, respectively; P < .05). The rate of fetal death, which was the most common cause of twin loss, was significantly higher in donors compared with recipient fetuses (23.6% vs 10.4%, respectively; P < .05). In cases with absent or reversed end-diastolic velocity in the donor umbilical artery, dual and donor survival rates were significantly lower compared with the remaining twin-to-twin transfusion syndrome pregnancies (40.0% vs 64.8% and 40.0% vs 76.1%, respectively; P < .05). There were no significant differences between the 2 groups in the survival of at least 1 twin and in the recipient survival. Endoscopic equatorial laser therapy was associated with a survival of both and at least 1 twin of approximately 55% and 83%, respectively, with a low rate of recurrent twin-to-twin transfusion syndrome and twin anemia-polycythemia sequence. In addition, the preoperative finding of abnormal donor umbilical artery Doppler on ultrasound identified a subgroup of twin-to-twin transfusion syndrome pregnancies with a lower dual survival rate caused by increased intrauterine deaths of donor twins.

Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management.

Cystitis and proctitis are defined as inflammation of bladder and rectum respectively. Haemorrhagic cystitis is the most severe clinical manifestation of radiation and chemical cystitis. Radiation proctitis and cystitis are major complications following radiotherapy. Prevention of radiation-induced haemorrhagic cystitis has been investigated using various oral agents with minimal benefit. Bladder irrigation remains the most frequently adopted modality followed by intra-vesical instillation of alum or formalin. In intractable cases, surgical intervention is required in the form of diversion ureterostomy or cystectomy. Proctitis is more common in even low dose ranges but is self-limiting and improves on treatment interruption. However, treatment of radiation proctitis is broadly non-invasive or invasive. Non-invasive treatment consists of non-steroid anti-inflammatory drugs (NSAIDs), anti-oxidants, sucralfate, short chain fatty acids and hyperbaric oxygen. Invasive treatment consists of ablative procedures like formalin application, endoscopic YAG laser coagulation or argon plasma coagulation and surgery as a last resort.

Color-dye injection of monochorionic placentas and correlation with pregnancy complications

IntroductionVascular anastomoses in monochorionic (MC) twin placenta can be easily identified with color-dye injection. The aim of this study is to analyze the relationship between different type of anastomoses and twin pregnancy complications. MethodsFrom January 2011 to October 2014, MC placentas were analyzed with color-dye injection and five group of pregnancies were identified: those that were not complicated (NC), those complicated with selective intrauterine growth restriction (sIUGR), twin–twin transfusion syndrome (TTTS), or twin anemia-polycitemia sequence (TAPS) and those with amniotic fluid discordance (AFD) between twins. Cases of TTTS treated with endoscopic laser coagulation of placenta anastomoses or cases with in utero death of one twin were excluded. ResultsA total of 118 MC placentas were observed, 58 (49%) NC, 35 (30%) sIUGR, 10 (8%) TTTS, 13 (11%) AFD and 2 (2%) TAPS. The median number of anastomoses was 7 (range 1–15), 8 (2–18), 4 (2–11), 7 (2–13) and 1 (1–1), respectively. At least one artero-venous anastomoses was found in the placenta observed, while the prevalence of artero-arterial anastomoses was 95% for NC, 91% for sIUGR, 60% for TTTS, and 77% for AFD; no TAPS placenta had this type of anastomoses. The diameter of arteroarterial anastomoses was greater in the AFD group (3.3 mm), compared to the NC, sIUGR and TTTS groups (2.3, 2.5 and 1.4 respectively, p 0.04). DiscussionIn this large serie of MC placenta analyzed with color-dye injection, a specific distribution of anastomoses emerged for twins with amniotic fluid discordance, which points to a need for intensive surveillance.

Endoscopic Placental Laser Coagulation in Monochorionic Diamniotic Twins with Type II Selective Fetal Growth Restriction

Objective: To determine predictors of survival in monochorionic diamniotic twins with selective fetal growth restriction type II (sFGR-II), with or without twin-to-twin transfusion syndrome (TTTS), treated by endoscopic placental laser coagulation. Methods: Laser surgery was performed at 20 (15-27) weeks' gestation in 405 cases of sFGR-II with and 142 without coexisting TTTS. Multivariable logistic regression analysis was performed to determine significant predictors of survival to discharge from hospital. Results: There was survival of the small twin in 216 (39.5%) and of the large twin in 379 (69.3%) cases. Significant predictors of survival of both the small and larger twin were ductus venosus Doppler findings in the small twin, gestational age at laser and cervical length, but not the presence of TTTS or Doppler findings in the large twin. Conclusions: In sFGR-II, survival after laser surgery is primarily dependent on the condition of the small twin.

