Separation Of Twins Research Articles

Born Apart, but Raised Together: Twins Delivered in Different Countries/Twin Research Reviews: Hallermann-Streiff Syndrome in Monozygotic (MZ) Twins; Effects of Technology on Conjoined Twin Separation; Reciprocal DIEP Transplantation Between MZ Twins; Guidelines for Multifetal Management/Media Reports: Book by World’s Oldest Auschwitz-Birkenau Twin Survivor; Passing of Ian Wilmut; Zhores Medvedev Was an Identical Twin; More Gay Fathers with Twin Sons; Twins

AbstractThe circumstances and subsequent life events of the first twins to have been born in different countries are examined. Given that both twins were born in the United Kingdom, their common citizenship was never questioned. In contrast, twins born in Canada to a legally married gay transnational couple — composed of one American and one Israeli — were assigned as citizens of different nations and their parents were regarded as if unmarried. This essay is followed by reviews of research on the Hallermann-Streiff syndrome in monozygotic (MZ) twins, the effects of technology on conjoined twin separation, reciprocal deep inferior epigastric perforator (DIEP) transplantation in MZ twins and new guidelines for managing multifetal pregnancies. Finally, media reports on a book by the world’s oldest Auschwitz-Birkenau twin survivor, the passing of Dr Ian Wilmut, the identical twinship of Zhores Medvedev, another case of gay fathers with twin sons, twins and siblings admitted to medical school, and the first and fourth records for major league baseball twins are presented.

Twin Research and Human Genetics - News, Views & Comments: Memoirs and Autobiographies by Twins: Research Angles and Human Interest/Twin Research Reviews: Fetal Reduction in Twin Pregnancy; Twins' Personality and Military Service; Growth Restriction in Twins; Advances in Conjoined Twin Separation/Media Reports: Update on Scientist Who Performed Gene Editing on Twins; Twins From 33-Year-Old Embryos; Twins' Outcomes From Dietary Differences;

Twins' memoirs and autobiographies both enlighten and entertain. These works, often overlooked by researchers, may suggest new avenues for investigation, such as nonshared environmental events that propel twins in different directions. Of course, MZ twins' generally parallel experiences and DZ twins generally criss-crossing paths are the bases of fascinating life stories. The following sections examined recent research on fetal reduction in twin pregnancy, twins' personality and military service, growth restriction in twins, and advances in conjoined twin separation. This article closes with reports of a scientist who performed gene editing on twins, a twin conception from 33-year-old embryos, twins' physical outcomes from dietary differences, fraternal twins with the world's largest height difference and the Twin Home Experts who conquer rat infestation in New York.

Separation of conjoined spinal cords in symmetrical pygopagus twins using intraoperative neuromonitoring: pearls and pitfalls

Pygopagus twin is a rare congenital malformation with a worldwide incidence of 1in 200,000. Few literature reports are published regarding the matter. In some cases, neuromonitoring is essential for safe surgical separation. We believe it is important to share our challenges and nuances in order to minimize obstacles one might encounter. We utilized neuromonitoring during our separation of both twins, and we planned a multidisciplinary approach and efficient communication system with the other teams in order to plan a successful, safe, and timely separation of the twins. We seek to highlight not our success but rather the obstacles and challenges we encountered during the separation of pygopagus twins in our institute using neuromonitoring for future reference.

A successful separation of omphalopagus twins during COVID-19 pandemic: A case report

Background: Omphalopagus is a rare condition involving digestive system and abdominal wall fusion. This study reports an omphalopagus case during the early phase of the coronavirus disease 2019 (COVID-19) pandemic in Indonesia.Case: Male conjoined twins, aged 14 months, were diagnosed with omphalopagus and several organ failures. We performed separation surgery of the omphalopagus with primary closure and post-surgical care for fifteen days. The early surgery was preferable in this case due to life-threatening issues of COVID-19, despite omphalopagus separation may cause post-surgical complications. Furthermore, the emerging pandemic conditions also required a more stringent procedure to avoid the risk of viral spread.Conclusion: We conclude that, in the lack of evidence-based instruction for hospital care during the early phase of COVID-19 in Indonesia, life-saving surgical considerations from death due to complications of COVID-19 infection and acute respiratory distress syndrome must be performed and prioritized. However, potential omphalopagus complications must be evaluated.

