Successful Separation of Conjoined Twins: The Contemporary Experience and Historic Review in Memphis

Rehabilitation and functional outcomes for thoraco-omphalo-ischiopagus conjoined twins five years after separation: A case report

Conjoined twins are identical twins joined in utero and are a rare phenomenon. This report discusses a case of female thoraco-omphalo-ischiopagus tripus conjoined twins. The twins were separated at age two, and once medically stable, spent one month in inpatient rehabilitation to improve their sitting balance and gross motor skills. This was followed by outpatient physical therapy. The twins initially had customized ZipZac seats, which they were able to wheel independently. After six months of therapy, the girls began walking with posterior walkers and prostheses. The hemipelvectomy prosthesis included a customized thoracolumbosacral orthosis component and was directly attached to a non-articulated pylon. A manual-locking hip joint was added to accommodate sitting. An articulated ankle-foot orthosis was used for the intact leg. Care of formerly conjoined twins requires comprehensive care from a multidisciplinary team involving, but not limited to, a physiatrist, orthopaedic surgeon, physical therapist, and orthotist/prosthetist. Complex congenital limb deficiencies are often a major undertaking for the rehabilitation team as continuous treatment and management are needed throughout the patient's lifetime due to growth, development, and evolving physical demands. Anatomic variations must be examined on a case-by-case basis but often include limb deficiencies, orthopedic abnormalities, and organ comorbidities.

The role of intraoperative neuromonitoring in pygopagus separation: two-institution experience in Indonesia

INTRODUCTION

Pygopagus comprises 17% of all conjoined twin cases. Survival rate is higher compared to other variations of conjoined twins, but separation is a great challenge due to multiorgan involvement. Intraoperative neuromonitoring (IONM) used aims to aid operator in preserving as much function as possible.

CASE PRESENTATIONS

The authors reported 2 pairs of pygopagus separation. Intraoperatively, motor-evoked potential (MEP) and sensory-evoked potential (SEP) were used in all patients. Three patients survived in which all had transient motor deficits. Urinary retention was reported in one patient. One patient died 2 weeks after separation as twins only had one kidney which was spared for the healthier twin.

DISCUSSION

IONM was used to guide operator in dissecting, identify the ownership of the neural structures, and determine the safest point to separate in pygopagus separation. Despite the normal MEP and SEP recordings, transient motor weakness may still occur transiently. The motor tract development of children is achieved in adolescence, making MEP less accurate. However, the reliability of MEP increases when it is combined with SEP. Autonomic function monitoring such as bulbocavernosus reflex (BCR) could not be assessed due to the unavailability of the probe.

CONCLUSION

IONM can aid operator in pygopagus separation during determining the origins of the structure, dissecting, and cutting the neural structures. Normal MEP interpretations are still possible to correlate with transient deficits, but reliability can be improved with the use of SEP. In surgeries involving the lower spine level, BCR monitoring is recommended to avoid autonomic deficits.

Conjoined Twin Separation: Review of 30-Year Case Experience and Lessons Learned

BACKGROUND

Conjoined twinning is a rare medical phenomenon, and numerous challenges remain with respect to surgical separation and reconstruction. The purpose of this study is to present a detailed discussion of the authors' institutional experience with eight conjoined twin separations over the past three decades, focusing on challenges and lessons gleaned from these cases.

METHODS

The records of all patients who underwent conjoined twin separation at The Hospital for Sick Children in Toronto, Ontario, Canada, from 1984 to 2018 were retrospectively reviewed.

RESULTS

Eight sets of conjoined twins were analyzed. Half of the sets [ n = 4 (50 percent)] were female. There were four sets (50 percent) of ischiopagus twins, three sets (37.5 percent) of omphalopagus twins, and one set (12.5 percent) of craniopagus twins. The median age at separation was 6.75 months. The mean durations of intensive care unit and hospital stay were 14.1 ± 12.9 days and 4.9 ± 4.8 months, respectively. Mean length of follow-up was 6.7 ± 4.4 years. Three deaths occurred in our series, with an overall survival rate of 81 percent. Two sets of twins experienced expander-related complications such as infection and bowel perforation. Three twins required reoperation because of flap necrosis or dehiscence after separation.

