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Complications hit twins operation

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Complications hit twins operation

There were some unexpected delays during the first phase of the surgery

Surgeons carrying out an operation to separate conjoined Iranian twins have warned that the operation will take longer than anticipated.

Neurosurgeons have discovered that the brains of Ladan and Laleh Bijani have become tightly fused over the past 29 years.

But doctors have overcome their first big hurdle, successfully re-routing a shared vein that drains blood from the twin sisters' brains.

A team of 28 doctors and 100 medical assistants are involved in the surgery to separate the twins, who are joined at the head.

Doctor Prem Kumar, speaking at a press conference at Raffles Hospital, Singapore said: "The brains are very adherent to each other. That means we have to be very careful. You can't just tear them apart."

"The neurosurgeons have to cut through the brains very carefully, literally millimetre by millimetre."

"In the process, we have encountered a lot of blood vessels and a lot of tissue that is taking a long time to separate," Dr Kumar said.

The operation is being further complicated because the blood circulation between the twins is unstable.

"There is still blood flowing between the two of them," Dr Kumar said.

"It means that the blood pressure needs to be monitored all the time."

"We anticipate that the process of separating the brain will continue well into the night and into tomorrow."

The operation began before dawn when surgeons began stitching a vein taken from Ladan's thigh to one of the twin's brains to compensate for the removal of the shared vein, chief surgeon Dr Kumar said.

If God wants us to live the rest of our lives as two separate independent individuals, we will -Ladan Bijani

Message from Bijanis

Surgeons are working 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, he added.

Iranians living in Singapore and around the world have gathered at Raffles Hospital to pray for the Bijani sisters as they undergo the surgery.

"I hope it will be successful and we pray a lot and we read the Koran," Azimi Shahin, 50, a businessman who has lived in Singapore for 20 years, said after taking time off work to come to the hospital on Monday.

Quality of life

After the separation, the doctors will perform the final surgical reconstruction of the skin and soft tissue on the exposed area of their heads, using muscle and skin grafts.

The twins were told they had only a 50-50 chance of survival, but said they are willing to risk death for the chance to lead separate lives.

The operation marks the first time surgeons have tried to separate adult craniopagus twins - siblings born joined at the head - since the operation was first successfully performed in 1952.

German doctors had turned away the Bijanis in 1996, deeming the operation to be too risky.

The chief surgeon at Raffles, Dr Keith Goh, said he had weighed up quality of life against risk before deciding to proceed.

The Iranian sisters said they understood the risks, but were still keen to go ahead with an operation they have wanted for years.

Now aged 29, they have become well-known in their home country for their courage and academic success - both are law graduates.

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Iranian Twins Die in Separation Surgery

By D'ARCY DORAN, Associated Press Writer

SINGAPORE - Iranian twins Laleh and Ladan Bijani, joined at the head for 29 years, died within 90 minutes of each other Tuesday after doctors separated them but were unable to control their bleeding in the unprecedented surgery.

In their homeland, people cried out in shock or wept as state television broke into normal programming to announce their deaths during the third day of surgery in Singapore.

"Is my beloved Ladan really not with us anymore?" Zari Bijani, an elder sister of the twins, said after Ladan's death was reported. Seconds later, she fainted.

Hospital officials said Ladan died 90 minutes ahead of her sister Laleh, with both deaths because of blood loss. They died while still under anesthesia.

"Everyone upstairs is crying," said the nurse, speaking on condition of anonymity. "We treated them like family because they had been here for seven months."

It was the first time surgeons tried to separate adult craniopagus twins — siblings born joined at the head. The surgery has been performed successfully since 1952 on infants, whose brains can more easily recover.

The twins had gone into the surgery saying they knew the risks but wanted to achieve their dream of living independent lives — Laden wanted to continue as a lawyer, Laleh wanted to switch to become a journalist. Speaking in English to journalists last month, their joined heads wrapped in a single scarf, the smiling and laughing sisters said they wanted for the first to look at each other face-to-face.

