Secuencia de perfusión arterial reversa en embarazo gemelar; coagulación de arteria nutricia. Reporte del primer caso en el país / Twin reversed arterial perfusion sequence; coagulation of the umbilical cord. A report on the first case in Uruguay / Seqüência reversa de perfusão arterial na gravidez gemelar; coagulação da artéria nutritiva. Relato do primeiro caso no país

Resumen: La secuencia de perfusión arterial reversa (TRAP) es una complicación muy poco frecuente y grave de los embarazos gemelares monocoriónicos. Generalmente ocurre cuando el corazón de un gemelo de apariencia normal sirve como bomba para uno o más gemelos dismórficos cuya cabeza, órganos torácicos y extremidades superiores no se desarrollan completamente o no se desarrollan en absoluto y, por lo tanto, carecen de actividad cardíaca. La arquitectura placentaria vascular anómala provoca un cambio en el flujo arterial hacia el gemelo acardíaco. Los mecanismos fisiopatológicos exactos que conducen a este fenómeno devastador no se conocen bien. Compartiremos el caso clínico de una paciente de 19 años, cursando un embarazo gemelar monocorial monoamniótico, en que realizamos diagnóstico de TRAPS, y realizamos la coagulación laser de la arteria nutricia del feto acárdico.

Abstract: Twin reversed arterial perfusion sequence (TRAPS) is rather an unusual and severe complication of monochorionic twin pregnancies. It usually occurs when the normal-appearance heart of a twin acts as a pump for one or more dysmorphic twins whose head, thoracic organs and upper limbs fail to totally develop or do not develop at all and thus, have no cardiac activity. The abnormal vascular architecture at the placenta changes the arterial flow towards the acardiac twin. The exact pathophysiological mechanisms that result in this devastating phenomenon are still unknown. The study presents the clinical case of a 19-year- old patient pregnant with monoamniotic, monochorionic twins and a diagnosis of TRAPS, treated by laser coagulation of the acardiac twin's umbilical cord.

Resumo: A seqüência reversa de perfusão arterial (TRAPS) é uma complicação muito rara e grave de gestações gemelares monocoriônicas. Geralmente ocorre quando o coração de um gêmeo de aparência normal serve como uma bomba para um ou mais gêmeos dismórficos cuja cabeça, órgãos torácicos e membros superiores não se desenvolvem totalmente ou não se desenvolvem e, portanto, não têm atividade cardíaca. A arquitetura vascular placentária anormal causa uma mudança no fluxo arterial para o gêmeo acardíaco. Os mecanismos fisiopatológicos exatos que levam a esse fenômeno devastador não são bem compreendidos. Descrevemos o caso clínico de uma paciente de 19 anos, portadora de gestação gemelar monocoriônica monoamniótica, na qual fizemos o diagnóstico de TRAPS e realizamos coagulação a laser da artéria nutritiva do feto acardíaco.

Onset of brain injury in infants with prenatally diagnosed congenital heart disease.

BACKGROUND: The exact onset of brain injury in infants with congenital heart disease (CHD) is unknown. Our aim was, therefore, to assess the association between prenatal Doppler flow patterns, postnatal cerebral oxygenation and short-term neurological outcome. METHODS: Prenatally, we measured pulsatility indices of the middle cerebral (MCA-PI) and umbilical artery (UA-PI) and calculated cerebroplacental ratio (CPR). After birth, cerebral oxygen saturation (rcSO2) and fractional tissue oxygen extraction (FTOE) were assessed during the first 3 days after birth, and during and for 24 hours after every surgical procedure within the first 3 months after birth. Neurological outcome was determined preoperatively and at 3 months of age by assessing general movements and calculating the Motor Optimality Score (MOS). RESULTS: Thirty-six infants were included. MOS at 3 months was associated with MCA-PI (rho 0.41, P = 0.04), UA-PI (rho -0.39, P = 0.047, and CPR (rho 0.50, P = 0.01). Infants with abnormal MOS had lower MCA-PI (P = 0.02) and CPR (P = 0.01) and higher UA-PI at the last measurement (P = 0.03) before birth. In infants with abnormal MOS, rcSO2 tended to be lower during the first 3 days after birth, and FTOE was significantly higher on the second day after birth (P = 0.04). Intraoperative and postoperative rcSO2 and FTOE were not associated with short-term neurological outcome. CONCLUSION: In infants with prenatally diagnosed CHD, the prenatal period may play an important role in developmental outcome. Additional research is needed to clarify the relationship between preoperative, intra-operative and postoperative cerebral oxygenation and developmental outcome in infants with prenatally diagnosed CHD.