Successful emergency separation of premature omphalopagus conjoined twins: an anaesthetic experience

Anaesthesia for early emergency separation of premature conjoined twins is extremely rare as surgery generally done electively between 2 to 4 months of age. However, urgent separation may be needed due to life-threatening complications. We report a case of successful early separation of premature omphalopagus twins at 36 weeks of gestational age with a combined weight of 2.7 kg. To the best of our knowledge, this was the lowest weight yet reported of successful surgical separation in Malaysia. Early separation was indicated as extrauterine twin-to-twin transfusion with unbalanced blood shunting through the porto-systemic anastomoses within the shared liver parenchyma potentially risked impending life-threatening organ failures. Anaesthesia for the separation of premature conjoined twins in the emergency setting requires extensive multidisciplinary discussion and planning. Factors predicting difficult anaesthesia in this case were the twins’ size and age as well as duration of anaesthesia. Two separate anaesthetic teams were required with all team members well versed in the operative workflow. Simultaneous airway management, prevention of hypothermia, and vigilant haemodynamic monitoring are key to successful anaesthesia in premature conjoined twin separation.

Low-cost simulation technique in planning and preparing perioperative team for conjoined twins separation surgery

Summary: The authors present a low-cost simulation technique to discuss the airway management, the surgical technique, the problems to be faced by the anesthesia and the operating teams, and how to proceed with the operative surgery to separate the conjoined twins.
 Key words: Conjoined twins; Simulation
 Citation: Shamim F, Syed R, Siddiqui K, Khan FA. Low-cost simulation technique in planning and preparing perioperative team for conjoined twins separation surgery. Anaesth. pain intensive care 2022;26(2):833−834.
 DOI: 10.35975/apic.v26i6.2059

The Multidisciplinary Perioperative Management of Conjoined Twin Separation Surgery During the Pandemic.

Conjoined twin management, especially separation surgery, is a complex procedure which requires multidisciplinary work in the perioperative period. This complexity further increased with the COVID-19 pandemic, where social distancing protocols and the general reduction in non-COVID-19-related health-care services added a new dimension to the modern form of teamwork. This study focused on the process of preparation for conjoined twin separation surgery during the pandemic from March 2020 to May 2022 with pre-pandemic era comparison. We described the decision-making process and the available facilities in terms of equipment, human resources, and the inclusion of information and technology. Among the essential requirements for separation surgery are doctors from various disciplines, pediatric anesthesiologists, nurses from different specialties, radiologists, rehabilitation specialists, nutritionists, pharmacists, psychologists, social workers, public relations, and information and technology staff. The team composition may change depending on the patient's clinical characteristics and social needs. Surgery preparation consists of a prognostication period, preoperative management, surgery, and discharge. Complex surgery such as conjoined twin separation can be managed effectively by a team of multidisciplinary experts. The application of information technology, to manage changes in multidisciplinary work pre- and post-pandemic, can reduce pandemic-related social restrictions while maintaining effectiveness and increasing efficiency.

Impact of Technology on Conjoined Twin Separation: Are We Further Ahead?

The success of conjoined twin separation has increased since the 1950s, notwithstanding the numerous technical and physiologic challenges encountered in such procedures. Together with improvements in our understanding of conjoined twin physiology and the accumulation of surgical expertise, technological advances have largely paralleled the improvement in outcomes. In particular, advances in imaging modalities, adjuncts to abdominal wall closure such as mesh and tissue expansion, and three-dimensional modeling have been instrumental in advancing care for these patients. Considered together, these domains have allowed multidisciplinary teams to better delineate conjoined anatomy, facilitated improved surgical planning and decision-making, and assisted in overcoming the frequent challenges associated with soft-tissue closure. This review delineates the improvements in these modalities and their relationship to increasingly successful conjoined twin separation in recent years.

