Successfully Separated Research Articles

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.

Narrowband multivariate source separation for semi-blind discovery of experiment contrasts

BackgroundElectrophysiological recordings contain mixtures of signals from distinct neural sources, impeding a straightforward interpretation of the sensor-level data. This mixing is particularly detrimental when distinct sources resonate in overlapping frequencies. Fortunately, the mixing is linear and instantaneous. Multivariate source separation methods may therefore successfully separate statistical sources, even with overlapping spatial distributions. New MethodWe demonstrate a feature-guided multivariate source separation method that is tuned to narrowband frequency content as well as binary condition differences. This method — comparison scanning generalized eigendecomposition, csGED — harnesses the covariance structure of multichannel data to find directions (i.e., eigenvectors) that maximally separate two subsets of data. To drive condition specificity and frequency specificity, our data subsets were taken from different task conditions and narrowband-filtered prior to applying GED. ResultsTo validate the method, we simulated MEG data in two conditions with shared noise characteristics and unique signal. csGED outperformed the best sensor at reconstructing the ground truth signals, even in the presence of large amounts of noise. We next applied csGED to a published empirical MEG dataset on visual perception vs. imagery. csGED identified sources in alpha, beta, and gamma bands, and successfully separated distinct networks in the same frequency band. Comparison with Existing Method(s)GED is a flexible feature-guided decomposition method that has previously successfully been applied. Our combined frequency- and condition-tuning is a novel adaptation that extends the power of GED in cognitive electrophysiology. ConclusionsWe demonstrate successful condition-specific source separation by applying csGED to simulated and empirical data.

Predictors of successful separation from high-flow nasal oxygen therapy in patients with acute respiratory failure: a retrospective monocenter study

BackgroundHigh-flow nasal oxygen therapy (HFOT) is a promising first-line therapy for acute respiratory failure. However, its weaning has never been investigated and could lead to unnecessary prolonged intensive-care unit (ICU) stay. The aim of this study is to assess predictors of successful separation from HFOT in critically ill patients. We performed a retrospective monocenter observational study over a 2-year period including all patients treated with HFOT for acute respiratory failure in the ICU. Those who died or were intubated without prior HFOT separation attempt, who were treated with non-invasive ventilation at the time of HFOT separation, or who received HFOT as a preventive treatment during the post-extubation period were excluded.ResultsFrom the 190 patients analyzed, 168 (88%) were successfully separated from HFOT at the first attempt. Patients who failed separation from HFOT at the first attempt had longer ICU length of stay than those who succeeded: 10 days (7–12) vs. 5 (4–8), p < 0.0001. Fraction of inspired oxygen (FiO2) ≤ 40% and a respiratory rate-oxygenation (ROX) index (calculated as the ratio of SpO2/FiO2 to the respiratory rate) ≥ 9.2 predicted successful separation from HFOT with sensitivity of 85% and 84%, respectively.ConclusionsFiO2 ≤ 40% and ROX index ≥ 9.2 were two predictors of successful separation from HFOT at the bedside. Prospective multicenter studies are needed to confirm these results.

S16-09 SESSION 16: PLANNING/IMAGING – PART II SEPARATING CRANIOPAGUS TWINS: A 4 STAGE APPROACH USING 3D IMAGING TECHNOLOGY