Local anatomy around terminal ureter related to the anterior leaf of the vesicouterine ligament in radical hysterectomy.

OBJECTIVES: Radical hysterectomy is performed for invasive cervical cancer. In this surgery, separation of the anterior leaf and posterior leaves of the vesicouterine ligament (VUL) is important. We studied the local anatomy of the anterior leaf of the VUL, especially the branches of the umbilical artery from the view point of surgery and cadaver dissection. STUDY DESIGN: We observed the cervicovesical blood vessels and the connective tissue layer continued from umbilical artery and searched for the origin of the cervicovesical blood vessels in radical hysterectomy. We also dissected a formalin-fixed female cadaver, and observed the same points. RESULTS: After separation of the connective tissue of urinary bladder from the cervical fascia, we could discern the outline of the distal ureter near the ureterovesical junction. We separate the connective tissue of the so-called anterior leaf of the VUL enwrapping the ureter gently, and then the ureter with the connective tissue is completely rolled out laterally. We identified a cervicovesical vessel crossing over the ureter. We looked for the central side of the cervicovesical vessel and found that cervicovesical vessel was a branch of the superior vesical artery. And, during cadaver dissection, we found that the connective tissue and the branches of the superior vesical artery were similarly observed. CONCLUSIONS: We found the precise anatomy of the connective tissue layer from umbilical artery to urinary bladder and the superior vesical artery. Our procedure based on the precise anatomy obtained in this study is reasonable anatomically as a method for separation of the vesicouterine ligament during radical hysterectomy.

Endovascular Management of a Large Persistent Sciatic Artery Aneurysm.

The persistent sciatic artery (PSA) is a remnant of the fetal circulatory system that is preserved in less than 0.1% of the population. Up to 60% of patients with this vascular anomaly will go on to development of a PSA aneurysm (PSAA), which can produce a variety of symptoms including neuropathy, claudication, and acute limb-threatening ischemia. Historical management is by open operation and interposition grafting, which can be highly morbid. We describe successful management of a large, symptomatic PSAA by endovascular stent grafting with intermediate term follow-up.

Anatomical description of the umbilical arteries and impact of their ligation on pelvic and perineal vascular supply after cystectomy in women.

OBJECTIVE: In radical cystectomy, the surgeon generally ligates the umbilical artery at its origin. This artery may give rise to several arteries that supply the sexual organs. Our aim was to evaluate pelvic and perineal devascularisation in women after total cystectomy. PATIENTS AND METHODS: We carried out a prospective anatomical and radiological study. We performed bilateral pelvic dissections of fresh adult female cadavers to identify the dividing branches of the umbilical artery. In parallel, we examined and compared the pre- and postoperative imaging investigations [magnetic resonance imaging (MRI) angiography] in patients undergoing cystectomy for benign disease to quantify the loss of pelvic vascularisation on the postoperative images by identifying the occluded arteries. RESULTS: The anatomical study together with the radiological study visualised 35 umbilical arteries (n = 70) with their branching patterns and collateral arteries. The uterine artery originated from the umbilical artery in more than 75% of cases (n = 54) of the internal pudendal artery in 34% (n = 24) and the vaginal artery in 43% (n = 30). The postoperative MRI angiograms showed pelvic devascularisation in four patients. Devascularisation was dependent on the level of surgical ligation. In the four patients with loss of pelvic vascular supply, the umbilical artery had been ligated at its origin. CONCLUSION: The umbilical artery gives rise to various branches that supply the pelvis and perineum. If the surgeon ligates the umbilical artery at its origin during total cystectomy, there is a significant risk of pelvic and perineal devascularisation.

Transumbilical arterial embolization of a large dural arteriovenous fistula in a low-birth-weight neonate with congestive heart failure.

