Twins surgery enters third day

Medicine & Biotech Forum

Tuesday, July 8, 2003 Posted: 1:33 AM EDT (0533 GMT)

(CNN) -- Neurosurgeons trying to separate two conjoined Iranian sisters are carefully teasing apart packed brain tissue millimeter by millimeter in a delicate and risky procedure as the life threatening operation entered its third day.

Surgery to separate 29-year-old Ladan and Laleh Bijani -- who are joined at the head -- began on Sunday and is taking longer than expected as doctors battled against unstable blood pressure levels as they slowly split apart the fused brain.

The complicated process of paring apart the twins' brains began late Monday, said Dr. Prem Kumar Nair, a spokesman for Raffles Hospital in Singapore where the operation is taking place.

Separating them is one of the most challenging parts of the surgery, dubbed "Operation Hope."

"As we have found with the skull bones, the two brains have been found to be very adherent to each other," Nair said.

"Although the brains are distinctly separate, because they have been fused for the last 29 years, they are very adherent to each other. Dissection to separate them is thus taking a long time," he told a press conference.

Prior to separating the brains, surgeons completed the process of rerouting a large vein that serves both their brains.

An international team of neurosurgeons, dozens of doctors, plus support staff created a bypass for Ladan, using a vein grafted from her leg.

This caused another complication, Nair said, as blood circulation between the twins became unstable.

But fluctuations in pressure were still within "acceptable levels," Nair said.

More hurdles ahead
Opening the skulls and forming the bypass formed the first major stage of the operation.

The next stage involved severing blood vessels and veins around the brains.

Then, neurosurgeons began the slow process of carefully cutting through the sisters' brain tissue.

In a statement, the hospital said dissection to separate the brains "is taking a long time because neurosurgeons have to carefully cut through the tissues millimeter by millimeter."

The bypass was considered one of the most risky aspects of the surgery which could prove fatal to one or both of the twins. The sisters, both law graduates, said they were willing to accept the risks and face those dangers to lead separate lives.

But Nair warned of further hurdles ahead.

"That was one tough part of the surgery, the other tough part is the actual separation of the brain. At the end of the day we are trying to achieve separation," he said.

The operation is a landmark procedure. Although Singapore doctors performed a similar operation in 2001 on infant Nepalese girls, surgery on adult twins is unprecedented.

The operation is more difficult in adults than in children, who have more recuperative powers.

Twins joined at the head are the rarest of conjoined twins, occurring one in every 2 million births. Twins joined elsewhere occur once in every 100,000 births.

The Bijanis' operation is considered elective because the women likely would live a normal life span without it.

However, testing has shown the sisters have high intracranial pressure, which, if untreated, could cause frequent debilitating migraines and impaired vision as well as deteriorating brain function, the hospital said.

The sisters have made an impression on Singapore's public, in part because of their cheerful demeanor before the operation. Cards, flowers, and offers of support have been sent to the hospital from around the world.

The hospital is paying for pre-operative fees and the medical costs involved in operation. The operating surgeons are waving their professional fees. The government of Iran said Monday it will pay $300,000 for post-operative care.

-- CNN Medical Correspondent Dr. Sanjay Gupta and Journalist Michael Dwyer contributed to this report.

At what point will our ability to perform medical miracles exceed all available funding to help people with desperate health problems? Money will be the god which will rule who lives and who dies.

It is a horrible outlook about the future for our children to deal with. Will they have medical insurance when they need it?? For most people in the world the answer is already NO.

Such a sad ending. Makes you really think about if this should have been done at all. Their life expectancy was normal. But they chose to take the risk. Difficult for me to understand.

The Risk That Failed
By William Safire
Op-ed columnist, New York Times
Thursday, July 10, 2003 Posted: 9:16 AM EDT (1316 GMT)

The world held its breath as the unprecedented separation of adult brains began. The attempt failed; both sisters bled to death; people everywhere were saddened.

We now step into the world of neuroethics. This is the field of philosophy that discusses the rights and wrongs of the treatment of, or enhancement of, the human brain.

Were these patients capable of making an informed choice? Nobody disputes the sisters' mental competency to stake their lives on their hopes for individuality. Doctors, not to mention pre-operation media interviewers, made them aware of the 50-50 chance of death. Most of us would hesitate to challenge their right to take that risk.

Was the medical team acting ethically, putting the patients' interests first, or was it influenced by the humanitarian prospect of the advancement of specific knowledge about the brain — or by the attraction of the world fame and professional prestige that would follow a high achievement?

The available evidence is that the doctors thought there was a reasonable chance for success. When added to the sisters' strong desire to live free of a connection they found unbearable, that seems to tip the balance to a conclusion that the operation was right to do, even though it could and did end in tragedy.

Not just neurosurgeons but other brain scientists are thinking long and hard about the morality (right or wrong) and the ethics (fair or unfair) of what such breakthroughs as genomics, molecular imaging and pharmaceuticals will make it possible for them to do.

In the treatment or cure of brain disease or disability, the public tends to support neuroscience's needs for closely controlled and informed experimentation. But in the enhancement of the brain's ability to learn or remember, or to be cheerful at home or attentive in school, many of the scientists are not so quick to embrace mood-manipulating drugs or a mindless race to enhance the mind.

The brain's ethical sense may run deeper than we think. "The essence of ethical behavior," writes the neuroscientist Antonio Damasio in "Looking for Spinoza," his newest book, "does not begin with humans." Ravens and vampire bats "can detect cheaters among the food gatherers in their group and punish them accordingly." Though human altruism is much further evolved, in one experiment "monkeys abstained from pulling a chain that would deliver food to them if pulling the chain caused another monkey to receive an electric shock."

Damasio does not believe that there is a gene for ethical behavior or that we are likely to find a moral center in the brain. But we may one day understand the "natural and automatic devices of homeostasis" -- the brain's system that balances appetites and controls emotions, much as a constitution and a system of laws regulates and governs a nation.

This week's sad loss of the conjoined twins in Singapore should remind us of more than the risks inherent in the most modern neurosurgery.

Something mysterious is going on in the minds of brain scientists as they debate going beyond the cure of disease to the possibilities of meddling with memory or implanting a happy demeanor. What drives them to grapple with the ethics of the manipulation or the equalization of the powers of the mind?

Maybe the human brain has a self-defense mechanism that causes brain scientists to pause before they improve on the healthy brain. Would we feel guilty about discovering the chemistry of conscience?

William Safire is an op-ed columnist with the New York Times.

Yes ..Sad..The only hope left is what was learned will help another someday..

I understand the twins taking the risk. I cannot imagine being linked to someone that way, day and night, for all those years. That anyone in that situation can grow to adulthood without committing suicide (or murder) is amazing to me. I am sure they have a sweet home in heaven right now--if anybody has earned it, they have.