Optimal Method and Timing of Intrauterine Intervention in Twin Reversed Arterial Perfusion Sequence: Case Study and Meta-Analysis

Introduction: The objective of this study was to define the optimal method and timing of intervention in twin reversed arterial perfusion (TRAP) sequence. Material and Methods: During a period of 20 years (1993-2013), we performed endoscopic laser coagulation of umbilical cord vessels or intrafetal laser in 67 pregnancies with TRAP sequence. These data were combined with those reported in the literature to determine the survival rate of the pump twin for different methods and timing of interventions. Results: A variety of techniques were used to interrupt the blood supply to the acardiac twin. Most procedures were performed at or after 16 weeks, and with most methods the survival rate of the pump twin was about 80%. Good results were also obtained for triplet pregnancies. In 18 of 30 cases (60%) diagnosed at 11-14 weeks, there was spontaneous cessation of flow in the acardiac twin before planned intervention at 16-18 weeks, and in 11 of these (61.1%) the pump twin died or suffered brain damage. In 103 pregnancies treated by intrafetal laser at 12-27 weeks, there was no correlation between gestational age at treatment and survival rate, but there was an inverse association between gestational age at treatment and gestational age at birth. Discussion: In TRAP sequence, survival may be improved by elective intervention at 12-14 weeks.

Interventions for the treatment of twin-twin transfusion syndrome.

Twin-twin transfusion syndrome, a condition affecting monochorionic twin pregnancies, is associated with a high risk of perinatal mortality and morbidity. A number of treatments have been introduced to treat the condition but it is unclear which intervention improves maternal and fetal outcome. The objective of this review was to evaluate the impact of treatment modalities in twin-twin transfusion syndrome. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Randomised and quasi-randomised studies of amnioreduction versus laser coagulation, septostomy versus laser coagulation or septostomy versus amnioreduction. Two review authors independently assessed eligibility and extracted data. We contacted study authors for additional information. Three studies (253 women and 506 babies) were included. All three trials were judged to be of moderate quality. One study compared amnioreduction with septostomy (71 women), whilst the other two studies compared amnioreduction with endoscopic laser coagulation (182 women). Not all trials provided outcome data that could be included in all meta-analyses. Amnioreduction compared with laser coagulation Although there was no difference in overall death between amnioreduction and laser coagulation (average risk ratio (RR) 0.87; 95% confidence interval (CI) 0.55 to 1.38 adjusted for clustering, two trials) or death of at least one infant per pregnancy (RR 0.91; 95% CI 0.75 to 1.09, two trials), or death of both infants per pregnancy (average RR 0.76; 95% 0.27 to 2.10, two trials), more babies were alive without neurological abnormality at the age of six years in the laser group than in the amnioreduction groups (RR 1.57; 95% CI 1.05 to 2.34 adjusted for clustering, one trial). There were no significant differences in the babies alive at six years with major neurological abnormality treated by laser coagulation or amnioreduction (RR 0.97; 95% CI 0.34 to 2.77 adjusted for clustering, one trial). Outcomes for death in this 2013 update are different from the previous 2008 update, where improvements in perinatal death and death of both infants per pregnancy were shown in the laser intervention arm. The NIHCD trial included in this update exerts an opposite direction of effects to the Eurofetus study, which was previously the only included laser study, hence the difference in outcome. Amnioreduction compared with septostomy There are no differences in overall death (RR 0.83; 95% CI 0.47 to 1.47, adjusted for clustering, one trial), death of at least one infant per pregnancy (RR 0.80; 95% CI 0.48 to 1.35, one trial), or death of both infants per pregnancy (RR 0.90; 95% CI 0.37 to 2.22, one trial) or gestational age at birth (RR 1.20; 95% CI -0.81 to 3.21, one trial) between amnioreduction and septostomy. Endoscopic laser coagulation of anastomotic vessels should continue to be considered in the treatment of all stages of twin-twin transfusion syndrome to improve neurodevelopmental outcomes.Further research targeted towards assessing the effect of treatment on milder (Quintero stage 1 and 2) and more severe (Quintero stage 4) forms of twin-twin transfusion syndrome is required. Studies should aim to assess long-term outcomes of survivors.

