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Shen R, Todingbua A, Suharto HA, Imelda M, Hartono M. Parasitic pygopagus conjoined twins' incidental findings in the obstructed labor of an intrapartum dead baby that had undergone emergency C-section: rare case report in South Papua. Childs Nerv Syst 2024; 40:2631-2635. [PMID: 38695890 DOI: 10.1007/s00381-024-06440-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/27/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Conjoined twins (CT), which used to be historically defined as "monstrous human" and previously so-called Siamese twins in the early eighteenth century, are one of the very rare congenital malformations with an uncertain etiology and complex yet remain inconclusively debatable regarding its pathophysiological mechanisms of fusion and fission theories. Among all types of CT, parasitic CT, especially the pygopagus sub-type, is exceedingly rarer. To the best of the authors' knowledge, no parasitic CT had been reported in Papua, and this is the first finding in South Papua. CASE REPORT Herein, a 30-year-old multigravida female with 37th-week gestation, previous twice spontaneous miscarriage, and non-adequate antenatal care history is presented with a chief complaint of painful construction and greenish fluid leakage from the vagina, with an examination that showed a cephalic presentation with a "peculiar" big mass at the upper uterus and complete cervical dilation toward second-stage inpartu. Vaginal delivery was performed with a complication of obstructed labor due to uncommon dystocia with a suspected "big mass" below the fetal buttocks and intrapartum dead. Intrapartum transabdominal ultrasound demonstrates a gross anatomically like an organ inside a fluid-filled mass with unidentified parts, leading to a suspected type of congenital malformation at the baby's sacral region. Emergency C-section was done with findings of parasitic pygopagus CT, showing an attachment of a large irregular fluid-filled mass-like incomplete twin (parasite) with palpable soft tissue and bony structure inside to the buttocks of a male autosite twin, and an additional third leg which happened to be an under-developed lower extremity with a sacrum-like structure. CONCLUSIONS An obstetrician's routine ANC and critical radiological evaluation will increase the odds of identifying CT or other congenital malformations to provide better delivery planning or further management. Increasing maternal health knowledge in society, improving medical skills and knowledge levels for health providers, and advancing supporting facilities and specialists are future strategies for managing and preventing such cases in low-middle-income countries.
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Affiliation(s)
- Robert Shen
- Atma Jaya Neuroscience and Cognitive Center (ANCC), School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia.
- Emergency Department, Bunda Pengharapan Hospital, Merauke, South Papua, Indonesia.
| | - Arthur Todingbua
- Department of Obstetrics and Gynecology, Bunda Pengharapan Hospital, Merauke, South Papua, Indonesia
| | - Hans Angelius Suharto
- Department of Pediatric, Bunda Pengharapan Hospital, Merauke, South Papua, Indonesia
| | - Meilina Imelda
- Department of Anesthesiology and Perioperative Medicine, Bunda Pengharapan Hospital, Merauke, South Papua, Indonesia
| | - Monika Hartono
- Emergency Department, Bunda Pengharapan Hospital, Merauke, South Papua, Indonesia
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Abas R, Masrudin SS, Harun AM, Omar NS, Omar NS. Gastrulation and Body Axes Formation: A Molecular Concept and Its Clinical Correlates. Malays J Med Sci 2022; 29:6-14. [PMID: 36818899 PMCID: PMC9910376 DOI: 10.21315/mjms2022.29.6.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/02/2021] [Indexed: 12/25/2022] Open
Abstract
During the third week of human pregnancy, an embryo transforms from two germinal disc layers of hypoblast and epiblast to three germinal layers of endoderm, mesoderm and ectoderm. Gastrulation is a complex process that includes cellular mobility, morphogenesis and cell signalling, as well as chemical morphogenic gradients, transcription factors and differential gene expression. During gastrulation, many signalling channels coordinate individual cell actions in precise time and location. These channels control cell proliferation, shape, fate and migration to the correct sites. Subsequently, the anteroposterior (AP), dorsoventral (DV) and left-right (LR) body axes are formed before and during gastrulation via these signalling regulation signals. Hence, the anomalies in gastrulation caused by insults to certain molecular pathways manifest as a wide range of body axes-related disorders. This article outlines the formation of body axes during gastrulation and the anomalies as well as the clinical implications.
