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Mathur P, Sharma S, Mittal P, Yadav RK, Barolia D. Heteropagus twins: six cases with systematic review and embryological insights. Pediatr Surg Int 2022; 38:963-983. [PMID: 35567628 DOI: 10.1007/s00383-022-05135-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Heteropagus twinning (HT) is a rare anomaly. Six new cases along with a systematic review are described. METHODS Six cases of HT managed at two tertiary care teaching hospitals over the last 26 years are described. A PubMed search with words: Heteropagus AND/ OR parasitic twins from 2001 to 2021 hit 183 articles. 36 were added from non-PubMed sources. Finally, 120 cases including 114 from 69 articles and 6 new cases were analysed. RESULTS Of the new cases, 2/6 had an antenatal diagnosis. Five were males. 4 autosites had omphaloceles. Split notochord and 2 parasites attached to a single autosite were encountered. 5/6 autosites survived. On systematic review, the most frequent variant seen was rachipagus (n = 50) followed by omphalopagus (n = 46). Limbs were reported in 75 cases. Congenital heart disease was seen in 17/120(14.2%) autosites. Omphalocele and meningomyelocele were the most common extracardiac anomalies in autosites. Weight along with the anatomy and position of heteropagus twins was a better determinant of the mode of delivery than weight alone. Mortality was reported in 12 cases. CONCLUSION Autosites in HT generally carry a good prognosis, however, final outcome depends mainly on associated major cardiac anomalies. Meticulous antenatal assessment and preoperative planning are of paramount importance. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Praveen Mathur
- Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, 302004, India
| | - Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Mittal
- Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, 302004, India.
| | - Raj Kumar Yadav
- Department of Radiodiagnosis, SMS Medical College, Jaipur, India
| | - Dinesh Barolia
- Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, 302004, India
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2
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Anatomical features and challenges in separation and reconstruction of heteropagus twins. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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3
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Falyoun MS, Mashlah Q, Aldiri Q, Mohamad AR, Daowd LK, Ayash M. Epigastric heteropagus and omphalocele. J Surg Case Rep 2020; 2020:rjaa437. [PMID: 33133510 PMCID: PMC7590534 DOI: 10.1093/jscr/rjaa437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 11/14/2022] Open
Abstract
We report a case of epigastric heteropagus twins with omphalocele. The parasite had two lower limbs, genitalia with developed phallus and scrotum but absent testis and absent anus. An omphalocele was present just below the attachment of the parasitic twin. No kidney or ureter but only a bladder filled with urine seen during exploration. The parasite bowel was attached to an omphalocele sac prolapsing through it and there was connection to the autosite liver, which forms the main source of its blood supply. Surgery was performed in the neonatal period (Day 12 after birth) for both excision of epigastric heteropagus and omphalocele repair.
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Affiliation(s)
| | - Qusai Mashlah
- Department of Pediatric Surgery, Children Hospital, Damascus, Syria
| | - Qusai Aldiri
- Department of Pediatric Surgery, Children Hospital, Damascus, Syria
| | | | | | - Malek Ayash
- Department of Pediatric Surgery, Children Hospital, Damascus, Syria
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4
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Saravanan N, David LS, Vijayaselvi R, Masih D, Beck MM. What is your diagnosis? J Turk Ger Gynecol Assoc 2019; 20:269-271. [PMID: 31245967 PMCID: PMC6883750 DOI: 10.4274/jtgga.galenos.2019.2019.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Nanthini Saravanan
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, South India
| | - Liji Sarah David
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, South India
| | - Reeta Vijayaselvi
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, South India
| | - Dipti Masih
- Department of Pathology, Christian Medical College and Hospital, Vellore, South India
| | - Manisha Madhai Beck
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, South India
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5
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Malik M, Bahadur Singh U, Hedge S, Mahajan JK, Samujh R. Omphalocele and epigastric heteropagus: implications and treatment. Oxf Med Case Reports 2018; 2018:omy074. [PMID: 30302264 PMCID: PMC6169197 DOI: 10.1093/omcr/omy074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/14/2018] [Accepted: 08/06/2018] [Indexed: 11/17/2022] Open
Abstract
In heteropagus twins, the parasitic twin is incompletely formed which is attached to the autosite. We report a case of epigastric heteropagus twins with omphalocele. The parasite had two lower limbs, a rudimentary upper limb, genitalia with developed phallus and scrotum but absent testis. An omphalocele was present just below the attachment of the parasitic twin. A single kidney with ureter and a bladder filled with urine seen during exploration. The parasite bowel was attached to a sleeve of liver tissue from the autosite within the omphalocele sac and this connection was also the main source of its blood supply. Less than 20 cases of omphalocele with EH have been reported previously. The thin sac with underlying adherent bowel led us to go ahead with surgery in the neonatal period for both, excision of epigastric heteropagus and omphalocele repair. The rectus sheath around the omphalocele sac helped in the final wound closure.
