A philosophical approach to conjoined twins

'Mutiny on the crown': two cases of rare cephalic malformations

The presentation and management of two bizarre congenital cephalic curiosities at the two extremes of the clinical spectrum are discussed herewith. Case 1: presented to us as a neonate with a scalp swelling mirror-imaging her head and face. The journey from clinics to wards and to the operation theatre and to her home is introspected. Case 2: presented to us as dicephalous dibrachius dipus parapagus conjoined twins. The detailed work-up of individual organ systems, the multidisciplinary approach to management and the final outcome are discussed. This is an unsolved mystery for the anatomists, paediatric surgeons, radiologists and the medical fraternity at large.

Conjoined twins and legal authorization for abortion

OBJECTIVE

To describe pregnancies with conjoined twins according to the request for legal termination of pregnancy.

METHODS

Retrospective review of pregnancies with conjoined twins, with no possibility of extrauterine survival or postnatal surgical separation, observed at a tertiary teaching hospital, between 1998 and 2010.

RESULTS

Amongst 30 cases seen during the study period, six (20.0%) couples decided to continue with the pregnancy, termination of pregnancy was not requested due to advanced gestational age (> 25 weeks) in 5 cases (16.7%). Legal authorization to terminate the pregnancy was requested in 19 (63.3%) cases: permission was granted in 12 (63.2%), denied in five (26.3%) and information was missing in two (10.5%) cases. A successful vaginal delivery was performed in 83.3% of the cases undergoing termination of pregnancy and a cesarean section was performed in all the remaining cases (p < 0.01).

CONCLUSION

In pregnancies with conjoined twins and without fetal prognosis, legal termination of the pregnancy is an alternative. Moreover, a successful vaginal delivery can be performed in most cases before the third trimester, further reducing maternal risks and parental suffering.

Long-term urological outcomes in six sets of conjoined twins

AIM

To review the long-term urological outcomes of six sets of ischiopagus and pygopagus conjoined twins. Emphasis is placed on the particular genitourinary challenges of separation, reconstruction and monitoring of these patients.

PATIENTS AND METHODS

We performed a longitudinal, retrospective analysis of six sets of conjoined twins who presented to a single center and describe their long-term urological outcomes.

RESULTS

Six sets of ischiopagus (4) and pygopagus (2) conjoined twins presented from 1993 to 2003 and have been followed up for a mean of 12 years (range 7-17 years). Separation was achieved in 5/6 cases; the remaining one died of intestinal perforation and resultant sepsis. One further child died of malaria after separation. Patterns of genitourinary anatomy found in these conjoined twins are described. Urinary continence was achieved in 2/6 ischiopagus and 3/4 pygopagus twins. Renal failure has developed in one child. Urinary tract infections have been common. Secondary urological surgery has been required in 3/6 ischiopagus twins, usually to perform an incontinent urinary diversion.

CONCLUSION

Complex urological problems occur in ischiopagus and pygopagus conjoined twins. Beyond the challenge of surgical separation, they continue to provide management challenges requiring secondary reconstructive surgery and close urological monitoring.

Prenatal Management and Postnatal Separation of Omphalopagus and Craniopagus Conjoined Twins

Two cases of prenatally diagnosed conjoined twins are presented: a set of omphalopagus twins sharing a common liver, and a set of craniopagus with involvement limited to the skull. In both cases, prenatal diagnosis allowed accurate planning of pre- and postnatal management. Prenatal management involved serial imaging and counseling with participation of different specialists according to imaging findings. In the rare case of conjoined twins, an interdisciplinary approach is required, with feto-maternal specialists playing a pivotal role in co-ordinating teamwork and planning successive stages of management.

Acute abdominal pain in a separated conjoined twin

Complications of conjoined twins are typically events surrounding the birth and surgical separation. We report an unusual late-onset complication, a grade IV duodenal disruption of the accessory system in a formerly conjoined twin. Because conjoined twins have unique anatomy based on the junction and division of organs, one must always consider a multitude of causes for common complaints. Basic operative principles apply: the acute abdomen must be explored. Finally, to avoid these complications, removal of all or nearly all parasitic structures must be considered at the initial separation.

Dicephalus conjoined twins: a historical review with emphasis on viability

Dicephalus conjoined twins (2 heads on 1 body) form a distinct subgroup. They are often stillborn because of cardiopulmonary malformations. This article describes 17 historical cases with particular emphasis on viability. There are reliable reports of unseparated dicephali reaching maturity; 1 pair (the Tocci brothers) reached at least 34 years of age. In the absence of concomitant cardiac, pulmonary, and intestinal malformations, dicephalus conjoined twins may well attain adulthood. This appears to be unrelated to whether they have 4 (dicephalus tetrabrachius) or 3 (dicephalus tribrachius) arms at birth.

Intelligence test scores from infancy to adulthood for a craniopagus twin pair neurosurgically separated at 4 months of age

Long-term effects in a neurosurgically separated twin pair were illuminated by standard psychological test scores obtained over a period from 2 to 38 years of age. Interdigitation of the gyri of their right frontal lobes had necessitated separation in two stages at 4 months of age. One twin clearly suffered some brain injury and showed some impairment during the testing at 5 years of age. The scores of both twins rose at the adult testing. The brighter twin has an IQ comparable to that of the mother. The unique data set is a kind of model for long-term assessment of early brain surgery, particularly with craniopagus twins.