PURPOSE: The purpose of this study was to report transumbilical arterial embolization of a large dural arteriovenous fistula (AVF) in a low-birth-weight neonate with congestive heart failure (CHF). CASE PRESENTATION: A female neonate was delivered by cesarean section at 31 weeks of gestation. Her birth weight was 1538 g and Apgar scores were 6 at both 1 and 5 min. Because of dyspnea and retracted respiration immediately after birth, she required mechanical ventilation. Ultrasound revealed right cardiac overload and a large cystic mass at the posterior brain. Magnetic resonance imaging on day 1 showed a large dural AVF (dural sinus malformation with arteriovenous (AV) shunts) at the torcular herophili. Umbilical artery and vein catheterization were performed on the same day for neurointervention. CHF prompted emergency embolization on day 8. The transfemoral arterial route could not be used because of its small size and compromised femoral artery blood flow. Transumbilical arterial embolization shrank the AV shunts markedly, resulting in clinical improvement, thus requiring no further intervention. Follow-up angiography at 4 months confirmed no residual AVF. Her growth and development were normal at the last follow-up at age 4 years. CONCLUSION: This patient apparently was the lowest birth weight neonate with a large AVF successfully treated by embolization, which is usually performed through the transfemoral arterial route. The transumbilical arterial route is an alternative for neonates with birth weight <2000 g and very small femoral arteries.

Cord Occlusion in Monochorionic Twins with Early Selective Intrauterine Growth Restriction and Abnormal Umbilical Artery Doppler: A Consecutive Series of 90 Cases.

OBJECTIVE: To describe perinatal outcomes achieved with cord occlusion (CO) in monochorionic twins with severe selective intrauterine growth restriction (sIUGR) and abnormal umbilical artery Doppler in the IUGR twin (types II and III). METHODS: We studied a consecutive series of 90 cases of sIUGR with abnormal Doppler treated with CO of the IUGR fetus. Abnormal Doppler was defined as continuous (type II, n = 41) or intermittent (type III, n = 49) absent/reversed end-diastolic flow. All cases presented at least one of the following severity criteria: gestational age (GA) <22 weeks, inter-twin estimated weight discordance >35%, reversed end-diastolic umbilical artery flow or ductus venosus pulsatility index >95th centile. We prospectively recorded pregnancy course and perinatal outcome. RESULTS: Median GA at surgery was 20.6 weeks and mean duration 22.4 min. Miscarriage (<24 weeks) occurred in 3.3% (3/90) and preterm delivery <32 weeks in 7.1% (6/84) of continuing pregnancies. GA at delivery was 36.4 weeks and neonatal survival of the larger twin was achieved in 93.3%. CONCLUSION: In a consecutive series studied by an experienced team, CO in monochorionic twins with severe sIUGR type II or III was associated with delivery >32 weeks in 92.9% and neonatal survival of the normal twin in 93.3% of pregnancies.

Perinatal survival in cases of twin-twin transfusion syndrome complicated by selective intrauterine growth restriction.

OBJECTIVE: To evaluate the impact of selective intrauterine growth restriction (SIUGR) on monochorionic multiples treated with selective laser photocoagulation of communicating vessels (SLPCVs) for twin-twin transfusion syndrome (TTTS). METHODS: Perinatal survival was compared among TTTS patients with and without SIUGR. The TTTS + SIUGR group was defined as TTTS patients with donor twin weight <10th percentile. Multivariable logistic regression analyses identified factors associated with 30-day survival. RESULTS: Of 369 patients, 65% (N = 241) had TTTS + SIUGR. Thirty-day donor twin survival for the TTTS-only group was 84% versus 75% in the TTTS + SIUGR group (p = 0.0348). Stage III donor involved (stage III donor, donor/recipient) TTTS + SIUGR patients (N = 110) had 66% 30-day donor survival. Multivariable logistic regression demonstrated that the TTTS-only group was twice as likely to achieve donor survival compared to the TTTS + SIUGR group (OR 2.01, 95% CI 1.11-3.66, p = 0.0214). In the TTTS + SIUGR group, patients not classified as stage III donor-involved were twice as likely to achieve donor survival as stage III donor-involved patients (OR 2.02, 95% CI 1.10-3.71, p = 0.0226). CONCLUSIONS: SIUGR, present in two-thirds of TTTS patients, was a risk factor for decreased donor survival. Patients with donor SIUGR and umbilical artery persistent or reversed end-diastolic flow (Quintero Stage III Donor-involved) were especially at risk.