Surgical Separation of Pygopagus Conjoined twins at Holy Family Hospital Rawalpindi; a Neurological Surgery Perspective and Outcomes: a Case Report

Objective: Objective: Conjoined twins are considered to be the result of aberrant embryogenesis with incomplete embryonic separation. Estimated incidence of Conjoined twins is 1:50,000 pregnancies, and 1:200,000 live births, in new-borns with a female predominance of 3:1. Conjoined twins are classified into different subtypes according to the site of fusion: Thoracopagus, Omphalopagus, Pygopagus, Ischiopagus, and craniopagus. Even in conjoined twins, Pygopagus has an incidence of 6-19%; subsequently, not many cases have been reported worldwide. Case: This case report is about 6 months old female Pygopagus conjoined twins who fused at the lumbosacral level with a shared spinal canal. They were successfully separated in Pakistan with great success and had no neurological deficits on consequent follow-ups. An adequate build-up of physiological parameters until twins are old enough to undergo separation with multi-disciplinary management is the cornerstone of the successful management and separation of Pygopagus twins which is only possible in planned elective settings. Whereas emergency separation in the background of concomitant sepsis and sharing of vital organs carries high mortality and raises valid ethical questions regarding which life to prioritize saving and what organs to give to either viable child in case of shared CVS, GIT, and genitourinary systems.

Conjoined Twin Separation: Review of 30-Year Case Experience and Lessons Learned.

Conjoined twinning is a rare medical phenomenon, and numerous challenges remain with respect to surgical separation and reconstruction. The purpose of this study is to present a detailed discussion of the authors' institutional experience with eight conjoined twin separations over the past three decades, focusing on challenges and lessons gleaned from these cases. The records of all patients who underwent conjoined twin separation at The Hospital for Sick Children in Toronto, Ontario, Canada, from 1984 to 2018 were retrospectively reviewed. Eight sets of conjoined twins were analyzed. Half of the sets [ n = 4 (50 percent)] were female. There were four sets (50 percent) of ischiopagus twins, three sets (37.5 percent) of omphalopagus twins, and one set (12.5 percent) of craniopagus twins. The median age at separation was 6.75 months. The mean durations of intensive care unit and hospital stay were 14.1 ± 12.9 days and 4.9 ± 4.8 months, respectively. Mean length of follow-up was 6.7 ± 4.4 years. Three deaths occurred in our series, with an overall survival rate of 81 percent. Two sets of twins experienced expander-related complications such as infection and bowel perforation. Three twins required reoperation because of flap necrosis or dehiscence after separation. The authors' results highlight the unique nature of each operation and the great ingenuity required in managing the particular considerations of each case and also adhering to a systematic approach of evaluation and planning. A number of novel strategies were used at the authors' center and have now become commonplace. The lessons learned from such procedures may improve care for future generations of patients. Therapeutic, V.

A Century With Craniopagus Twin Separation Surgeries: Nihilism to Optimism.

Craniopagus conjoined twins are extremely rare, reported 1 in 2.5 million live births. To date, 62 separation attempts in 69 well-documented cases of craniopagus twins have been made. Of these, 34 were performed in a single-stage approach, and 28 were attempted in a multistage approach. One or both twins died of massive intraoperative blood loss and cardiac arrest in 14 cases. We report our surgical experience with conjoined craniopagus twins (JB) with type III total vertical joining and shared circumferential/circular sinus with left-sided dominance. A brief review of the literature is also provided. In our twins, the meticulous preoperative study and planning by the multidisciplinary team consisting of 125-member, first-staged surgical separation consisted of creation of venous conduit to bypass part of shared circumferential sinus and partial hemispheric disconnection. Six weeks later, twin J manifested acute cardiac overload because of one-way fistula development from blocked venous bypass graft necessitating emergency final separation surgery. Unique perioperative issues were abnormal anatomy, hemodynamic sequelae from one-way fistula development after venous bypass graft thrombosis, cardiac arrest after massive venous air embolism requiring prolonged cardiopulmonary resuscitation, and return of spontaneous circulation at 15 minutes immediately after separation. This is the first Indian craniopagus separation surgery in a complex total vertical craniopagus twin reported by a single-center multidisciplinary team. Both twins could be sent home, but one remained severely handicapped. Adequate perioperative planning and multidisciplinary team approach are vital in craniopagus twin separation surgeries.