"We have different ideas about our lives," Laleh said. "Actually, we are opposites," Ladan interrupted, laughing.

"If God wants us to live the rest of our lives as two separate, independent individuals, we will," Ladan said before the final tests Saturday ahead of the surgery.

The risky, marathon separation procedure began about 10 p.m. EDT Saturday. Before the operation, doctors warned that the surgery could kill one or both of the twins, or leave them brain-dead.

"When we undertook this challenge, we knew the risks were great. But we were hopeful. Ladan and Laleh knew the risks too," said Dr. Loo Choon Yong, chairman of Raffles Hospital. "As doctors there is only so much we can do as the rest we have to leave it to the Almighty."

From the start, doctors ran into unexpected obstacles not found in the infants that the operation has until now been performed on. It took longer to cut through portions of the sisters' skulls because their older bones were denser than previously believed.

And though the Ladan and Laleh's brains were separate, they had adhered to each other after years of growing and sharing the same space. That forced doctors to meticulously cut the organs apart, "millimeter by millimeter," Raffles hospital spokesman Dr. Prem Kumar said.

"As the separation was coming to a close, a lot of blood was lost. The twins were subsequently in a critical state," said Kumar.

Working in two groups, surgeons gave each twin blood transfusions, but in the end they were unable to cope with the unusual blood flow patterns, he said.

"I was concentrating very hard on Laleh at the time," lead neurosurgeon Dr. Keith Goh said, recounting the moment when he knew the operation had gone wrong. "I was very saddened when I looked over and saw them struggling, of course at the same time, we were struggling too."

A crucial part of the surgery had been to deal with a finger-thick vein shared by the sisters that drained blood from the brain. In 1996, German doctors had told the twins that shared vein made surgery too dangerous.

During the operation, the surgeons grafted a similar sized vein from Ladan's right thigh to her brain, then rerouted the shared brain to her sister.

But Ladan's new vein became congested, and surgeons Monday night considered wheter to call off the rest of the operation and leave the twins joined or "continue with final stage of the surgery, which we knew would be very, very risky," Loo said.

"The team wanted to know once again what were the wishes of Ladan and Laleh," Loo said. "We were told that Ladan and Laleh's wishes were to be separated under all circumstances."

For more than 50 hours, the team of 28 doctors and about 100 medical assistants worked in tight spaces in front of and behind the twins, who were in a sitting position in a custom-built brace connected to IVs and monitors. Classical music played softly, and surgeons whose expertise was not needed at the moment would slip out of the room for rest.

In the final hours, the surgeons had to contend with unstable pressure levels inside the twins' brains just before they worked to uncouple the sisters' brains and cut through the last bit of skull joining them, Kumar said.

"I am very sad, as all of us are," Goh said. "Over the last six months, everyone who came in contact with them was touched by their personalities and the kind of people they were."

The courage of the twins won them a place in the hearts of Iranians. Television devoted many programs to the twins. Newspapers published page after page about their life and the protracted operation.

Parents of the twins, Dadollah Bijani and Maryam Safari, thanked the Iranian nation for praying for their children, the state-run Tehran radio reported.

"It's a national tragedy," said Ahmad Mahmoudi, a photographer in Tehran.

Housewife Noushin Nowrouzi promptly parked her car after she heard the news on the radio so she could cry in peace.

The sisters were born into a poor family of 11 children in Firouzabad, southern Iran, but grew up in Tehran under doctors' care.

The Iranian government said Monday it would pay the nearly $300,000 cost of the operation and care for the twins.

Participating neurosurgeon Dr. Benjamin Carson, director of pediatric neurosurgery at Johns Hopkins Children's Center in Baltimore, has separated three sets of craniopagus twins.

____

Editor's Note: Emma Ross, an AP medical writer, contributed to this story from London; AP writer Ali Akbar Dareini contributed from Tehran.

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