Congenital umbilical arterio-venous malformation: a word of caution.

We report on an 18-month old girl who presented in good clinical shape with a pulsatile tumour in the umbilical area which had a shape and localization similar to that of an umbilical bowel hernia. The Doppler ultrasound of the umbilical tumour revealed a large arterio-venous vascular malformation with a haemodynamically significant blood shunting. Furthermore, the inferior caval vein and the hepatic veins were dilated. Computed tomography angiography revealed permeable umbilical veins and arteries communicating within a large dilated arterio-venous fistula. The growing tumour was excised without any perioperative complications. Further postoperative recovery was uneventful and the baby was discharged 10 days after surgery. We advocate careful antenatal ultrasound evaluation of these vascular malformations. Early surgical removal in newborns is vital in order to avoid severe complications.

[Interstitial laser coagulation in Twin Reversed Arterial Perfusion sequence]. / Mikroinwazyjna laserowa koagulacja naczyn wewnatrzbrzusznych w zespole odwróconej perfuzji tetniczej.

Twin Reversed Arterial Perfusion (TRAP) sequence complicates about 1% of all monochorionic twin pregnancies and about 1 to 35000 of all pregnancies. It involves an acardiac twin whose structural defects are incompatible with life, and an otherwise normal "pump" co-twin. As the blood flow in the acardiac twin is reversed, it keeps on growing owing to the oxygenated blood from the co-twin. Here we report a case of monochorionic, diamniotic twin pregnancy after ICS/-ET complicated with TRAP sequence, diagnosed at 11 weeks of pregnancy The unusual finding in this case was the residual heart in the so called acardiac twin. Gradually the normal twin developed signs of hemodynamic compromise. Reversed a-wave in ductus venosus was observed. The acardiac twin showed subcutaneous oedema. On 24 November 2011 a successful interstitial ultrasound-guided laser coagulation was performed at 16 weeks of gestation. 17G needle and 0.6 mm laser fibre were used. The needle was introduced into the pelvic region of the acardiac twin through the abdominal wall. A series of laser bursts lasting 5-10 seconds were fired, until cessation of blood flow in the pelvic vessels and umbilical cord of the acardiac twin was confirmed using colour Doppler. The course of the intervention was uneventful. Routine steroid therapy was administered at 27 weeks of gestation. At 32 weeks the patient was hospitalized and oral antibiotics were administered due to premature rupture of the membranes and suspicion of intrauterine growth retardation of the pump twin. The patient delivered spontaneously at completed 33 weeks of pregnancy (weight 1805g, Apgar 10). After the delivery a stage 2 intraventricular hemorrhage and jaundice were observed in the neonate. Phototherapy was administered and the mother and the child were eventually discharged from the hospital, both in good general condition. Since then, two more successful interstitial laser coagulations in TRAP sequence were performed in our institution. The essence of the treatment of TRAP sequence is cessation of the blood flow from the pump to the acardiac twin. Fetoscopic cord ligature or coagulation, and laser or radiofreqency ablations of the acardiac twin vessels, are the possible methods of intervention. The interstitial laser coagulation of the acardiac twin is less invasive than fetoscopic umbilical cord coagulation, as the outer diameter of the 17G needle is much smaller. A meticulous comparison of these methods would require a randomised study but at 16 weeks of MCDA twin pregnancy interstitial laser coagulation seems to be the method of choice. The outcome of the procedure and possible treatment options in case of TRAP together with the review of literature, are presented in the article.

Anti-inflammatory therapy in an ovine model of fetal hypoxia induced by single umbilical artery ligation.