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Affiliation(s)
- MuneerAbas Malik
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Umesh Bahadur Singh
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalini Hedge
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Mahajan
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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6
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Recurrence of parasite in epigastric heteropagus. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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7
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Epigastric heteropagus associated with an omphalocele and double outlet right ventricle. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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8
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Calderoni DR, Mizukami A, Nunes PHF, Kharmandayan P. Thoraco-omphalopagus asymmetric conjoined twins: Report of a case and complete review of the literature. J Plast Reconstr Aesthet Surg 2014; 67:e18-21. [DOI: 10.1016/j.bjps.2013.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/27/2013] [Accepted: 06/04/2013] [Indexed: 11/16/2022]
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9
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Kesan K, Gupta A, Gupta RK, Kothari P, Ranjan R, Karkera P, Mudkhedkar K. Gluteal flap for omphalocele repair in a case of epigastric heteropagus: A novel approach for surgical management. Indian J Plast Surg 2013; 46:127-9. [PMID: 23960319 PMCID: PMC3745099 DOI: 10.4103/0970-0358.113731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Epigastric heteropagus is an extremely rare congenital anomaly, in which there is asymmetrical conjoined twinning, with the parasitic twin attached to the epigastrium. A 2-day-old male, with epigastric heteropagus and omphalocele, was operated in our institution. After excision of the parasitic twin, omphalocele was covered with a gluteal skin flap available from the parasitic twin. Post-operative course was uneventful, except for infection along the edges of the skin flaps, which was managed conservatively. Only 44 cases of epigastric heteropagus twins have been reported previously in world literature. We present a novel surgical approach for the repair of the omphalocele in a case of epigastric heteropagus twins, probably the 45(th) case to be reported in the world literature.
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Affiliation(s)
- Krushnakumar Kesan
- Department of Pediatric Surgery, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
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10
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Hynd TE, Buckley CL, Lozanoff S. Case of cephalothoracopagus conjoined twinning in an embryonic mouse. ACTA ACUST UNITED AC 2013; 97:421-4. [PMID: 23761017 DOI: 10.1002/bdra.23151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/15/2013] [Accepted: 04/19/2013] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cephalothoracopagus twinning is extremely rare, and it is characterized by fusion of the head and thorax, two separate spines, pelves, and fore- and hindlimbs. CASE In this case study, we describe cephalothoracopagus twinning in an embryonic mouse displaying a large but exencephalic head, median facial cleft, a single eye, and a second hindbrain rotated roughly 90° from a second spinal cord. There is a bony connection joining the clavicles, resulting in merged asternal thoracic cavities containing two hearts and four lungs. The abdominal cavities contain double caudal digestive tract structures, but a single esophagus and stomach. CONCLUSION There are several proposed theories regarding the mechanism of spontaneous conjoined twinning; however, the specific mechanisms are still largely unknown. In this report, we highlight the morphological features in a murine example of cephalothoracopagus twinning, furthering our understanding of this rare occurrence while also demonstrating developmental morphogenesis consistent with that reported for human conjoined twins.
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Affiliation(s)
- Thomas E Hynd
- Department of Anatomy, Biochemistry and Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA.
