Conjoined Twins

Introduction: With recent advances in brain imaging and neurosurgical techniques, there has been a renewed interest in the surgical separation of craniopagus twins. Successful separation in recent cases, along with widespread publicity, has attracted craniopagus twins from all over the world to be referred to pediatric neurosurgical centers for evaluation and consideration for surgical separation. Separation of blood supply: It has become apparent, however, that the most critical decisions in surgical planning are related to separation of the blood supply to the conjoined brains. In fact, in craniopagus twins that survive pregnan-cy or the first few days of life, there is usually little shared brain tissue. The shared blood supply is far and away the more critical issue. It is very difficult to successfully separate craniopagus twins in one surgical procedure. Staged separation, with gradual re-routing of the shared blood supply, has been a successful alternative. Case studies and discussion: We discuss here our experience with three sets of craniopagus twins and our approach to staged separation.

Conjoined twins are rare and are classified as symmetrical or asymmetrical, in which a member, the host (autosite), is near normal and bears the parasite, which is incomplete, smaller, and fully dependent for growth on it. This form of conjoined twins is referred to as heteropagus and when attached to the epigastrium of the autosite is called epigastric heteropagus. Only 44 cases of epigastric heteropagus twins have been previously reported in the world literature. We hereby report the successful separation of a pair of heteropagus twins.

Dicephalus twinning is an extremely rare type of conjoined twins. Early prenatal diagnosis of this condition is important to provide an opportunity for pregnancy termination. We present such a case, which was diagnosed by ultrasound examination at 12 weeks of gestation. The ultrasonographic criteria are discussed together with implications for management. #

There is a legislative gap concerning the conjoined twins in many countries of the world, including Georgia, primarily because there are no targeted interdisciplinary researches, among them in the field of law, conducted with relevant intensity, scope and quality, which not only leaves some unanswered questions, but also causes the absence of questions at first glance. 
This text aims at promoting the legal issues on conjoined twins, identifying important questions (research topics) and providing an incentive for researchers to conduct a profound and detailed study of the issues discussed in the text.
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მსოფლიოს სხვადასხვა ქვეყნებში, მათ შორის საქართველოში, შეერთებულ ტყუპებთან დაკავშირებით არსებული სამართლებრივი ვაკუუმი უპირველესყოვლისა ეფუძნება იმ გარემოებას, რომ შესაბამისი ინტენსივობით, მოცულობითა და ხარისხით არ წარმოებს მიზნობრივი ინტერდისციპლინური კვლევები, მათ შორის სამართლის მიმართულებით, რაც არა თუ პასუხგაუცემელს ტოვებს კითხვებს, არამედ კითხვების ერთი შეხედვით არარსებობასაც იწვევს.

Background: Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature. Methods: The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. Results: We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. Conclusion: Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Building on arguments from G.A. Cohen and Kasper Lippert-Rasmussen, I argue here that our rights in our bodies are not well explained by self-ownership – and thus that we cannot infer self-ownership from intuitions about body rights, via inference to the best explanation. I begin by arguing that self-ownership does not explain our rights in our bodies unless it is a reflexive relation, wherein for each rational adult X, X quite literally owns X – whatever X is. In the bulk of the paper, I canvas the most prominent metaphysical theories of what we are, arguing that each of these theories makes it hard to see how our self-ownership implies (much less explains) any plausible profile of claims regarding rights in bodies. I go on to sketch an alternative ownership-like theory of our rights in our bodies, on which our interests in fluent bodily functioning explain why others should respect our authority over our embodiments. Such an explanation, I argue, requires reference to social practices: our body rights are grounded, partly, in facts about actual practices, and partly, in facts about what any practices worth hoping for would require. I defend this appeal to social practices against objections, appealing to Kantian ideas about hope and faith to show why we might have reason to respect some body rights in advance of the arrival of practices that protect them.

