Pioneering surgeon gives fetal twins a chance at life

Today at a reunion at Lowry Park Zoo, Dr. Ruben Quintero meets his former patients, including four sets of triplets and 45 sets of twins.

Published April 9, 2005

TAMPA - A slender metal tube poked out of the curve of Jackie Bennett's pregnant belly. Inside it, a tiny camera lens - just 3.3 millimeters wide - rushed toward the twins inside.

Silver gray metal zoomed on a video screen as the lens ran through the tube. Then, suddenly, a hand appeared - the delicate skin translucent, the fingers outstretched.

This was one of the fragile lives that Dr. Ruben Quintero was here to save.

Bennett was 17 weeks pregnant with twin girls. She found out April 1 that the twins were suffering from an abnormal blood supply.

Without help, they were almost certain to die.

By Thursday, Bennett had left her home outside Jacksonville and come to St. Joseph's Women's Hospital, where Quintero performs the fetal surgeries he is famous for.

Quintero is one of a handful of surgeons in the world who perform endoscopic laser surgery to treat a condition called twin-to-twin transfusion syndrome. He is widely known for developing the technique to identify the abnormal blood vessels that need to be sealed.

The syndrome happens to about 5 to 10 percent of identical twins. These twins share a placenta, the structure in the uterus that delivers oxygen and nutrients to a fetus through its umbilical cord.

But in these twins, some blood vessels in the placenta are placed so that, instead of giving blood to each baby, the blood flows from one baby to the other. One gets too little blood and nutrients, while the other gets too much. Usually, both die.

Quintero's surgery gives such twins a chance. Quintero, 46, a native of Venezuela who trained at Yale University, worked for a few years in a well-known fetal medicine program at Wayne State University in Detroit before coming to Tampa in 1996. He is known as a pioneer in treating the twin syndrome and other fetal problems with endoscopes, using minimally invasive techniques in a field so new that he designed many of the instruments himself.

In the twin surgery, after a laser seals off the abnormal vessels, each twin can develop normally, getting blood from the remaining vessels in the placenta. About 85 percent of the time, at least one twin survives. In 50 to 60 percent of the surgeries, both twins do.

Today many of those survivors will gather for the fourth reunion of Quintero's patients at Lowry Park Zoo. Families from 20 states are expected to attend. Among them: four sets of triplets, 45 sets of twins, and 20 children who survived after their twins died in the womb.

Quintero loves these reunions.

"Many of these babies, I've never seen in my life," he said. "I only met them in utero."

Quintero, whose license plate reads "FETALMD," followed in the footsteps of his father, an ob/gyn who specialized in infertility.

Bennett, 36, and her husband Chris, 40, talked to one of those families before Thursday's surgery, trying to learn more about what lies ahead. The Bennetts have three boys, ages 14, 3 and 2. But last fall, their baby girl was stillborn.

"It's been a hard year," Jackie Bennett said.

And then they heard about the twins.

Bennett's surgery presented an especially difficult case for Quintero. The placenta was attached at the front of the uterus. That meant Quintero would have to manipulate the laser at an unusual angle. Also, the "donor" twin, the smaller one losing blood, was in an awkward location.

And finally, the twins were young for the surgery - 16 weeks and 6 days.

But they were already having trouble, and nobody wanted to wait.

"Next week, because the babies are so sick, maybe they're not alive," Quintero said, as he and the fetal surgeon assisting him, Dr. Ramen Chmait, scrubbed their hands outside Operating Room Q, where Bennett was waiting. "We're between a rock and a hard place."

As the surgery got under way, Quintero warned Bennett before he inserted the metal tube. Even with the local anesthetic she had received, she would still feel pressure as it went in.

"Oh," she said softly.

"That's all you're going to feel," Quintero told her.

He studied the view from the endoscope, a third of the size of the scopes used for most adult surgeries. Normally, Quintero would study the entire placenta and map each abnormal vessel before using the laser.

But because finding the right angle was so hard, Quintero didn't want to take chances.

"Because of the location, we're going to do this piecemeal, little by little," he said. "We're lucky to get where we are right now."

Quintero trained the laser on a dark blood vessel, snaking across the pinkish-white field of placenta. A blinking red dot showed where the laser would fire.

Beep, beep, beep.

A section of the vessel vanished, replaced by a creamy patch.

The camera lens traveled across the placenta, tracing vessels back to their source, identifying the bad ones.

"We're being very careful here. We're near an area (of normal veins) the baby needs," Quintero said. "This is a very tricky spot."

Another red flash. Beep, beep, beep. Gone.

"We're almost done," Quintero told Bennett.

"I'm so pleased we were able to see," she said.

But the best pictures were still ahead. Quintero had sealed 12 blood vessels - his average tally is five - and checked to make sure each one was sealed. Then the camera had another job.

"It's baby show time," he announced.

Quintero trained the lens on tiny feet, stick-like legs. A round belly, an elbow, a tiny face. Her eyelids gleamed white in the lens. At this point in development, the average fetus is about 6 inches long.

Then on to the other girl. Both twins' hands looked impossibly large. Their arms and legs impossibly scrawny.

Just seeing her daughter's fingers wave across the lens made Bennett's heart leap.

"It was so exciting," she said. "Seeing her move is so reassuring when you know they're in trouble."

The surgery was a success, but it is too soon to know if the girls will survive. Only time will tell if enough normal blood vessels remain in the placenta to nourish them and let them grow.

"Remember both these babies are very sick," Quintero told Bennett.

"Now, it's up to the babies."