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11
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Trainavicius K, Kazlauskas V, Gurskas P. Epigastric heteropagus conjoined twins. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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12
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Xie JT, Zhou L, Yang ZL, Sun HY. Epigastric heteropagus conjoined twins: two case studies and associated DNA analysis. Clinics (Sao Paulo) 2012; 67:527-9. [PMID: 22666802 PMCID: PMC3351264 DOI: 10.6061/clinics/2012(05)22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jun-tao Xie
- Sun Yat-sen University, The First Affiliated Hospital of Guangzhou, Department of Pediatric Surgery, People's Republic of China
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13
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Kota R, Srirampur S, Kannaiyan L, Irfan GM, Sharab H, Rao S. Parasitic twinning - Varied presentations. JOURNAL OF DR. NTR UNIVERSITY OF HEALTH SCIENCES 2012. [DOI: 10.4103/2277-8632.102445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Ozkan-Ulu H, Yilmaz Y, Sari FN, Altug N, Uras N, Dilmen U. An unusual case of heteropagus: autosite with a complex cardiac malformation. Pediatr Neonatol 2011; 52:358-60. [PMID: 22192266 DOI: 10.1016/j.pedneo.2011.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 12/06/2010] [Accepted: 01/07/2011] [Indexed: 10/15/2022] Open
Abstract
Asymmetrical form of conjoined twinning (heteropagus) is an extremely rare event with an incidence of 1-2 million live births. The incomplete component of heteropagus, namely, parasite, usually consists of rudimentary organs. Therefore, the autosite component of heteropagus can be separated successfully. A wide spectrum of associated congenital cardiac malformations, which are usually minor, has been described in autosites. However, a single-ventricle heart anomaly in the autosite has been reported in a very few cases. We report an unusual case of heteropagus with a complex cardiac malformation. To the best of our knowledge, this is the third heteropagus case in the literature with a single-ventricle heart in the autosite.
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Affiliation(s)
- Hulya Ozkan-Ulu
- Division of Paediatric Surgery, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
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15
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Heteropagus (parasitic) twins: a review. J Pediatr Surg 2010; 45:2454-63. [PMID: 21129567 DOI: 10.1016/j.jpedsurg.2010.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/21/2022]
Abstract
Heteropagus, or "parasitic," twins are asymmetric conjoined twins in which the tissues of a severely defective twin (parasite) are dependent on the cardiovascular system of the other, largely intact twin (autosite) for survival. The estimated incidence of heteropagus twins is approximately 1 per 1 million live births. Isolated case reports comprise most of published work on this rare congenital anomaly. In the past, review articles have focused narrowly on one particular anatomical subtype of parasitic twin and/or on the anatomicopathology observed. Here, we present the epidemiology, proposed pathoembryogenic origins, anatomical abnormalities, management, and outcomes of the wide array of heteropagus twins described in the English language literature.
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16
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Jain P, Borwankar SS, Parelkar S, Mishra P. Parasitic omphalopagus with cranioencephalic malformation and rudimentary cardio-pulmonary system. Indian J Pediatr 2010; 77:704-5. [PMID: 20454937 DOI: 10.1007/s12098-010-0071-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Abstract
A female neonate with a complex form of epigastric heteropagus and with three legs was referred to us. The left leg appeared normal, the central one was hypoplastic and resected 1 month after birth, and the right one projected in the cranial direction with knee flexion contracture. Three bones of the parasite were sandwiched between the right ilium and the ischiopubic bones of the autosite. At the age of 4, we performed the subtrochanteric femoral osteotomy with 90 degrees of varization and rotation, along with knee disarticulation. Ambulation was successfully achieved with the prosthesis with a multiaxis knee unit.
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Ozturk H, Otcu S, Ozturk H, Duran H. Umbilical heteropagous twinning: a case report. Fetal Pediatr Pathol 2007; 26:255-60. [PMID: 18363158 DOI: 10.1080/15513810701818411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heteropagous conjoined twins are rare and umbilical heteropagous conjoined twins are extremely rare. We present a case with umbilical heteropagous conjoined twins and discuss the diagnosis and management. The parasitic component of heteropagous can be separated and treated successfully in the majority of cases.
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Affiliation(s)
- Hayrettin Ozturk
- Medical School, Department of Pediatric Surgery, Abant Izzet Baysal University, Bolu, Turkey.
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Kanamori Y, Tomonaga T, Sugiyama M, Hashizume K, Goishi K, Haga N. Bizarre Presentation of Epigastric Heteropagus: Report of a Case. Surg Today 2006; 36:914-8. [PMID: 16998686 DOI: 10.1007/s00595-006-3275-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 03/14/2006] [Indexed: 10/24/2022]
Abstract
We report an unusual case of epigastric heteropagus in a female neonate. The parasite had a single lung as well as a liver, stomach, intestine, pancreas, ovaries, a single kidney, and a bladder. These visceral organs were located in the abdominal and pelvic space of the autosite, and the pelvic bone and lower legs of the parasite were fused with the respective organs in the autosite. The infant underwent operations to remove the central leg and some of the intra-abdominal organs of the parasite, but she must still undergo further surgery to remove the genitourinary organs and pelvic bones of the parasite, and repair her very abducted and rotated right leg.
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Affiliation(s)
- Yutaka Kanamori
- Departments of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Tokyo 113-8655, Japan
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