Introduction: Craniopagus twins are the most rare form of conjoined twins, and successful separation poses a significant challenge to both neurosurgical and plastic surgical teams. Total craniopagus twins share a unified calvarium that houses two fused brains with shared venous sinuses. Orientation of total craniopagus twins, as classified by Stone and Goodrich, may be angular or vertical. To overcome the neurosurgical challenge is to separate two fused brains rotated at different orientations and safely separating the share venous system. The plastic surgery team aims to plan the complex cranial vault reconstruction of two fused calvaria. 3D technology was used to assist in these endeavors. One of the senior authors has previously separated 11 cases of craniopagus twins, and the advantages of our most recent approach using 3D technology will be discussed relative to these cases. Methods: Two sets of total craniopagus twins were separated in 4 stages (n=4). 3D technology was used for pre-operative planning, intra-operative execution, and post-operative analysis of reconstructive outcomes. Virtual surgical planning with 3D printed jigs and guides, 3D surface analysis, and 3D printed models were used at each stage. A two-team approach with neurosurgery and plastic surgery was employed at each stage, and 3D-technology was used by each team. Results: Two sets of total craniopagus twins were successfully separated using a 4-stage, two-team approach supplemented by 3D-technology. The neurosurgical team used 3D-printed models of the brains and vasculature to plan and perform dissection. Plastic surgery used VSP to select tissue expanders and design templates for incisions and osteotomies. 3D printed models offered intraoperative reference to safely separate the brain and its vasculature. 3D printed jigs and guides were fit on the calvarium to guide osteotomies for cranial vault reconstruction, and onto the scalp to guide soft tissue reconstruction. Conclusion: Separation the brain and its vasculature was aided by pre-operative 3D printed anatomic models that were then used as freely rotational reference intra-operatively. Calvarial and scalp reconstruction was improved with virtual surgical planning and 3D printed guides at each stage to precisely plan type and placement of tissue expanders, osteotomies and scalp rotation flaps. 3D technology offers anatomic reference and surgical guidance in the multistage separation of total craniopagus twins, and its potential to further assist in such complex surgical endeavors is a topic of continued investigation.

Monolithic Column Ion-Pair Chromatography with Indirect Ultraviolet Detection for the Determination of Three Acid Radical Anions Containing Fluorine in Ionic Liquids

A rapid ion-pair chromatographic method was developed on a monolithic column for the determination of trifluoroacetate, trifluoromethanesulfonate, and tetrafluoroborate. The three anions were successfully detected using indirect ultraviolet detection. These analyte anions were separated using a tetrabutylammonium hydroxide - p-toluenesulfonic acid – acetonitrile mobile phase on a silica-based monolithic column with an octadecyl functional group. The effects of detection wavelength, mobile phase, column temperature and flow rate on the retention of the anions were investigated. The chromatographic conditions were optimized and the retention properties were evaluated. Under the selected optimal conditions, the successful separation of the anions was achieved within 3.5 min. The detection limits were less than 1.0 mg/L for trifluoroacetate, trifluoromethanesulfonate, and tetrafluoroborate. The relative standard deviations for five repeated measurement of retention time and peak area were no more than 0.2%. The linear ranges extended across two orders of magnitude. The three anions in synthetic ionic liquid samples were successfully separated and detected by this method. The results show that the recoveries of this method were between 94.0% and 99.0%. The method was rapid, simple, and easy to use.

Separation of omphalopagus conjoined twins with ruptured omphalocele, complex biliary sharing and a choledochal cyst

Abstract Separating conjoined twins requires a multidisciplinary team to manage all the phases of care. These phases include initial resuscitation, managing the often discordant physiology between each twin prior to separation, planning for and carrying out the separation operation, and postoperative management. Each phase has unique challenges. The decision on timing of separation is critical in achieving success and is influenced by the stability of each infant, the confidence and experience of the team and full preoperative understanding of the shared anatomy to the extent possible. We successfully separated omphalopagus conjoined twins complicated by complex sharing of the biliary tree and the presence of an infected choledochal cyst. Preoperative optimization, MRI and MRCP, intraoperative US along with an experienced pediatric surgical team proved critical to successful separation and survival of each twin.