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Affiliation(s)
- Razif Abas
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia,Department of Anatomy and Embryology, Faculty of Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Siti Saleha Masrudin
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | | | - Noorkardiffa Syawalina Omar
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia,Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Toyama C, Nomura M, Tazuke Y, Yokota C, Kagawa N, Kishima H, Yoshimura A, Ujike T, Nagahara A, Nonomura N, Kubo T, Matsui F, Matsumoto F, Okuyama H. Successful separation of male pygopagus with anal canal and urethral reconstruction: a case report. Surg Case Rep 2022; 8:43. [PMID: 35292861 PMCID: PMC8924340 DOI: 10.1186/s40792-022-01398-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pygopagus is a type of conjoined twin binding at the buttocks. Some cases of pygopagus involve the fusion of the gastrointestinal tract, urinary tract, and spinal cord. Few cases of male pygopagus have been reported; however, the prognosis after separation is unclear. Herein, we report a case of male pygopagus in which successful separation was performed with the reconstruction of the anal canal. Case presentation Twins with male pygopagus were born at 35 weeks by cesarean section. They shared a common anus, penis, and scrotum with four testes. The infants had normal defecation and urination after birth. The separation surgery was scheduled when they were 5 months. Two distinct anesthesia teams and four surgical teams (neurosurgery, pediatric urology, plastic surgery, and pediatric surgery) were involved in the multidisciplinary approach. After separating the spinal cord, we found that the anal canal and sphincter muscle complex were fused near the anal aperture, and we separated them. The fused penis and testis were separated and reconstructed using the same incisional line as the other separation, and the reconstructions of the anal canals with the sphincter muscle complex were completed. Both patients had an uneventful postoperative course. At 2 years of age, they could walk and defecate independently. In addition, they voided spontaneously without urinary incontinence at the time of 3 years and 11 months. Conclusions Separation of the spinal cord with anal canal and urethral reconstruction is important for male pygopagus patients as it allows them to preserve their independent function.
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Affiliation(s)
- Chiyoshi Toyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Motonari Nomura
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Chisato Yokota
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Naoki Kagawa
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Akihiro Yoshimura
- Department of Urology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Takeshi Ujike
- Department of Urology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Akira Nagahara
- Department of Urology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Futoshi Matsui
- Department of Pediatric Urology, Osaka Women's and Children's Hospital, Murodo-Cho 840, Izumi, Osaka, 594-1101, Japan
| | - Fumi Matsumoto
- Department of Pediatric Urology, Osaka Women's and Children's Hospital, Murodo-Cho 840, Izumi, Osaka, 594-1101, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
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Thompson DNP. Gastrulation : Current Concepts and Implications for Spinal Malformations. J Korean Neurosurg Soc 2020; 64:329-339. [PMID: 33321561 PMCID: PMC8128527 DOI: 10.3340/jkns.2020.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/02/2020] [Indexed: 11/27/2022] Open
Abstract
It has been recognised for over a century that the events of gastrulation are fundamental in determining, not only the development of the neuraxis but the organisation of the entire primitive embryo. Until recently our understanding of gastrulation was based on detailed histological analysis in animal models and relatively rare human tissue preparations from aborted fetuses. Such studies resulted in a model of gastrulation that neurosurgeons have subsequently used as a means of trying to explain some of the congenital anomalies of caudal spinal cord and vertebral development that present in paediatric neurosurgical practice. Recent advances in developmental biology, in particular cellular biology and molecular genetics have offered new insights into very early development. Understanding the processes that underlie cellular interactions, gene expression and activation/inhibition of signalling pathways has changed the way embryologists view gastrulation and this has led to a shift in emphasis from the ‘descriptive and morphological’ to the ‘mechanistic and functional’. Unfortunately, thus far it has proved difficult to translate this improved knowledge of normal development, typically derived from non-human models, into an understanding of the mechanisms underlying human malformations such as the spinal dysraphisms and anomalies of caudal development. A paediatric neurosurgeons perspective of current concepts in gastrulation is presented along with a critical review of the current hypotheses of human malformations that have been attributed to disorders of this stage of embryogenesis.
