Cases reported "Twins, Conjoined"

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1/15. Thermocoagulation for selective reduction of conjoined twins at 12 weeks of gestation.

    Conjoined twins occur rarely. Most of the prenatally diagnosed cases are terminated either because of extensive organ sharing or because of the presence of major structural abnormalities. We present a case of omphalopagus conjoined twins diagnosed at 10 weeks of gestation with selective reduction performed at 12 weeks. The twins were conjoined at the umbilicus with vascular communication demonstrated at the conjunction. Twin A was normal but twin B was growth restricted and hydropic. Thermocoagulation of twin B was performed at 12 weeks by passing an insulated electric wire through a 18-gauge needle placed close to the fetal heart. Reassessment at 15 weeks showed that twin A was growing normally with a small dead twin B attached at its umbilicus. Twin B was subsequently sloughed off from this attachment and could be seen lying free in the amniotic cavity at 17 weeks. Twin A was delivered at term and was healthy. A small scar could be seen just above the umbilical cord insertion. This case represents the first antenatal example of selective reduction of conjoined twins by thermocoagulation.
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2/15. Unusual cardiac malformations in conjoined twins: thoracopagus twins with conjoined pentalogy of cantrell and an omphalopagus twin with atretic ventricles.

    Two unrelated cases of conjoined twins were found to have cardiac malformations that apparently have not been reported previously. In one case, thoracopagus twins had an extensive thoracoabdominal wall defect that resulted in ectopia cordis of a conjoined heart along with evisceration of the shared liver and intestine along with one spleen. These malformations, accompanied by defects in the sternum, diaphragm, and supraumbilical abdominal wall, constitute a conjoined pentalogy of cantrell. In the second case, the heart of one of omphalopagus twins consisted of a solid ventricular mass with only a minute aortic cavity but no atrioventricular communication-an ineffective heart that could develop only in a conjoined or chorioangiopagus twin. In both cases, a common atrium lay in the primitive (embryologic) position caudal to the ventricles.
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3/15. Anesthetic management for a five-day separation of craniopagus twins.

    Craniopagus twinning is a rare form of the already uncommon entity of conjoint twins. With advances in medical technology and expertise, future attempts at surgical separation of these increasingly complex cases are likely to occur. Despite this, medical literature on the anesthetic management of these cases is sparse. The following case report details the anesthetic management and planning leading to and including the 5-dy separation of 11-mo-old craniopagus twins. The report emphasizes the importance of teamwork, communication, and advanced planning required in cases such as this. IMPLICATIONS: The following case report documents the anesthetic planning and management leading to and including a 5-day separation of twins joined at the head. This case report also details the difficulties encountered during the unique combination of a rarely performed procedure and a long operating time.
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4/15. Advanced "tactile" medical imaging for separation surgeries of conjoined twins.

    BACKGROUND: Understanding the anatomy of conjoined twins is difficult because of the rarity of this congenital malformation and the scarcity of reported cases in medical literature. NEW technology: Advances in radiologic imaging, computer modeling, and sophisticated manufacturing techniques enable medical imaging datasets to be translated into accurate, solid, life-size models. These models, which can be designed to include various combinations of anatomical features revealed by established imaging modalities, are important for pre-surgical assessments and planning, as well as for reference during the actual operative procedure. In addition, they provide a valuable basis for communication between the groups of specialists who are involved in these cases. CASE STUDIES: This article will describe the advances in technology behind this process and illustrate its value in two cases of craniopagus twins.
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5/15. Two babies, one heart, and no airway.

    The medical literature on conjoined twins is replete with descriptions of the complexity of surgical separations. However, airway management, although quite challenging, is neglected in literature. We present experience with conjoined twins united anteriorly at the thorax and abdomen sharing one six-chambered heart. laryngoscopy and intubation recommendations, bronchoscopy techniques, and tracheotomy strategies are outlined for the face-to-face twins. Difficult, unique case report at tertiary care medical center. Conjoined thoraco-omphalopagus twins were successfully intubated at birth using the rigid Seldinger-assisted videotelescopic intubation (SAVI) technique. Flexible airway endoscopy allows for timely management of ventilator-dependent conjoined twins. tracheotomy was later performed with the twins in the upright position with heads slightly rotated. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team. Conjoined thoraco-omphalopagus twins united anteriorly require a challenging airway management strategy. A three-dimensional perspective is utilized for intubation and tracheotomy. The SAVI technique is helpful for difficult intubations in the emergent twin airways.
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6/15. Successful separation of xiphoomphalopagus twins.