Development of a design of experiments optimized method for quantification of polysorbate 80 based on oleic acid using UHPLC-MS

The aim was to develop a straightforward UHPLC-MS quantification method for polysorbate 80 using oleic acid as surrogate marker, which was the commonest substance within the emulsifier. However, hydrolysis of polysorbate 80 and subsequent analysis of fatty acids revealed a co-elution of oleic acid and an isomer while all the other fatty acids were successfully separated by varying retention times and mass-to-charge ratios. For identification and separation of the isomer a derivatization method was evaluated. Oxidation to the corresponding dihydroxystearic acids with potassium permanganate resulted in peak separation of cis/trans and structural isomers of the 18:1 fatty acids. Hydrolyzed and derivatized polysorbate 80 was quantified indirectly in the range of 0.046–5.83 μg/mL (R2 > 0.997) with a limit of detection of 11.4 ng/mL. Quantification of polysorbate 80 using oleic acid as a surrogate marker showed good reproducibility and linearity. As all isomers of the 18:1 fatty acids were successfully separated, the previously co-eluting peak was identified as elaidic acid and was found as a component in the mixture of the emulsifier polysorbate 80. Additionally, cis-vaccenic acid was separated as a second co-eluting isomer. Therefore, derivatization led to successful chromatographical separation of cis/trans and structural 18:1 fatty acid isomers.

Cojoined twins thoracoonfalophagus separation and liver bipartition (case report)

Background: Cojoined twins are a rare phenomenon of monochorionic and monoamniotic twins. The incidence varies from 1 in 50,000 to 1 in 200,000 live births. Female fetuses are more commonly affected, with a ratio of men to women being 1:3, particularly in the thoracic type. The thoraco onfalophagus twins are joined and can share body part as the respiratory, cardiovascular and gastrointestinal systems, besides of thoracoabdominal wall. in the present case shared thoracoabdominal wall and livers and one of the twins has congenital complex cardiac malformation. These types of twins have better chances of survival if they are separated successfully. Methods: We present a rare case of male thoraco onfalóphagus twins successfully separated at 28 days old. We reviewed the postnatal study, the surgical technical aspects of the separation and the postoperative evolution of both twins. These twins are the product of primigesta of 22 years (G1P1001), without significant antecedents, with prenatal diagnosis of double gestation type Siameses thoraco onfalóphagus, the delivery was by caesarean section at 34 weeks of gestation for acute fetal distress. and we confirm that the Siameses are joined by the thoracoabdominal wall; Ultrasound studies and AngioCtScan showed that shared the visceras: heart and liver, the separation surgery was successfully performed with a multidisciplinary team of anesthesiologists, hepatobiliary surgeons, pediatric cardiovascular surgeons, plastic surgeons, pediatric surgeons, Results: The intraoperative findings, hearts and independent great vessels were seen, the pericardium, diaphragm and costal arches were shared, absence of sternum, the livers were joined by a bridge with an area of approximately 7 cm2 of parenchyma and maintained independence from the portal systems, A left portal branch coming from siamese 2 was common, veins cavas and suprahepatic veins as well as the biliary system were independent, there was a complex cardiac malformation in the Siames 1 (double exit route from the right ventricle, subvalvular and pulmonary valve stenosis, double-related ventricular septal defect) and malformation cardiac failure in the Siamese 2 (interatrial communication without hemodynamic repercussion), intestinal malrotation in the Siamese 1. Successful separation of the Cojoined twins was achieved through hepatic transection with ultrasonic dissector (CUSA), in addition to the use of monopolar and bipolar electrocautery, the shared portal vein was sutured; The separation of the thoracic and abdominal wall components described was carried out. In siamese 1 the total closure of the chest wall was not achieved and it was covered with a dermal patch that guarantees the posterior reconstruction, the abdominal wall was closed satisfactorily with lateral incisions of discharge. In siamese 2, satisfactory closure of the chest wall and abdominal wall with lateral discharge incisions was achieved. Conclusion: The management of cojoined twins together remains a medical challenge, due to multiple congenital anomalies associated, as in this case they lead to low success rate. The specialized and multidisciplinary integral management of these cojoined twins is necessary to guarantee success in terms of reducing complications and increasing survival. In this particular case, we performed the separation of thoracoonfalophagus and liver Bipartition succesfully and the current evolution is satisfactory, with emphasis on the subsequent correction of chest wall defects and associated cardiac congenital malformations.