Perinatal morbidity and mortality are significantly higher in pregnancies complicated by chronic hypoxia and intrauterine growth restriction (IUGR). Clinically, placental insufficiency and IUGR are strongly associated with a fetoplacental inflammatory response. To explore this further, hypoxia was induced in one fetus in twin-bearing pregnant sheep (n=9) by performing single umbilical artery ligation (SUAL) at 110 days gestation. Five ewes were administered the anti-inflammatory drug sulfasalazine (SSZ) daily, beginning 24h before surgery. Fetal blood gases and inflammatory markers were examined. In both SSZ- and placebo-treated ewes, SUAL fetuses were hypoxic and growth-restricted at 1 week (P<0.05). A fetoplacental inflammatory response was observed in SUAL pregnancies, with elevated pro-inflammatory cytokines, activin A and prostaglandin E(2). SSZ did not mitigate this inflammatory response. It is concluded that SUAL induces fetal hypoxia and a fetoplacental inflammatory response and that SSZ does not improve oxygenation or reduce inflammation. Further studies to explore whether alternative anti-inflammatory treatments may improve IUGR outcomes are warranted.

Validation of Quintero stage III sub-classification for twin-twin transfusion syndrome based on visibility of donor bladder: characteristic differences in pathophysiology and prognosis.

OBJECTIVE: To validate the Quintero stage III subclassification for twin-twin transfusion syndrome (TTTS) based on visibility of the bladder of the donor twin. METHODS: Between July 2002 and August 2006, there were 131 pregnant Japanese women affected by severe TTTS before 26 weeks' gestation, treated with fetoscopic laser surgery at five centers in Japan, whose pregnancies continued beyond 22 weeks. Outcome data were available in all cases and surviving infants were followed up for at least 6 years. This study focused on the Stage III TTTS patients. These were subclassified into Stage III atypical (abnormal Doppler flow with visible donor bladder) and Stage III classical (abnormal Doppler flow with non-visible donor bladder) groups. Perioperative data and postnatal outcomes were compared between the groups. RESULTS: Seven Stage I, 22 Stage II, 82 Stage III and 20 Stage IV pregnancies continued beyond 22 weeks. There was a significantly higher incidence of absent or reversed end-diastolic velocity in the umbilical artery (UA-AREDV) of the donor in Stage III atypical than in Stage III classical patients (83.8% vs. 53.3%, P = 0.004). Stage III atypical cases also had a significantly higher incidence of arterioarterial (AA) anastomoses (72.9% vs. 17.8%, P < 0.001) and intrauterine fetal demise (IUFD) of the donor (43.2% vs. 13.3%, P = 0.002). However, there were no differences in overall survival or in abnormal brain scans of surviving infants. Donors with both UA-AREDV and AA anastomoses had a significantly higher incidence of IUFD compared with the others (53.3%, P < 0.001). CONCLUSIONS: Quintero stage III atypical was characterized by a high incidence of AA anastomoses and UA-AREDV of the donor, resulting in IUFD. Subclassification of Stage III based on visibility of the bladder of the donor twin was adequate for and compatible with differentiating prognosis and pathophysiology.

The role of laser surgery in dissecting the etiology of absent or reverse end-diastolic velocity in the umbilical artery of the donor twin in twin-twin transfusion syndrome.

OBJECTIVE: This study was undertaken to gain insight on the cause of absent or reverse end-diastolic velocity (AREDV) in the umbilical artery (UA) of the donor twin by analysis of individual placental mass and vascular anastomoses in patients with twin-twin transfusion syndrome (TTTS) treated with laser. STUDY DESIGN: TTTS patients who successfully underwent selective laser photocoagulation of communicating vessels (SLPCV), 16 and 26 weeks' gestation, with both twins born alive and complete Doppler and placental data were considered eligible for the study. Doppler examination of the UA was performed before and 24 hours after SLPCV. Abnormal UA Doppler findings were defined as persistent AREDV. Pre- and post-SLPCV UA Doppler results yielded the following 4 groups: (1) normal-normal; (2) normal-abnormal; (3) abnormal-normal; and (4) abnormal-abnormal. The types of vascular anastomoses were categorized during surgery. Individual placental territory (IPT) was defined as individual placental weight divided by total placental weight x 100. RESULTS: There were 132 cases in group 1 and no patients in group 2. AREDV resolved in 78% (28/36) of patients (group 3) and remained unchanged in 22% (8/36) (group 4). The mean IPT-donor in group 4 was significantly smaller than in group 1 (P = .015). Patients with preoperative AREDV (groups 3 and 4) were more likely to have artery-to-artery anastomoses (P = .002). However, AREDV resolved in 57% (16/28) patients without artery-to-artery anastomoses. CONCLUSION: Preoperative AREDV may result from a small IPT, placental vascular anastomoses, or both. AREDV resulting from a small IPT may have a similar cause to that of singletons, and may be inferred by lack of postoperative resolution. Resolution of AREDV after SLPCV implies the presence of an adequate IPT and removal of donor hypotension.