According to the newest report issued by the Guttmacher Institute, 926,200 abortions were performed in the US in 2014. A holistic approach which accounts for biblical, biological, and philosophical truths must conclude that these unborn represent human beings with full personhood. Biblically, God the Almighty Creator establishes the worth and value of humanity by making all people in His own image (Genesis 1:26-27). From Scripture, a progression can be given which traces this image from adults, to the unborn, to conception. Biologically, it is an undisputed fact that a new, complete, genetically-distinct, individual human being is present at conception. Although attempts to redefine conception have been made, embryologists have consistently defined conception as the moment of fertilization for over 100 years. Abortion also cannot be justified philosophically. Some of the most common philosophical arguments for abortion are evaluated and discussed: (1) embryos lack consciousness, (2) abortion prevents children from being born into poverty, (3) monozygotic twinning proves personhood cannot begin at conception, (4) rape justifies abortion, (5) incest warrants abortion, and (6) abortion is often necessary to save the life of the mother.

According to the newest report issued by the Guttmacher Institute, 926,200 abortions were performed in the US in 2014. A holistic approach which accounts for biblical, biological, and philosophical truths must conclude that these unborn represent human beings with full personhood. Biblically, God the Almighty Creator establishes the worth and value of humanity by making all people in His own image (Genesis 1:26–27). From Scripture, a progression can be given which traces this image from adults, to the unborn, to conception. Biologically, it is an undisputed fact that a new, complete, genetically-distinct, individual human being is present at conception. Although attempts to redefine conception have been made, embryologists have consistently defined conception as the moment of fertilization for over 100 years. Abortion also cannot be justified philosophically. Some of the most common philosophical arguments for abortion are evaluated and discussed: (1) embryos lack consciousness, (2)...

I argue that the separation of conjoined twins in infancy or early childhood is unethical (rare exceptions aside). Cases may be divided into three types: both twins suffer from lethal abnormalities, only one twin has a lethal abnormality, or neither twin does. In the first kind of case, there is no reason to separate, since both twins will die regardless of treatment. In the third kind of case, I argue that separation at an early age is unethical because the twins are likely to achieve an irreplaceably good quality of life—the goods of conjoinment—that separation takes away. Evaluation of this possibility requires maturation past early childhood. Regarding the second type, I point out that with conceivable but unrecorded exceptions, these cases will consistently involve sacrifice separation. I present an argument that sacrifice separation is unethical, but in some cases a moral dilemma may exist in which separation and refraining from separation are both unethical. Perhaps in such cases a decision can be made on non-moral grounds; however, the possibility of such a decision serves not to mitigate but to underscore the fact that the separation is unethical. My conclusion, which applies to all three types of cases, is that it is unethical to separate conjoined twins before their developing personalities give some reliable indication as to whether they desire separation and whether they will achieve those goods of conjoinment.

The role that the Principle of Double Effect plays is brought into full relief in hard cases. Consider just such a difficult situation. In 2000, thoracopagus (joined chest-to-chest) twins Gracie and Rosie Attard were the subject of a legal case heard by the British Court of Appeals. Although both twins had hearts, they shared a common aorta and Rosie’s heart was far less developed than her sister’s. She depended upon Gracie’s heart to help circulate her blood. Doctors predicted that Gracie’s heart would last no more than a few months with this workload, and wanted to separate the twins to save Gracie. The surgery would result in Rosie’s death when her aorta was clamped off. Their parents did not consent to the procedure, but the court ruled that the separation could proceed anyway for the purpose of saving Gracie’s life.  If the principle of double effect had been brought to bear explicitly, based as it is on intent and proportionality, how would the judge have evaluated such a scenario? Doubtless each party to the separation would claim that the intended effect was to save Gracie, and Rosie’s death was an unintended bad effect. But how could a doctor who clamps off a patient’s aorta with no plan or intent for resuscitation  realistically claim that he does not intend to kill her?
Philosophers advocating double effect have advanced ways to draw a distinction between the clamping and the killing, with the goal that a doctor may intend one but not the other. This assumes that agents have very fine-grained control over their intentions, but consideration of real people in real medical situations casts doubt on this. We will argue that this conceptual distinction is of no practical use – agents in general cannot credibly claim that they do not intend effects which they directly bring about and have no idea what the technical means would look like for avoiding (or intentionally do not pursue such means).
Our argument focuses on the application of double effect to the case of conjoined twins, but has wider implications for action theory, medical ethics and the use of double effect in general, although we will only note some of those implications in passing.