CONCLUSIONS

The authors' results highlight the unique nature of each operation and the great ingenuity required in managing the particular considerations of each case and also adhering to a systematic approach of evaluation and planning. A number of novel strategies were used at the authors' center and have now become commonplace. The lessons learned from such procedures may improve care for future generations of patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A case report describing the successful separation of ischiopagus tetrapus conjoined twins in Vietnam

Ischiopagus conjoined twinning is a rare congenital defect. The surgical separation of conjoined twins is difficult because of the complex anatomy and physiology. Careful preoperative assessment, planning, and effective surgical teams are critically important for achieving a good outcome. We describe the successful separation of ischiopagus tetrapus conjoined twins as a representative case demonstrating the growth of pediatric surgery in southern Vietnam.

Use of local perforator flaps for closure of a thoraco-omphalopagus conjoined twin defect after separation during the COVID-19 pandemic

Introduction

Conjoined twins are a rare medical phenomenon that poses unique challenges for surgeons. Separation of conjoined twins involves multidisciplinary teamwork, complex medical management and surgical planning, and multi-stage operations and often still has a high mortality and morbidity rate. In the times of the COVID-19 pandemic, separation of conjoined twins pose even greater challenges. Aiming for the best outcome possible, while minimizing the risk of COVID transmission and ensuring the safety of the personnel, is paramount. This case report presents thoraco-omphalopagus twins who were successfully separated at 4 months of age. The preoperative planning, operative details, postoperative follow-ups, and outcomes are discussed.

Methods

The absence of a tissue expander and the inability to acquire it due to travel restrictions from COVID-19 further complicated the management on this patient. A Routine Polymerase Chain Reaction (PCR) swab test was performed on the patients and personnel. Standardized personnel protective equipment (PPE) was worn during ward and surgical care. After separation of the twins by cardiothoracic and pediatric surgeons, one twin underwent immediate skin closure using a double keystone perforator island flap and a lower abdominal perforator flap. Due to extensive defects, closure was delayed for the second twin. After a series of dressing changes, eventually local perforator flaps could be raised to close the defect using staged tension sutures and skin grafts for secondary defects.

Results

Both twins were discharged with no significant morbidity, and no personnel were exposed to COVID-19 infection during the management.

Conclusion

Preoperative coordination and planning, multidisciplinary effort, adherence to screening protocols for COVID, and strict use of standardized PPE all contributed to the successful separation of thoraco-omphalopagus conjoined twins during the COVID-19 pandemic.

Predictors of in-hospital mortality in newborn conjoined twins

BACKGROUND

Conjoined twins are rare developmental anomalies. There is a paucity of literature other than case reports and small case series. The aim of this study was to examine national outcomes and identify predictors of mortality in newborn conjoined twins.

METHODS

We reviewed data on newborn conjoined twins from the Kids' Inpatient Database (1997-2012).

RESULTS

A total of 240 patients were identified for a nationally weighted incidence of 1 per 100,000 live births. The majority of conjoined twins were female (n = 190 [81%]). The most commonly associated anomalies were cardiac (n = 87 [36%]), gastrointestinal (n = 41 [17%]), and abdominal wall (n = 32 [13%]) defects. Fifty-six (23%) patients underwent operative procedures, including 28 (12%) neonatal separation surgeries. The overall mortality rate was 61%; most deaths occurred within 24 hours (99 of 146 [68%]) to 48 hours (129 of 146 [88%]) after birth. Mortality was higher in female compared with male children (66% vs 38%, P = .025), premature compared with full-term children (72% vs 44%, P = .007), and in children with extremely low birth weight (95% vs 59%, P = .002). Congenital diaphragmatic hernias were seen in 15 (6%) patients and were uniformly fatal (100% vs 58%, P = .029). Mortality was highest in hospitals not designated as children's hospitals (72%) compared with children's hospitals (44%) (P = .007).

CONCLUSION

Conjoined twins are rare anomalies who are susceptible to extremely high perinatal mortality, especially in female children, those who are premature, or those who have low birth weight. These data support caring for these complex patients at hospitals equipped to care for this fragile population.

The surgical principles of conjoined twin separation

The surgical management of conjoined twin separation is a complex, multidisciplinary process that requires extensive pre operative planning and organization for optimal outcomes. Identification of detailed anatomic relationships is necessary prior to the separation. The use of 3D modeling is extremely helpful for conceptualization of the operation. The principles of the separation are dependent on the type of twin, although each variant of symmetric twins has certain commonalities related to their embryology that can be considered when planning the operation. The use of tissue expansion in the pre operative planning stage is highly recommended due to known issues with closure after separation. In order to ensure a safe, successful operation, we recommend organized pre operative planning meetings with at least one simulation of the separation event with multidisciplinary involvement.