Operative fetoscopy via telesurgery.

We describe a case in which telesurgical consultation from Tampa, Florida, USA was used to accomplish operative fetoscopy in Santiago, Chile for the treatment of a twin pregnancy involving an acardiac twin. The procedure was successful and a healthy infant was delivered at 37.5 weeks. Operative fetoscopy, a surgical approach to correct birth defects in utero via combined ultrasound and endoscopy, is only available in a handful of centers worldwide. Telesurgery makes use of telecommunication to allow a surgeon at a primary operating site to consult with another experienced surgeon for complex surgical cases. This case illustrates the potential for ultrasound and telesurgery to expand the horizons of operative fetoscopy.

Impact of laser coagulation in severe twin-twin transfusion syndrome on fetal Doppler indices and venous blood flow volume.

OBJECTIVE: To evaluate the impact of fetoscopic laser coagulation of placental anastomoses in severe twin-twin transfusion syndrome on fetal Doppler indices and umbilical vein blood flow volume as calculated with Doppler and two-dimensional ultrasound. METHODS: Thirty-two cases of second-trimester severe twin-twin transfusion undergoing laser therapy were examined with serial ultrasound before and 1, 3 and 5 days after therapy. Pulsatility indices in the umbilical artery and ductus venosus were measured. Blood volume flow at the level of the intra-abdominal umbilical vein was calculated by means of Doppler and two-dimensional ultrasound. The development of hydropic signs in donors was recorded. Perinatal outcome in terms of neonatal survival was recorded for all cases. RESULTS: In recipients, ductus venosus pulsatility index decreased progressively after therapy and, by day 5, median pulsatility index was significantly lower than that before therapy (0.97 vs. 0.82, P < 0.0001). Umbilical vein blood flow volume in recipient twins showed no significant variations before and after laser. In donors, umbilical artery pulsatility index decreased significantly by the first day following therapy (2.1 vs. 1.6, P < 0.0001). Previously absent or reverse umbilical end-diastolic flow reappeared after therapy in 46% (7/15) of donors. Ductus venosus pulsatility index in donors increased significantly by day 1 after therapy (0.99 vs. 1.35, P < 0.0001) but, over days 3 and 5, it returned towards preoperative values. Umbilical vein flow volume measurements (mL/min/kg) in the donor increased by approximately 50% the day after treatment (151 vs. 232, P < 0.0001) and remained elevated. Umbilical vein flow volume before laser therapy was significantly lower in donors compared to recipients (151 vs. 260, P < 0.0001), but the difference was non-significant after treatment (240 vs. 267). One or more hydropic signs developed in eight (25%) donors during the 5 days' observation after therapy. CONCLUSIONS: Laser therapy induced important changes in fetal hemodynamic parameters, resulting in a reversion of the disturbances associated with severe twin-twin transfusion syndrome. The recipient twin showed a progressive improvement of previous signs of right cardiac overload. The donor experienced a substantial increase in umbilical vein blood volume flow accompanied by a transitory state of relative right overload, which may explain the development of transient hydropic signs in a proportion of donors.

Use of an endoscopic suturing device for laparoscopic resection of the apex of the bladder and umbilical structures in normal neonatal calves.

OBJECTIVE: To develop a laparoscopic technique using an endoscopic suturing device for the resection of the apex of the bladder and the umbilical structures in large-animal neonates. Study Design-Experimental study. Animals or Sample Population-Seven healthy male Holstein calves. METHODS: A laparoscopic technique for resection of the apex of the bladder was developed on 2 calf cadavers, then evaluated on 5 anesthetized calves. The calves were positioned in dorsal recumbency, and 4 ventral abdominal portals were used. The umbilical vessels were double-ligated using an endoscopic suturing device and subsequently transected. The apex of the bladder was transected between a row of laparoscopic clips applied near the apex and atraumatic laparoscopic forceps applied distally; then, the edges were apposed using an endoscopic suturing device. The dissected umbilical remnants were removed from the abdomen through a small incision centered at the umbilicus. One month later, the calves were euthanatized and a second-look laparoscopy performed; then, bladders were collected for gross and histologic examination. RESULTS: No major complications occurred during or after surgery. The endoscopic suturing device permitted both effective ligation of the umbilical vessels and closure of the bladder. During second-look laparoscopy, healing of the peritoneal surface of the bladder and umbilical vessels was assessed to be excellent in 4 calves. A focal adhesion of omentum to the bladder suture line was observed in 1 calf. Focal adhesions of the omentum to the umbilical incision site occurred in 2 calves. The bladder mucosa was completely healed at the surgical sites. CONCLUSION AND CLINICAL RELEVANCE: Resection of the apex of the bladder and umbilical vessels in calves can be accomplished laparoscopically using an endoscopic suturing device.