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Can DDT, Lepard JR, Tri TT, Van Duong T, Thuy NT, Thach PN, Johnston JM, Oakes WJ, Dong A T. The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report. J Neurosurg Pediatr 2020; 25:445-451. [PMID: 31952040 DOI: 10.3171/2019.11.peds19291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/14/2019] [Indexed: 11/06/2022]
Abstract
Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise.A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In August 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect.The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up.
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Affiliation(s)
- Dang D T Can
- 1Neurosurgical Department, Children's Hospital 2, and
- 9University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Jacob R Lepard
- 1Neurosurgical Department, Children's Hospital 2, and
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 8Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Tran T Tri
- 4Pediatric Surgery Department, Children's Hospital 2, Ho Chi Minh City
| | - Tran Van Duong
- 5Plastic Surgery Department, Cho Ray Hospital, Ho Chi Minh City
| | | | - Pham N Thach
- 7Urology Department, Children's Hospital 2, Ho Chi Minh City, Vietnam; and
| | - James M Johnston
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 3Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - W Jerry Oakes
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 3Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Tran Dong A
- 4Pediatric Surgery Department, Children's Hospital 2, Ho Chi Minh City
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Jain P, Kundal AK, Sharma R, Khilnani P, Kumar P, Kumar P. Surgical separation of pygopagus twins: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Hirokazu T, Takayuki I, Yoshinori H, Kazunari K, Akio A, Keiji K. Separation surgery of pygopagus asymmetrical conjoined twins sharing U-shaped spinal cord: case report and literature review. Childs Nerv Syst 2013; 29:699-706. [PMID: 23274640 DOI: 10.1007/s00381-012-2007-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Takami Hirokazu
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
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Lazarus J, Raad J, Rode H, Millar A. Long-term urological outcomes in six sets of conjoined twins. J Pediatr Urol 2011; 7:520-5. [PMID: 20933474 DOI: 10.1016/j.jpurol.2010.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 09/01/2010] [Indexed: 10/19/2022]
Abstract
AIM To review the long-term urological outcomes of six sets of ischiopagus and pygopagus conjoined twins. Emphasis is placed on the particular genitourinary challenges of separation, reconstruction and monitoring of these patients. PATIENTS AND METHODS We performed a longitudinal, retrospective analysis of six sets of conjoined twins who presented to a single center and describe their long-term urological outcomes. RESULTS Six sets of ischiopagus (4) and pygopagus (2) conjoined twins presented from 1993 to 2003 and have been followed up for a mean of 12 years (range 7-17 years). Separation was achieved in 5/6 cases; the remaining one died of intestinal perforation and resultant sepsis. One further child died of malaria after separation. Patterns of genitourinary anatomy found in these conjoined twins are described. Urinary continence was achieved in 2/6 ischiopagus and 3/4 pygopagus twins. Renal failure has developed in one child. Urinary tract infections have been common. Secondary urological surgery has been required in 3/6 ischiopagus twins, usually to perform an incontinent urinary diversion. CONCLUSION Complex urological problems occur in ischiopagus and pygopagus conjoined twins. Beyond the challenge of surgical separation, they continue to provide management challenges requiring secondary reconstructive surgery and close urological monitoring.
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Affiliation(s)
- John Lazarus
- Division of Urology, Red Cross Children's Hospital, University of Cape Town, Western Cape 7700, South Africa.
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Successful separation of the conjoined thecal sac with an epidermal cyst in pygopagus twins. J Pediatr Surg 2011; 46:e25-7. [PMID: 21929972 DOI: 10.1016/j.jpedsurg.2011.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/23/2011] [Accepted: 05/29/2011] [Indexed: 11/23/2022]
Abstract
Pygopagus conjoined twins are very rare, and half of all pygopagus twins have other anomalies. This report describes the successful surgical separation of pygopagus twins who had a conjoined thecal sac and an epidermal cyst. Meticulous preoperative planning, development of a model simulator, multispecialty teamwork, and a staged surgery contributed to a successful outcome.
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