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A trilogy on twins: Conjoined twins

The title of today’s outing is strictly not an original of mine. It is a recall of when I read that Hollywood saga comprising of the Dream Merchants, the Carpet Beggars and the Inheritors by Sydney Sheldon. The three books in combination are often referred to as a trilogy. But we are not talking about books here today but telling the story of twins. The coincidence is that since I came back from Oshogbo, and the next two weeks it has been twins encounter galore. Firstly, on arrival in Lagos; it was straight to the theatre to deliver a set on twins, a baby boy and girl. When they came out, I thought of the current deplorable economic situation in the country and winced.
As if that wasn’t enough, a couple of days after, I was invited to that same hospital to see a patient with the working diagnosis of twin pregnancy in obstructed labour. On arrival, I was indignantly unsettled on noticing the florid signs of obstructed labour on this patient who has had two normal deliveries previously. Besides twin babies when compared to singleton babies are relatively smaller in size and also tend to weigh less. Even then, why was the oedema of the lower genitals? This usually is as a result of the obstruction of the lymphatic and venous drainages. The only reasonable answer was that perchance this has been going on for quite some time. The patient was in distress and was also running a low grade fever but the babies’ heartbeats were still very strong. We decided to get consent and proceed with a surgical delivery.
Both twins were coming with their heads. The head of the supposed first twin was already engaged in the pelvic cavity while that of the second was still up there in the uterine cavity for obvious reason. We decided to deliver the second twin first and later decide on how to extract the first twin. We were pleasantly shocked that the second twin was not easily forthcoming. It was as if it was stuck to something we couldn’t figure out at that time. What we did was to grab the legs of the twins and pulled them out. Immediately they came out, the medical director of the hospital shouted: “CONJOINED TWINS.” At that point we didn’t really know how to react to the incident: whether to be happy or depressed. Twins though with their blessings could be a challenge, but conjoined; that definitely is a government property. To the surgeon at that point in time their mother was more important and we had to secure haemostasis or rather stop bleeding quickly and close up the wound. The twins didn’t need resuscitation; they were in good condition. At that point I had to tender my apologies to the hospital staff for the impressions l had on arrival. It is not commonplace to run into a clinical condition that one may see once in every one hundred fifty thousand life births. The apology was accepted and we moved on.
For the records, Conjoined twins commonly referred to Siamese twins, whose name is derived from Chang and Eng Bunker from Thailand formally known as Siam is a condition in which twins are born joined together. This is a very rare birth condition that is found in Asia and Africa. The joining of the twins can be at any part of the body and it’s accordingly described. For example the two boys we delivered are joined in the umbilical area of the abdomen. This type of conjoined twins is referred to as OMPHALOPAGUS. The good news in our case is that surgical separation may be relatively easy. The reason is that the digestive system and the liver are likely to be the shared organs. In THORACOPAGUS, the two bodies are fused at the chest and the twins usually share one heart. The implication of this is that in the event of separation one of the twins is invariably sacrificed as the heart goes to the other twin. There are different types of fusions that space would not allow us here.
However mention must be made of the Iranian ladies who were joined at the head but had separate brains. This is known as CRANIOPAGUS. Ladan and Laleh Bijani at the age of 29years decided that they wanted a separation. They were told about the possibility of a catastrophic consequence. The two women were separated on July 6 2003, but died soon after surgery due to bleeding from a prominent vein that was not detected by brain scans.
The cause of conjoining for now is theoretical. It is believed to be due to the failure of complete division of the fertilized egg to produce two identical twins. Thus this incompletely divided stem cell continues to proliferate and differentiate to produce twins joined together. This is known as FISSION THEORY. Surgical separation is the preferred option of management. This may range from a simple procedure to very difficult and cumbersome operation depending on the point of attachment and internal organs shared by the twins. With regards to our index case, Diagnosis believes that the separation can be done here and that the chance of both twins surviving is very, very high. A good radiological evaluation is a mandatory preparation for the separation of the twins. Luckily for us and in all fairness there is hardly any radio diagnostic equipment you’d look for in this country that you won’t get. Having examined the diameter of the point of attachment, I have a hunch that there may not be much that would need to be repaired if a good line of cleavage is identified. Meticulous planning and execution should be the hallmark of this surgical intervention by the team. This is very doable and for national pride should be done here.
One is not unmindful of the current desperate economic situation in the country. There is no gainsaying that the young parents would need a lot of financial and psychological support at this point in time. At the last count, the twins have been referred to Lagos University Teaching Hospital. Hopefully things would soon be at top gear. They have my prayers and wishes of good luck for the task ahead. I have been reliably informed that the Ebonyi State Governor is very much interested in the case. May God bless him and help him to keep it mind and not be distracted by the challenges of governance. We all know that this is not the best of time. Finally Mrs Ambode, the wife of the Lagos State Governor knows that this is at her door step.




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