Surgeons debate separating conjoined twins
The agonizing decision to attempt to separate twins conjoined at the head -- and the mid-surgery decision to abort the attempt -- is detailed in a fascinating essay published this week in the journal Plastic and Reconstructive Surgery.
Doctors from Cleveland’s Rainbow Babies & Children’s Hospital describe the case of 2-year-old conjoined twin girls who arrived at the hospital from their home in Italy in 2007. The smaller twin was conjoined to the back of the larger twin’s head. While the larger twin had most of the brain blood flow, the smaller twin had two kidneys and the larger twin had none.
Craniopagus conjoined twins (joined at the head) are rare; about one in 2.5 million births. Such twins rarely live into adulthood. The risks of surgery are also high. Based on other cases in medical literature, only seven of 60 craniopagus separation surgeries were achieved without significant side effects, such as permanent brain damage. But, the authors of the paper wrote, there are historical accounts of craniopagus twins surviving into adulthood with satisfying lives.
Medical advances have improved the success of separation surgeries in recent years. In August, British surgeons successfully separated twins joined at the head.
The Cleveland hospital’s case, however, posed enormous ethical and medical challenges, the doctors wrote. The operation could cause irreversible harm to one twin while improving the quality of life for the other. With the children far too young to consent to surgery, the doctors and parents had to consider the children’s best interests.
The decision to attempt a separation was made after the medical team concluded that the “benefit of separation outweighed the harm because viable solutions were found for the anticipated postoperative” problems. For example, one twin would require kidney dialysis and a kidney transplant.
But the twins’ brains swelled during the June 2007 operation and the blood pressure of one twin dropped dangerously. The balance of harm-versus-benefit changed abruptly, and the procedure was stopped, the surgeons said. The twins recovered.
The review of the ethical principles of the case is especially important in pediatric plastic surgery, the authors say because of the many instances “in which life-threatening procedures are carried out for conditions that affect the quality of life but may not be life threatening.”
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