Successful Separation of Conjoined Twins: Experience of a Tertiary Care Hospital

Background: The separation of conjoined twins presents a unique challenge to many pediatric surgical specialties. Meticulous preoperative investigations, planning and multidisciplinary team approach led by pediatric surgeon contribute to the success of surgical separation. The aim of this study is to share our experiences of one hospital to enhance skill for treating conjoined twins regarding anatomic variations, investigations, surgical aspects, outcomes and rehabilitation.Methodology: All cases of symmetrical conjoined twins who were treated from July 2009 to February 2018 at the Pediatric Surgery Department of Dhaka Medical College Hospital, Dhaka, Bangladesh were included in this prospective type of study. All types of parasitic twins were excluded. Prenatal ultrasound diagnosis, gender, birth weight, anatomy of the twins, the age and weight at the time of the separation surgery, the length of surgery, the duration of anesthesia during the separation surgery, a detailed description of the separation surgery, the type of skin closure, postoperative complications and death were studied.Results: There were three sets of thoraco-omphalo-ischiopagus twins, one set of thoraco-omphalopagus twins, one set of pygopagus twins. Three sets had no prenatal visit or ultrasound evaluation. Two sets of conjoined twins were failed to separate due to the complexity of the organs that were shared by both twins and instability leading to death. Only one set of pygopagus twins was successfully separated. Emergency colostomies were done on pygopagus twins due to the presence of anorectal anomalies. The surgical survival rate was 100%. One set of twins who did not undergo separation due to refusal of treatment was currently alive. One set of twins was under evaluation and currently alive.Conclusion: The overall success of conjoined twin separation depends on the experience and preparedness of treating team led by pediatric surgeon and resources available at the hospital. No single discipline can expect to have all the necessary talents.Bangladesh J Child Health 2018; VOL 42 (2) :73-78

Non-fluoride dissolution of tantalum and niobium oxides and their separation using ion exchange

The study involved the separation of Ta and Nb in a phosphate matrix using ion exchange chromatography. Experimental variations included different types of Ta/Nb containing samples, types of resin, phosphoric acid concentration as eluent, flow rate and column dimensions. Experimental conditions were developed and refined using a pure 1:1 (Ta/Nb)2O5 synthetic mixture and the optimum conditions were then applied to a real tantalite mineral sample. Experimental results indicated the successful separation of the Ta and Nb in the synthetic sample using the weak basic Dowex Mathon and Dowex 66 free base resins. Almost complete recovery of Nb was achieved with 200mL of 8M H3PO4. It was found that Ta was more strongly absorbed but by using a stronger acid concentration of 10M H3PO4, almost complete recovery was also obtained for Ta. Excellent elemental separation (α=11.5) and recoveries were also obtained with tantalite mineral as sample under identical experimental conditions. Almost complete recoveries for both Nb and Ta were obtained after elution with 8.0M and 10.0M H3PO4 respectively. Apart from the complete separation of Ta and Nb, minor elements which are also present in tantalite like Fe, Mn and U could also be successfully separated and quantitatively recovered. However, the Nb fraction was contaminated with Ti because under these conditions these two elements are simultaneously eluted.The successful separation and recovery of both Ta and Nb from a phosphate matrix suggest a possible alternative to the conventional fluoride beneficiation methods. This method also has the potential of industrial applications.