Anticipating twin-twin transfusion syndrome in monochorionic twin pregnancy. Is there a role for nuchal translucency and ductus venosus blood flow evaluation at 11-14 weeks?

Twin-twin transfusion syndrome is a major complication of monochorionic twin pregnancies. In foetuses from monochorionic twinning the presence of increased nuchal translucency thickness (NT) has been associated with an increased risk of developing this syndrome. One of the presumed mechanisms of increased NT is early cardiac failure, indirectly indicated by abnormal blood flow in the ductus venosus. We present eleven cases of monochorionic twin pregnancies in which nuchal translucency thickness and ductus venosus blood flow evaluation was performed at 11-14 weeks. In the two cases presenting with nuchal translucency discrepancy between the two foetuses along with anomalous ductus venosus blood flow in the foetus with increased nuchal translucency, twin-twin transfusion syndrome (TTTS) eventually developed. In none of the twins displaying no inter-twin difference in NT measurements and in those with discrepant NT but normal flow in both ductus venosus, was the progression to TTTS observed. In the two cases which developed TTTS, foetoscopic laser coagulation of the vascular anastomosis was successfully carried out at 18 weeks and normalisation of the venous return was registered. These findings suggest that the association of increased NT and abnormal flow in the ductus venosus in monochorionic twins may be an early manifestation of haemodynamic imbalance between the donor and the recipient eventually manifested as twin-twin transfusion syndrome. Further studies, however, are necessary to establish the potential role of the combination of NT and ductus venosus blood flow assessment as a screening method for TTTS.

Laparoscopically assisted resection of umbilical structures in foals.

A technique for laparoscopically assisted resection of umbilical structures in foals was developed. Eleven foals ranging from 8 to 42 days old underwent this procedure. Results of bacteriologic culture of umbilical structures were positive in 7 foals. Mean duration of anesthesia was 99 minutes, of which the initial 20 to 25 minutes were typically devoted to positioning and preparation of the foal for surgery. Major complications did not develop in any foal. Minor complications, such as slippage of the endoscopic ligating clip or laceration of the bladder during dissection, were dealt with successfully during the procedure. Potential benefits of use of laparoscopy (i.e., decreased postoperative morbidity, smaller incisions, and increased intraoperative access to structures) must be carefully weighed against the risks of increased duration of anesthesia. However, anesthetic-related complications were not observed in any foal.

Treatment of acardiac twinning.

BACKGROUND: The twin reversed-arterial-perfusion sequence is a complication of monochorionic twin pregnancies characterized by the hemodynamic dependence of a "recipient" twin from a "pump" twin. The recipient twin exhibits lethal abnormalities including acardia and acephaly. The pump twin has a mortality rate of 50% as a result of high-output heart failure. CASE: The blood supply to an acardiac-acephalus twin was interrupted at 24 weeks' gestation using endoscopic laser coagulation. The co-twin was delivered at 35 weeks and had an uneventful neonatal course following correction of a persistent patent ductus arteriosus. Review of the literature reveals 22 cases of acardiac twinning treated with invasive procedures, seven of them using endoscopic laser coagulation. Pump twin mortality with fetal surgery was 13.6% in comparison with 50% mortality with expectant management (P < .001). CONCLUSION: Fetal surgery is the best available treatment for acardiac twinning. Endoscopic laser coagulation at or before 24 weeks and endoscopic or sonographic guided umbilical cord ligation after this gestational age seem to be the best treatments for this condition.