Conjoined Twins - Update for Monday July 7, 2003

SINGAPORE (AP) _ Neurosurgeons working to separate Iranian twin sisters joined at the head completed one of the most dangerous steps Monday by rerouting a shared vein as thick as a finger that helped blood flow through their brains, a hospital official said.

An international team of five neurosurgeons successfully attached a vein graft before beginning the process of separating the brains of 29-year-old Ladan and Laleh Bijani in the unprecedented operation expected to last up to four days, a Raffles Hospital official said on condition of anonymity.

Doctors were not going to cut through the twins' fused skull bone and move their heads apart for the first time until determining that the vein graft was successful and making sure that there were no connections between the brains that escaped notice in pre-operative exams.

The women's brains touch inside their skulls, but going into the operation doctors did not believe the brains were joined. The sisters' bodies are otherwise distinct.

Rerouting the shared vein was considered the biggest obstacle in the surgery. German doctors told the twins in 1996 that the vein, which drains blood from their brains, made surgery too dangerous. ``There may still be some difficulties encountered, but up until now we are quite satisfied with the progress of the whole surgery,'' hospital spokesman Dr. Prem Kumar said Monday. ``They are stable, the anesthesia is working quite well, so we are cautiously optimistic.''

The operation could kill one or both of the sisters, but after a lifetime of compromising on everything from when to wake up to what career to pursue, the Bijani sisters said they would rather face those dangers than continue living joined. Before dawn, surgeons began stitching a vein taken from Ladan Bijani's thigh to one of the twin's brains to compensate for the removal of the shared vein, Kumar said. He would not say who received the original, finger-thick shared vein.

Classical music played softly as surgeons worked simultaneously in tight spaces in front of and behind the twins, who are sitting in a custom-built brace connected to an array of lines feeding them intravenously and monitoring their vital signs, Kumar said. ``Nothing is going on at a hurried pace,'' he said. ``Everything is quite calm and measured. There's lots of discussion.''

Surgeons had earlier encountered unexpected delays cutting through their skulls when the bone turned out to be denser than previously believed, Kumar said. ``The procedure took six hours _ longer than originally expected _ because the bones were thick and compact, especially in the areas where the two skull bones fuse,'' Kumar said. The twins spent months training at a gym to build up strength for the surgery and Kumar said they could be kept asleep for four days if necessary. The twins said they wanted to walk into the operating room as a sign of courage, but they were brought in by wheelchair because they were too tired to stand, Kumar said.

Participating neurosurgeon Dr. Benjamin Carson, the director of pediatric neurosurgery at Johns Hopkins Children's Center in Baltimore has successfully separated three sets of craniopagus twins _ siblings born joined at the head. However, this is the first time surgeons have tried to separate adult craniopagus twins. The surgery has only been performed successfully since 1952 on infants, whose brains can more easily adapt and recover. ``If God wants us to live the rest of our lives as two separate, independent individuals, we will,'' Ladan Bijani said before the operation.

The Bijani sisters were born in Firouzabad in southern Iran in 1974. In a statement read on state-run Iran television late Sunday, President Mohammad Khatami hoped for success. ``The prayers of the Iranian nation are with you,'' Khatami said in a message addressed to the medical team. ``I hope to see my patient daughters Laleh and Ladan healthy and fresh as soon as possible.'' An international team of 28 doctors and about 100 medical assistants were enlisted for the surgery.

Also Monday, the Iranian government said it would cover the nearly $300,000 cost of the surgery and care for the twins. Earlier, Raffles Hospital offered to underwrite the cost of the operation and doctors offered to waive their fees.

Update:

Surgeons Work to Separate Conjoined Twins

By D'ARCY DORAN
Associated Press Writer
July 07, 2003

Iranian conjoined twins Ladan, left, and Laleh Bijani speak to a group of reporters in Singapore in this June 11, 2003 file photo. A risky operation to separate the 29 year old sisters who were born joined at the head, began early Sunday and is now entering the critical phase as an International team of neurosurgeons work on rerouting a key vein. (AP Photo/Ed Wray)

Neurosurgeons separating 29-year-old Iranian sisters joined at the head cut through brain tissue millimeter by millimeter Tuesday after rerouting a thick, shared vein and stitching in a new one.

The team of doctors also contended with unstable pressure levels inside the twins' fused skulls as they began uncoupling the sisters' brains, a hospital official said. The risky, marathon procedure - which could kill both women - began about 10 p.m. EDT Saturday and could take four days.

The brains of Ladan and Laleh Bijani are separate, but after lying alongside each other for decades are nonetheless stuck together, a Raffles Hospital spokesman said.

"They have to be teased apart very slowly," Dr. Prem Kumar said. "Cut. Teased apart. Cut. Teased apart. In the process, you encounter a lot of blood vessels and other tissues. That's taking a long time.

"Parts of the blood vessel and the brain can be ripped apart if you're not careful," Kumar said, adding surgeons were working "millimeter by millimeter."

Dr. Marc Mayberg, chairman of neurosurgery at the Cleveland Clinic in Ohio, said surgeons could cut viable tissue if the twins' brains are fused together.

"But presumably, in the area where the two brains are touching, there isn't much function emanating from there at the moment, so theoretically one would think you could go through tissue like that," Mayberg said by telephone.

The operation was complicated further when the team discovered that the pressure in the twins' brains and circulatory system was fluctuating.

Kumar said the fluctuations were within "tolerable levels," but he was not prepared to immediately explain what would happen if that changed.

Mayberg said the pressure fluctuations could be fatal.

"If the pressure is due to the fact that there is insufficient drainage from this vein, in either cranium, that could be a life-threatening condition," he said.

On Monday, five neurosurgeons completed one of the most dangerous steps in the surgery by rerouting the shared vein and successfully attaching a vein graft from Ladan Bijani's thigh. The shared vein, thick as a finger, drained blood from the twins' brains to their hearts.

Although a large part of the twins' fused skull was severed in two, the blood vessels will not be disconnected - and the new vein will not be put to work in Ladan Bijani's head - until after the brains are separated, Kumar said. Their bodies are otherwise distinct.

Rerouting the shared vein was considered one of the biggest obstacles in the surgery. German doctors told the twins in 1996 that the surgery was too dangerous, but the Singapore team benefited from technological advances, Kumar said.

Excerpted from Tuscaloosa News

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