Successful Separation of Rachipagus Parasiticus Neonate: Case Report and Review of the literature

Background Data: Lumbosacral Rachipagus Parasiticus is an extremely rare condition. Separation of a parasitic twin that is attached at the lumbosacral spine in the neonates is even less frequent. In this case the spinal cord was herniated through a spina bifida into the parasite. Purpose: The aim of this report is to present a case of RachipagusParasiticus in which surgical separation was successfully performed. Study Design: Case Report and review of the literature. Patients and Methods: The child was 28 days old. Computed tomography, magnetic resonance imaging of the whole spine focusing on the lumbosacral spine provided the information necessary to perform surgery. The duration of surgery was 150 minutes. The parasitic twin hadn’t neural attachment with the myelomeningocele. The child received 120 CC of blood. After separation of the parasitic leg, the dura was repaired using autogenous graft. Skin and subcutaneous tissue were closed directly after application of a wound drain for 24 hours. Results: The parasitic twin was successfully separated, and the patient was discharged from the hospital after 4 days, moving her lower limbs proximally with some weakness in both feet. Conclusion: Rachipagus parasitic twin is a rare form of conjoined twin with a favorable outcome.Detailed perioperative evaluation and management planning, as well as multidisciplinary microvascular approach, are integral to perform the best separation surgery. (2016ESJ096)

Adsorption Separation of R‐22, R‐32 and R‐125 Fluorocarbons using 4A Molecular Sieve Zeolite

AbstractGlobal warming has received great attention over the past decades, which is having costly impacts on our communities, health and climate. Fluorocarbon derivatives that are widely used in various industries such as refrigerants and solvents have significant effect on global warming due to their high global warming potential. Recycling and reuse of fluorocarbons help not only to minimize the environmental release but also to fulfill the future demand with the rapid phase out of some of the fluorocarbons. Herein, our work reports the adsorption separation of mixtures of difluoromethane (R‐32), chlorodifluoromethane (R‐22) and pentafluoroethane (R‐125) into their pure components using 4A molecular sieve zeolite under ambient conditions. Pure gas equilibrium isotherm measurements indicate that the uptake capacity follows the order of R‐32 &gt; R‐22 &gt; R‐125 on 4A zeolite with negligible uptake capacity for R‐125. As evidenced by the gas breakthrough results, R‐32, R‐22 and R‐125 could be successfully separated into pure components using 4A zeolite. Steric effects were responsible for the separation of R‐32 and R‐22 from R‐125 while slower uptake rate of R‐22 compared to R‐32 facilitated the successful separation of R‐22 from R‐32. The regular pore structure, excellent match of pore size of 4A zeolite with the molecular sizes of the fluorocarbon make the product gases very pure, to the extent of direct industrial applications.

Computation-aided separation of seven components from Spirodela polyrrhiza (L.) via counter-current chromatography

Abstract In this study, seven flavonoids were successfully separated from Spirodela polyrrhiza (L.) Schleid. via high-speed counter-current chromatography (HSCCC) with elution–extrusion and online recycling elution modes. The first step for successful HSCCC separation is the crucial solvent system selection. In this work, nonrandom two-liquid segment activity coefficient (NRTL-SAC) method, a computational strategy, was used to facilitate the solvent system selection process. According to the NRTL-SAC method, a suitable solvent system can be rapidly predicted and screened by calculating the partition coefficient rather than by performing tedious experimental measurements. Based on the method, two solvent systems of hexane/ethyl acetate/ethanol/water (1:3:1:3 and 1:9:1:9, v/v) were predicted as the most suitable systems for HSCCC separation. To avoid unnecessary waste of the stationary or mobile phase, both the mobile and stationary phases were prepared independently based on the calculated phase compositions by thermodynamic method. Consequently, seven compounds were successfully separated with high purity (>90%). The separated compounds were identified through UV spectra and high-resolution tandem mass spectroscopy. These compounds include orientin ( 1 ), vitexin ( 2 ), luteolin 7-O-glucoside ( 3 ), apigenin 7-O-glucoside ( 4 ), luteolin 8-C-(2′′-O-feruloyl-) glucoside ( 5 ), apigenin 8-C-(-2′′-O-feruloyl-) glucoside ( 6 ), and luteolin ( 7 ). This work demonstrates that HSCCC is suitable for separation of natural products, and computational strategy is very helpful for enhancing the efficiency of CCC experiments.