Successful Separation of Siamese Twins at Conakry University Hospital

Introduction: The birth of conjoined twins is an event extremely rare which offers unique therapeutic challenges and circumstances. Each situation must be examined with the many questions that arise and which sometimes require a long reflection. We report a case of separation of pygopage twins as well as a review of the literature. Patients and Observation: A pair of conjoined twins of 11 days of life, weighing 3080g between them, was referred to the neonatal service from the Faranah prefecture, 300 km from Conakry, for treatment. The mother, a 30-yearold housewife, multiparous, eight gestures and nine parities, had not followed any prenatal consultation. The birth took place at home in a village with the death of the mother in the immediate postpartum period. The clinical and para-clinical investigation had concluded with the diagnosis of Siamese pygopage type. After a multidisciplinary consultation, the surgical treatment by separation of the twins was carried out at the age of 50 days with success and conservation of physiological functions. Conclusion: The birth of conjoined twins is extremely rare. Each pair of Siamese is different and the surgical strategy must be adapted according to the shared organs. The perfect multidisciplinary work of the nursing staff has been the main contribution to our success.

First Successful Separation of Craniopagus Twins in India-Plastic Surgical Considerations.

Separation of total vertical craniopagus with shared venous sinuses poses multiple challenges. Provision of soft-tissue cover to the exposed brains at the time of total separation is one of them, due to the large size of the defect and paucity of local tissues. Staged separation of twins is advised with partial venous and parenchymal disconnection in the first stage and total separation in the second stage. Tissue expanders are inserted in the first stage, and second stage planned to coincide with the period of adequate expansion. In the child being reported, emergency second stage was done due to the deteriorating general condition of the children. Left with inadequate expanded skin, the critical defect in a twin was managed with bilateral trapezius myocutaneous flaps. High ionotropic support of the postoperative period resulted in superficial necrosis of the flap, which was managed by debridement, allograft application and autograft later. Both twins had well-healed wounds by 3 months.

Successful Anesthetic Management from Separation Surgery of Pygopagus Conjoined Twin; Lesson-Learning With A Teleanesthesia

Introduction: The management of conjoined twins requires multidisciplinary teamwork. The complex problems in conjoined twin separation surgery are challenging for anesthesiologists without experience in the management of conjoined twins. Objective: To describe anesthetic management and utilization of teleanesthesia in conjoined twin separation surgery. Case Report: Sixty days-old pygopagus type conjoined twins, with a total body weight of 7030 grams. Both babies looked healthy, moved actively, found no respiratory function disorders, were hemodynamically stable and had no congenital abnormalities. The sacral region's computerized tomography scan (CT-scan) reveals conjoined twins with skin unification and subcutaneous in the perianal region and no internal-vertebral-spinal fusion. Two anesthesia teams performed the management of anesthesia. After confirming there was no cross-circulation with the atropine test, we alternately induced anesthesia by inhalation technique while maintaining spontaneous breathing. Anesthesia was maintained with sevoflurane 2.0-3.0 vol%, in a mixture of oxygen and air with a flow of 4 L/min using Jackson Reese. Circulating volume, hemodynamic stability, and normothermia were maintained intraoperatively. The separation surgery lasted 20 minutes, and the total surgical time for each baby was two hours. Awake extubation was performed immediately after the surgery was complete. Both babies underwent postoperative care at the PICU and were discharged on day 11. During the pre-operative for surgery, the local team conducted telemedicine consultations with the pediatric anesthesia team at Dr. Soetomo hospital and performed intra-anesthesia telementoring. Conclusion: Careful preparation and pre-operative evaluation, proper intra-anesthesia maintenance and monitoring, as well as good communication and teamwork, are keys to successful anesthesia management in conjoined twin separation surgery. Consultation and assistance from an experienced team during surgery using teleanesthesia are significantly beneficial to the anesthesiologist without experience in conjoined twin separation surgery.

