Al-Ahram Weekly Online   16 - 22 October 2003
Issue No. 660
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Separate lives

In just two weeks, two pairs of Egyptian conjoined twins -- one in the US and the other in Saudi Arabia -- have been surgically separated. Reem Nafie investigates

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From top: Talia and Taleen; Ahmed and Mohamed before the operations
At the Children's Medical Centre (CMC) in Dallas, Texas, Ibrahim Mohamed Ibrahim fainted when he was told the operation had succeeded, and he now had two separate children.

His two boys, Ahmed and Mohamed, were born on 2 June 2001. They were joined at the head. In fact, the two boys had separate brains, but shared the sagittal sinus, the main vessel that drains blood from the brain. The twins were moved from the tiny village of Al- Homr, near the southern city of Qus -- where they were born -- to Cairo University Hospital to undergo tests. The hospital's head of neonatal surgery -- Nasser Abdel-'Al -- recommended they try Dallas, where the chances for a successful separation surgery were relatively high.

The Dallas-based World Craniofacial Foundation (WCF), a non-profit group that helps children with deformities of the head and face, paid for and arranged the Egyptian twins' trip to Dallas in June 2002 for an evaluation. There, a team of WCF specialists determined the boys could be separated, although the risks included possible brain damage and death.

The issue ended up sparking a debate in religious circles in Egypt and America. Could one life be sacrificed for the sake of the other? Ahmed El-Tayeb, Egypt's mufti at the time, declared that the surgeons "were justified" if going through with the operation meant at least one of the twins might live. According to El-Tayeb, the matter would be different if the surgery was "experimental".

The boys' father told doctors the risk was worth it if it meant his boys may get a chance to lead a normal life.

The operation began on Saturday, and went on for nearly 34 hours -- ending late Sunday afternoon. Led by a team of 18 American doctors, the procedure began with an intricate disconnection of the blood vessels joining the two boys' heads. When the heads were physically separated, doctors then dealt with the head wounds and bone fragments exposed by the surgery, using tissue from the twins' thighs to treat them.

As of Al-Ahram Weekly's going to press, the twins were listed in critical but stable condition. They still face risks of stroke, infection, and neurological damage. Doctors are also concerned about how the wounds will heal; the boys will need additional reconstructive surgery in the coming years.

Ahmed and Mohamed were to remain in a drug-induced coma for three to four days, and will remain at CMC until they are stable. Doctors expect they will head back to North Texas Children's Hospital at Medical City Dallas, where they were being cared for before the operation at CMC, by Thursday.

Kenneth Salyer, the craniofacial surgeon who founded the organisation that brought the boys to Dallas, said his feelings had ranged "from moments of ecstasy to moments of anxiety", during the operation.

At a press conference on Sunday afternoon, some of the members of the medical team that performed the operation fielded questions about the boys' future. "We're very pleased with the surgical outcome," said Dale Swift, one of five pediatric neurosurgeons involved, "but the post-surgical care is extremely important -- it really can determine your outcome. So right now, we're waiting."

Only a week earlier, another set of Egyptian twins -- two four- month-old girls named Talia and Taleen -- were surgically separated at the King Abdul- Aziz Medical City (KAMC) in Saudi Arabia. That seven-hour operation was aired live on Arab satellite channel ART.

Unlike Ahmed and Mohamed, Talia and Taleen were conjoined in the liver, stomach and chest areas. The 45 doctor team was led by Abdullah Al- Rabia, the Saudi Arabian executive manager of KAMC, who told the Weekly that the children should be back in Egypt by the start of Ramadan (which is set to begin near the end of October this year) after "a safe recovery period in Saudi Arabia".

The one million Saudi riyal operation (around LE2 million) was bankrolled by Crown Prince Abdullah Bin Abdul- Aziz, as a gesture of "cooperative efforts between Arab nations".

According to Al-Rabia, the toughest part of the surgery was separating the liver, which the doctors managed to do without losing a large amount of blood, which could have jeopardised the children's survival. When the two girls were physically separated, doctors began performing plastic surgery using skin taken from both girls to patch the exposed stomach and chest areas.

A day after the operation, at the Pediatric Intensive Care Unit, Talia and Taleen were weaned off the artificial respirator, and then the arterial and venous catheters were removed. "Apart from a low-grade fever," said Al-Rabia, "there were no major complications."

According to Al-Rabia, "operations on Siamese twins began in Saudi Arabia in 1990, and since then seven twins have been separated in major and successful procedures. Two smaller cases of parasitic twin separation were also handled. Overall, our centre has worked with a total of 21 cases in the past 13 years, nine of which went to surgery."

Al-Rabia attributed what appeared to be a recent increase in the number of conjoined twins to either "hormones mothers use before pregnancy, or increased pollution". He cushioned the statement, however, with a warning against making generalisations, emphasising that these are "random cases".

In Rome, meanwhile, a set of four- month-old twin girls from Greece who were joined at the temple were also operated on. The ANSA news agency said the 12-hour surgery was relatively simple because the infants didn't share any organs.

Of the five other most recent separation operations around the world, only three were fully successful. In one of the other cases, one of the twins died. In another, both passed away.

This latter case had captured the world's attention. During their separation surgery in Singapore last July, 29- year-old Iranian twins Laleh and Ladan Bijani died within 90 minutes of each other as a result of massive blood loss.

Al-Rabia said operating on the Iranians meant taking a "wild chance", since the "age and weight of the conjoined twins plays an important role in the operation's chances of success". Surgeons prefer to operate on twins with a combined weight of 8-10 kilogrammes; otherwise the operation becomes "more difficult", and the children need extensive "psychotherapy" later on.

While the Dallas separation basked in the global media spotlight, the operation in Saudi Arabia has been far lower key. That was one of the impetuses behind the decision to air the surgical process live on television, Al-Rabia said -- "to show the world that Arab health care can compete and compare with health care in other countries".

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