Treatment of twin to twin transfusion syndrome – comparison of two therapeutic methods – amnioreduction and lasertherapy

Twin to twin transfusion syndrome occurs in 15% of monochorionic twin pregnancies. Untreated, TTTS has been reported to have a mortality of nearly 100%. Two main therapies include serial amnioreduction and fetoscopic laser coagulation for the vascular anastomoses. The aim of the project was to investigate the optimal diagnostic and therapeutic procedure in pregnancies complicated by TTTS. Additionally the study was supposed to compare non-invasive and invasive methods of treatment and to show antenatal and postnatal follow - up to 4 months of age. 42 pregnant women with twin-to-twin transfusion syndrome were assigned to laser therapy using diode laser and 33 pregnant women underwent only several amnioreductions. Selected parameters characterizing the pregnancy were compared in both groups. In the amnioreduction group, the perinatal survival rate seven days after the delivery was 31.8%. The survival rate of at least one twin was 39.4%. As compared to the amnioreduction group, in the laser group the survival rate of at least one twin was observed in 31 cases (31/42) and it was equal to 74%. Neurological complications in the amninoreduction group were observed in 19% (4/21) of cases, in the laser group and in 5% (2/40) of neonates at 4 months of age. Currently the preferred and only method that addresses the cause of the disease is the endoscopic laser coagulation of anastomoses. Comparison of the two treatments shows better outcomes with higher survival rates and minor neurological defects in cases treated with laser coagulation.

P09.19: Feasibility of fetoscopic laser surgery for twin amniotic fluid discordance

Objectives: Twin to twin transfusion syndrome occurs In 15% of monochorionic twin pregnancies. Untreated, TTTS has traditionally been quoted to have a mortality of nearly 100%. The aim of the project was the investigation of the most optimal way of the diagnostic and therapeutic procedure in pregnancies complicated with TTTS and show antenatal and postnatal follow-up with at least 12 months of age. Methods: 64 pregnant women with twin to twin transfusion syndrome were assigned to laser therapy using diode laser. They underwent laser procedure at mean gestational age of 22 weeks of gestation at Quintero stages II–IV. Fetal echocardiography was performed before and after laser procedure; chosen parameters characterizing pregnancy were detailed described and analysed. Results: Survival rate of at least one twin was observed in 48 cases /48/64/ /considering at least 12 months follow-up/and it was equal to 75%. Neurological complications were observed in 4% /3/64/ in neonates at 6 months of age. Conclusions: Currently, preferred and the only method, which touches the cause of disease is endoscopic laser coagulation of anastomoses.

Long-term morbidity after fetal endoscopic surgery for severe twin-to-twin transfusion syndrome

Background/Purpose Severe twin-to-twin transfusion syndrome (TTTS) leads to 80% to 100% dual mortality. Endoscopic laser coagulation of connecting vessels improves outcome to 80% survival of at least 1 twin. There is limited long-term follow-up of surviving TTTS patients. The aim of this study was to analyze gestational age-stratified, long-term morbidity in these patients. Methods A retrospective case-control study of TTTS surviving patients (38 patients, 72% follow-up rate) from one center. Perinatal and pediatric records were reviewed, and outcomes were compared with published reports and gestational age-matched controls. Results Forty percent (15/38) had at least 1 major sequela, all but 6 of which were fully resolved at a median follow-up of 4.4 years. There were no permanent cardiac, genitourinary, renal, or respiratory sequelae. All major complications were in patients born <29 weeks. There were no significant differences in complications between this cohort of patients and gestational age (GA)-matched control patients. Conclusions The long-term morbidity of monochorionic twins after fetal laser surgery for severe TTTS is 13%. At a median follow-up of more than 4 years, these children fare no worse than gestational age-matched, non-operated twins and singletons. The degree of prematurity at birth is the best predictor of temporary or permanent sequela in this group of patients.

Endoscopic laser coagulation following amnioreduction for the management of a large placental chorioangioma

Endoscopic laser coagulation following amnioreduction for the management of a large placental chorioangioma

Is it Safe to Use Aluminum in the Treatment of Pediatric Hemorrhagic Cystitis?