Exploration of Twin Separation and Adult Experiences: A Qualitative Study

Many researchers have studied the long-term impact of nontwin sibling separation in foster care, but little is known about the separation of twins. In this study, we examined how one specific set of adult fraternal twin sisters interpreted their personal experiences of separation from each other while in foster care and whether this experience affected their interpersonal relationships. The researchers relied on the theoretical foundations of attachment theory to support the use of existing literature and to integrate the research findings into current child welfare practice for human services professionals. Through personal interviews, each twin was asked to recall experiences from foster care and comment on the effects of being separated from their twin. Thematic analysis of the interview data and observations of the interview process helped to identify four themes: forming successful attachments, mental health issues, trauma history, and number and type of placements experienced. Implications for human services professionals working in social services agencies with youth in foster care are also discussed.

Erratum to: Emergency Separation of Extreme VLBW Omphalopagus Twins: Case Report

[This corrects the article DOI: 10.1055/s-0042-1750134.].

Thoraco-omphalopagus twins with complex biliary tree, pancreatic and intestinal anatomy: Planning behind successful separation, “the Santorini difference”

Here we report the separation of thoraco-omphalopagus twins at week 17th after birth, that are already 11-year-old and performing satisfactorily at the family, school, and social level. At birth, hearts shared a common pericardium and livers were fused along the anterior edge. Small bowel was common from duodenum down to the terminal ileum and invested by a dual mesentery. From the bifurcation bowels were normal. Bile and pancreatic ducts discharged into the duodenum but whether they were fused, or not, and details of the terminal ducts did not show up in the study. Vasculatures were independent. Teams -anesthesia, reconstructive, cardio-surgery, digestive, management-were formed and given specific tasks. Separation, programed for week 24, was performed at week 17 due to an emergency. In the intervention, the central step was the exploration of bile and pancreatic discharges. The duct of Santorini was searched for and identified; it discharged at the minor papilla in the duodenum prior to fusion. Both Wirsungs and the already fused common bile duct discharged in a single major papilla in a fused duodenum. The distance between papillae allowed for a duodenal transection between them. This scenario, considered during planning, commanded the separation. T1 kept the major papilla, while T2, the minor papilla complemented with a cholecystojejunostomy. Careful planning and management were keys to overcome both emergency and incomplete preoperative information.

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

The Outcomes of Surgical Separation in Thoracopagus Twins with Conjoined Hearts: An Analysis of the Literature.

We sought to perform a comprehensive review of reported cases of conjoined thoracopagus twins with cardiovascular conjunction to determine the overall survival after separation and factors that might be associated with survival. We performed a systematic review of cases of thoracopagus twins with conjoined cardiovascular systems reported in the English medical literature using Embase, PubMed, Web of Science, and Scopus. We employed standard statistical methods to analyze differences among groups. We identified 102 unique cases of thoracopagus twins (69% female) with some degree of cardiovascular conjunction who had undergone surgical separation. We identified 6 distinct types of cardiovascular union. Median age was 47days (IQR 12, 120). Survival to at least hospital discharge occurred in 51% (105/204). Median age at separation was lower in emergent (9days, IQR 1, 25) versus elective cases (93days, IQR 49, 180) (p < 0.0001). Survival to hospital discharge was higher in those who underwent elective separation (70%, 93/132 total children versus 17%, 12/72) (p < 0.0001). Survival was associated with the type of cardiovascular union (p < 0.0001). The separation of thoracopagus twins with cardiovascular conjunction is higher than expected. Increased survival is associated with elective separation, older age, and shared pericardium only. These findings suggest survival could be improved with better delineation of degree of union and delayed separation.

Anatomical features and challenges in separation and reconstruction of heteropagus twins

Heteropagus twins are an extremely rare condition and the term describes asymmetrical conjoined twins in which one twin (“autosite”) has a mostly intact body and the other twin (“parasite”) remains anatomically incomplete but is attached to and nourished by the other one. Autosites may show severe malformations themselves that are not associated with the twins’ fusion. Beyond the challenge of surgical separation further complex reconstructions may be necessary. In this case series we want to demonstrate that despite complex anatomic features, good functional (e.g. gastrointestinal, genitourinary and motoric) and aesthetic results can be achieved.