LC–MS/MS characterization of the forced degradation products of ezetemibe: Development and validation of a stability-indicating UPLC method

The present study reports the characterization of four degradation products from ezetemibe (EZB) through liquid chromatography–tandem mass spectrometry (LC–MS/MS) and the development of a validated and stability-indicating reversed-phase ultra-performance liquid chromatographic method for the determination of EZB in the presence of its process-related impurities in bulk drugs. The forced decomposition of EZB was carried out and studied under acidic, basic, oxidative, photolytic and thermal conditions. The degradation of EZB was observed under basic and acidic conditions, and four degradation products (DPs) were formed. Successful chromatographic separation of EZB and its degradation products were successfully separated through chromatography with a Waters Acquity HSST3 C18 stationary phase (50×2.1mm, 1.7μm). The analytes were detected with a PDA detector set at 230nm. The figures of merit for this method were adequate. The assay remained linear from concentrations of 0.09μgmL−1 to 600μgmL−1 for EZB and its four DPs (r2=0.99914, 0.99945, 0.99917, 0.99923 and 0.99936 for EZB, Imp-A, Imp-B, Imp-C, and Imp-D, respectively). The method precision, which was expressed as the %RSD, ranged from 0.2 to 1.0 for the four impurities. The DPs from EZB were characterized by LC–MS/MS, and the most likely degradation and fragmentation pathways for EZB and its DPs were proposed.

Reversed-phase chromatography in extended-nano space for the separation of amino acids

In this work we used reversed-phase chromatography in extended-nano channels to separate amino acids. A hydrophobic surface modification of extended-nano channels was established. A sample mixture of fluorescein and sulforhodamine B (0.5 and 0.05mM respectively) was used for the demonstration of a reversed-phase separation mode. A small amount of sample band (30fL) was injected into the separation channel, and two compounds were successfully separated. The maximum theoretical plate number of sulforhodamine B was 300,000plates/m. Two sets of 3 amino acids (3.75mM each) were separated using 0.01M citrate buffer (pH 5.5) with 0.01M sodium perchlorate and 12 and 25% of acetonitrile as a mobile phase. A successful separation (320,000plates/m with plate height of 3.2μm for serine) was accomplished.

Carboxyl modified magnetic nanoparticles coated open tubular column for capillary electrochromatographic separation of biomolecules

Carboxyl modified magnetic nanoparticles (Fe3O4-COOH MNPs) coated open tubular (OT) columns were prepared for capillary electrochromatography. The Fe3O4-COOH MNPs coatings were constructed on the surface of positively charged poly(diallydimethylammonium chloride) (PDDA) modified capillaries through electrostatic self-assembly approach. The as-prepared PDDA@Fe3O4-COOH MNPs coated OT columns were characterized by scanning electron microscopy and electroosmotic flow measurement. The electrochromatographic characterization of the OT columns was evaluated by separation of amino acids, dipeptides and proteins. The influences of background solution pH, concentration, and organic modifier content on separation were investigated. The separation of these analytes was primarily based on the electrophoretic mechanism in combination with chromatographic mechanism. The Fe3O4-COOH MNPs coatings improved the separation resolution of these analytes due to their large surface area. Three variants of bovine serum albumin, two variants of β-lactoglobulin and nine glycoisoforms of ovalbumin were successfully separated. The relative standard deviations of migration times of analytes representing run-to-run, day-to-day and column-to-column were less than 4.3%. Furthermore, the feasibility of the PDDA@Fe3O4-COOH MNPs coated OT column was verified by successful separation of acidic proteins in egg white.