    A pair of female xiphoomphalopagus twins were delivered by Caesarean section at 35th week of gestation on March 2, 1982, their combined weight being 4,800 g. Examinations revealed that they were conjoined from the xiphoid process down to the umbilicus. infant A also had congenital heart defect (VSD). X-ray and echography showed that they had a fused liver and two independent biliary systems and alimentary tracts. After 6 weeks, the twins gained weight up to 7,000 g. The separation operation was performed at 1 1/2 months of age. During operation it was demonstrated that the xiphoid process and costal cartilages were fused together and the peritoneal cavities were of free communication above the umbilicus, and the livers merged into a single common liver. The large single liver was divided by electrocautery, resulting in a section surface of 8 X 7.5 cm. After separation, the closure of the abdominal wall in both infants presented some difficulties which were resolved by making relaxation incisions on either flanks. In the post operative period, the ventral wounds of both infants were disrupted for several centimetres and infant B had wound infection. The granulating area of skin defect on either relaxation incision of the flanks and ventral denuded wound were covered with full-thickness dead-foetus homografts. The wounds were well healed. Eventually both infants were discharged in good condition at 2 1/2 months after operation. Now they live well at 2 1/2 years of age.
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7/15. Thoraco-omphalopagus conjoined twins: successful surgical separation.

    Male thoraco-omphalopagus conjoined twins were evaluated systematically with respect to visceral joining. Cardiac studies included electrocardiography, echocardiography, and a dynamic radioactive heart scan. No union was found. liver union was demonstrated by scanning and angiographic studies. No communication between the gastrointestinal tracts was found, and no other major anomalies were discovered. When the twins were approximately 3 months of age, surgical separation was performed. A common pericardium, two separate hearts, and a union of the liver were found. Prosthetic sheeting was used to close the pericardium and the thoracic-abdominal defects in both. In one, primary skin closure was possible. In the other silicone rubber sheeting was used to close a large skin defect in the chest. Both have done well over a follow-up period of 14 months. One is larger than the other, but the growth rate of both has improved in the last 6 months.
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8/15. Cardiovascular anomalies in thoracopagus twins and the importance of preoperative cardiac evaluation.

    Four pairs of thoracopagus twins have been described. Cardiac catheterisation was performed in all the cases. Angiocardiographic and necropsy findings suggest that the most common abnormality was some form of univentricular heart. The communication between the 2 hearts was at atrial level in 2 cases. Separation was performed in 1 of these cases but only 1 of the twins survived for 14 hours after operation. It is suggested that full cardiac catheterisation with selective angiocardiogram is essential before separation is considered. Identical heart rates were observed in each pair and there was invariably a major communication between the hearts of the twins.
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9/15. Anaesthesia for separation of conjoined twins.

    Anaesthetic procedures for successful separation of pygopagus twins are described. A bony union in the sacral region and communication of the subarachnoid space in this region were the main abnormalities. Various anaesthetic problems during the operation and in the immediate postoperative period are discussed.
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10/15. Shared coronary arteries and coronary venous drainage in thoracopagus twins.

    A pair of type B thoracopagus twins with complex cyanotic heart disease had shared coronary arteries and coronary venous drainage. Surgical separation was not attempted and the twins died at 10.5 months of age. Antemortem angiography demonstrated that Twin A's right coronary artery supplied Twin B's diaphragmatic and anterior ventricular myocardial free wall. A midline communication existed between each twin's right atrium at a common coronary sinus. The crossing coronary artery coursed alongside this connection and was visualized echocardiographically. At postmortem examination, the great cardiac vein of Twin A drained into the orifice of the common coronary sinus on Twin B's side of the midline. In five of six previously reported cases, the children died at attempted separation shortly after ligation of the interatrial communication. This may have been because of occlusion of a coronary artery or acute obstruction of a coronary vein. Consideration of separation of type B thoracopagus twins requires anatomic delineation of the coronary arteries and veins.
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