Conjoined twins: medical, surgical and ethical challenges

Full-body impression technique for conjoined twins: A clinical report

This clinical report describes a unique impression technique devised for fabrication of a full-body cast of conjoined twins. The authors describe how the cast was used by the medical team to plan the surgical flap design for effective abdominal wall closure during the 27-hour operation sequence that resulted in the twins' separation. The cast, in turn, proved invaluable in planning the complicated surgical procedures necessary to separate them.

Anaesthetic managements for conjoined twins with complex cardiac anomalies

PURPOSE

To describe the perioperative assessment and anaesthetic management for surgical separation of three sets of conjoined twins with complex cardiac anomalies threatened with arterial desaturation and haemodynamic instability.

CLINICAL FEATURES

Three sets of conjoined twins, one omphaloischiopagus, one omphalopagus, and one thoraco-omphalopagus, were considered for separation during the perinatal or infantile period. Preoperative functional evaluation including continuous pulse oximetry, capnography, and cardiac electrophysiological studies were considered to be as important as anatomical evaluation of the cardiac anomalies and cross-circulation by angiography in assessing the feasibility of surgical separation. Ipsilateral infusion of prostaglandin E1 and phenylephrine were applied to the cyanotic and healthy twins respectively, to restore arterial oxygenation intraoperatively and to avoid profound hypoxaemia.

CONCLUSION

Surgical separation and anaesthesia should be well planned and rehearsed before clinical deterioration of the weaker twin. Aggressive pharmacological intervention and understanding of the cross-circulation pathophysiology is necessary to manage critical situations during surgical separation and in the postoperative period.

[Conjoined omphalopagous twins separated at fifteen days of age]

BACKGROUND

Conjoined (siamese) twins represent a rare situation which may occur in 1 of every 50,000 births. A prenatal diagnosis usually leads to stopping pregnancy. We report a case with successful surgical separation at the age of 15 days.

CASE REPORT

Ultrasonographic examination at 20 weeks of gestation showed omphalopagus siamese joined at the abdomen from the xiphoid process to the umbilicus. Conjoined structures included liver. There was a multicystic right kidney in one twin, without other malformation. Karyotype was normal, 46XX. The mother refused interruption of her pregnancy. Both girls were born by cesarean section. Angiography, magnetic resonance imaging and intravenous urography confirmed the ultrasound examination. There was no cross circulation into the liver and the gastrointestinal tract was not conjoined. The twins were separated at 15 days of age with right heminephrectomy of the multicystic kidney. The girls are now 16 months old and are in very good health.

CONCLUSION

Prognosis of siamese twins depends on the nature of joined structures and presence of malformations. Ultrasonographic examination during pregnancy shows the possibility of surgical separation, which is performed by a double anesthetic and surgical pediatric team. Preoperative investigations must include MRI.