In pediatric oncology patients, hemorrhagic cystitis can be a life-threatening complication of bone marrow transplantation, chemotherapy, and radiation therapy. The treatment of this condition is often challenging and includes intravesical irrigation with aluminum, embolization, endoscopic laser coagulation, hydrostatic pressure, use of hyperbaric oxygen, instillation of formalin, prostaglandins, and oral sodium pentosan polysulfate. Although the efficacy of aluminum irrigation is well documented for the management of hemorrhagic cystitis in adults, there are limited reports describing its use in children. The potential multisystem toxic effects of aluminum are well described and the range and progression of aluminum toxicity can be devastating. We report a case of a 9-year-old girl suffering from acute lymphocytic leukemia with hemorrhagic cystitis. Although the symptoms resolved after intravesical aluminum treatment, she developed significant aluminum toxicity. We have reviewed the literature relating to aluminum toxicity in the pediatric age group and present our recommendations for the effective and safe use of aluminum in this cohort of patients.

Endoscopic laser coagulation of feeding vessels in large placental chorioangiomas: report of three cases and review of invasive treatment options

To report three cases of large placental chorioangiomas managed with endoscopic laser coagulation of the feeding vessels, and review the literature regarding cases of chorioangioma treated with invasive techniques. Intrauterine endoscopic surgery was performed using a 2.5-mm fetoscope under epidural anesthesia. Coagulation of the feeding vessels was attempted with laser energy, and the operation was completed with amniodrainage. The feeding vessels were successfully coagulated in one case, resulting in a term delivery. Histopathologic examination of the placenta confirmed a capillary chorioangioma with extensive necrosis. There were intraoperative complications in the other two cases, including bleeding at the site of coagulation requiring intrauterine transfusion in one, and incomplete vascular ablation in the other. In the former case the infant was born prematurely and developed chronic renal insufficiency. In the latter, the fetus died within the first week of the surgery. There are limited interventions available for the management of large, symptomatic placental chorioangiomas. Although they can be treated with endoscopic laser coagulation of the feeding vessels, fetal bleeding, exsanguination, and death are potential complications of the procedure; therefore, this technique should be used with caution. The role of this treatment modality in the early devascularization of placental chorioangiomas prior to the development of significant complications warrants consideration.

390: Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome (TTTS) in the eurofoetus trial

390: Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome (TTTS) in the eurofoetus trial

Interventions for twin–twin transfusion syndrome: a Cochrane review

We performed a Cochrane review to assess which of the treatments for twin-twin transfusion syndrome (TTTS) improves fetal, childhood and maternal outcomes. This article represents a version of the review which includes additional data to the published version. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2007) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, October 2007) for randomized and quasi-randomized studies of amnioreduction, laser coagulation and septostomy and compared their outcomes. We also searched conference proceedings and contacted the authors of published trials for clarification and additional data. No trials compared intervention with no intervention. Three studies (253 women) were included. Laser coagulation resulted in less overall death (48% vs. 59%; relative risk (RR), 0.81; 95% CI, 0.65-1.01 adjusted for clustering; two trials, 364 fetuses), perinatal death (26% vs. 44%; RR, 0.59; 95% CI, 0.40-0.87 adjusted for clustering; one trial, 284 fetuses) and neonatal death (8% vs. 26%; RR, 0.29; 95% CI, 0.14-0.61 adjusted for clustering; one trial, 284 fetuses) when compared with amnioreduction. There was no difference in perinatal outcome between amnioreduction and septostomy. More babies were alive without neurological abnormality at the age of 6 months in the laser group than in the amnioreduction group (52% vs. 31%; RR, 1.66; 95% CI, 1.17-2.35 adjusted for clustering; one trial). There was no difference in the proportion of babies alive at 6 months that had undergone treatment for major neurological abnormality between the laser coagulation and the amnioreduction groups (4% vs. 7%; RR, 0.58; 95% CI, 0.18-1.86 adjusted for clustering; one trial). The results suggest that endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of TTTS to improve perinatal and neonatal outcome.

A definition of selectivity in laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome and its relationship to perinatal outcome

This study was undertaken to correlate selectivity of surgery and perinatal outcome in twin-to-twin transfusion syndrome treated by endoscopic laser coagulation, using a quantitative definition of selectivity. 287 consecutive cases of severe twin-to-twin transfusion syndrome were reviewed. A selectivity index was built as the ratio of selective over nonselective coagulations per procedure. Outcome measures were survival at 28 days and failure of surgery as defined by recurrence of twin-to-twin transfusion syndrome or fetofetal hemorrhage. Two populations were identified: a high selectivity group (63.8%) and a low selectivity group (36.2%). Survival of at least one twin and survival of both twins were higher in the high-selectivity group (p = .007 and p = .04 respectively). Failure of surgery rates were similar in both groups. A quantitative definition of selectivity appears justified by the large variations found in the practice of a single center and by significant differences in outcome. Survival is significantly improved in highly selective procedures.