Combinative Application of pH-Zone-Refining Counter-Current Chromatography and Preparative HPLC for the Separation of Alkaloids From Lycoris radiata

The bulb of Lycoris radiata as a traditional folk medicine is well known for its biological activities and has been used for the treatment of many diseases. The major chemical ingredients of this herb are alkaloids including lycoramine, galantamine, and so on. In order to further articulate the pharmacological activities of the herb, relatively purified alkaloids are needed. Therefore, a rapid and efficient method for the isolation and purification of these alkaloids from the bulb of Lycoris radiata is of great interest. We herein report a new technique pH-zone-refining counter-current chromatography (CCC) combined with preparative high-performance liquid chromatography (HPLC) for the isolation and purification of these active ingredients. Although the conventional high-speed HSCCC method for the successful separation of the alkaloids from Lycoris radiata has been reported, only two alkaloids are obtained. In the present study, seven alkaloids all with a purity of over 95% are successfully separated using this combinative technique. And the sample loading capacity is increased by 150-fold compared with that mentioned in the literature. Therefore, the combinative application of pH-zone-refining CCC and preparative HPLC is a rapid and efficient method for the separation and purification of natural compounds.

English

Conjoined twins are rare occurrences in medical practice. In this study, two cases of conjoined twins, parapagus dicephalus and ischiopagus tetrapus are reported in Dr. Sardjito General Hospital, Yogyakarta, Indonesia. The first case i.e. five-day-old male parapagus dicephalus conjoined twins referred to the hospital. The twins have two heads, two arms and two legs. X-ray examination reveals two vertebrae collumn, single heart, and single pelvis. Moreover ultrasonography examination reveals conjoining of liver and echocardiography examinatin reveals single atrium. The twins were diagnosed as parapagus dicephalus. As a result of their fusion, operative care had been considered to be unacceptable. After several weeks in neonatal intensive care, they died. The second case i.e. two-day-old female conjoined twins with conjoining at ischium region referred to the hospital. Ultrasonography and abdominal examination reveal conjoining at intestinum, buttock and ischium. The twins was diagnsed as ischiopagus tetrapus. They were successfully separated at 6 months of age. They are alive and well so far for more than 7 years. In conclusion, the prognosis of conjoined twins is related to the type, extent of union and organ abnormalities. The successful separation of conjoined twins might be determined by good planning and staff enthusiasm and dedication.

Thoraco-omphalopagus conjoined twins: impact of ultrasound assessment on successful surgical separation

In this case report, we present a case of thoraco-omphalopagus conjoined twins who were successfully separated and had long-term survival. We performed ultrasound assessment and found that the twins shared the liver and that the fusion site of their liver had gross communication of blood vessel. Ultrasound cardiogram examination showed that the anomalous vessels that connected their hearts drained from the number 1 infant to the number 2 infant. The ultrasound assessment has significant impact on the successful surgical separation of the thoraco-omphalopagus twins.

Anatomy of successfully separated thoracopagus–omphalopagus conjoined twins

The birth of conjoined twins occurs in approximately 1 in 50,000 to 1 in 100,000 deliveries, and the majority are either stillborn or die early in life. Approximately 184 successful separations have been described. The authors describe the preoperative radiologic evaluation of a set of thoracopagus-omphalopagus twins and their successful surgical separation. Preoperative radiologic imaging demonstrated that the twins did not share myocardium, but an ectopic cordis was present. The inferior vena cavae entered the right atria at more acute angles than normal. The liver was fused, two gallbladders were present, and there was a large bridging portal vein that crossed the hepatic isthmus of one twin to the conjoined twin's portal venous system. Replaced hepatic arteries originated from the superior mesenteric arteries. Each twin had separate kidneys, colons, and rectums. Preoperative tissue expansion was necessary, and the twins were separated at 5 1/2 months of life. Successful separation of twins conjoined by several organ systems requires a multispecialty approach. Preoperative knowledge of shared anatomy is necessary for adequate preparation and planning. Despite meticulous preoperative investigations, certain anatomy can only be discovered at the time of surgery, and the ability to adjust to these findings is imperative.