When asked, almost anyone can give an answer to the question, what is a body? While such a question seems simple, it is anything but straightforward. Different ontologies of what a body is have vast material consequences: in some cases, the stakes are life and death. I examine some problems with a particular ontology of the body – that of Immanuel Kant – in reference to a particular empirical case – that of conjoined twin separation surgeries. Specifically, I want to look at how the notion of bodily integrity, a notion often treated as universal, can mean very different things in relation to different discursive contexts and relationships of power. The Kantian conception of the body as a bounded and bordered entity over which a single individual must exercise control has problematic consequences. In the case of Rosie Attard, a similar conception of bodily integrity was used by a British court to justify her death. On the basis of an analysis of the legal case of Rosie and Gracie Attard, I propose an alternative account of embodiment meant to better accommodate the needs of conjoined individuals. This alternative account emphasizes openness and complexity, rather than autonomy and fixity. I contrast these two accounts and look at some of the ethical consequences that result from each one, not in order to find an answer to the question ‘what is a body,’ but to problematize attempts at giving a universal answer.

Conjoined twins represent the most uncommon twinning mechanism in humans, with an incidence approaching 1:100,000 deliveries. Although several conjoined male twins have occasionally been reported, for unexplained reasons most cases of conjoined twins are female. Of all the female conjoined twin sets either documented by medical authorities or referenced in ancient literary sources, in only one case were pregnancy and delivery successfully achieved by the conjoined twins themselves. We describe the highly unusual circumstance of the Blazek sisters, an extreme developmental example of the terminal monogenital pygopagus type of conjoined twins in which one of the joined sisters conceived and underwent labor and childbirth. Although little information is known about their own birth, these conjoined twins paradoxically hold a unique place in the history of obstetrics. Information from formal anatomic examinations of the sisters and their exploitative circus exhibitions is outlined with a view to explain relevant reproductive events. We present the sensational conception, pregnancy course, and subsequent vaginal delivery of a healthy male infant as summarized from contemporary sources. Additionally, the significance of pygopagus twins is discussed with regard to other types of monozygous twinning. Although modern operative techniques have been a welcome advance in the science of conjoined twin separation, the Blazek case is another reminder that, even in the era before complex surgery, conjoined twins were not necessarily consigned to an incomplete reproductive career

I argue that the separation of conjoined twins in infancy or early childhood is unethical (rare exceptions aside). Cases may be divided into three types: both twins suffer from lethal abnormalities; only one twin has a lethal abnormality, or neither twin does. In the first kind of case, there is no reason to separate, since both will die regardless of treatment. In the third kind of case, I argue that separation at an early age is unethical because the twins are likely to achieve an irreplaceably good quality of life – the " goods of conjoinment " – that separation takes away. Evaluation of this possibility requires maturation past early childhood. Regarding the middle case, I point out that with conceivable but unrecorded exceptions, these are consistently cases of " sacrifice separation. " I present an argument that sacrifice separation is unethical, but that in some cases a moral dilemma may exist in which each available option is unethical. Perhaps in such cases a decision can be made on non-moral grounds, but this does not alleviate but rather underscores the fact that the separation is unethical. My conclusion is that conjoined twins should remain conjoined until their developing personalities give some reliable indication of whether they desire separation and whether they will achieve those " goods of conjoinment. "

A differential diagnosis between fetus amorphus and placental teratoma based on the presence of an umbilical cord and/or skeletal organization in the fetus amorphus has been proposed (Fox and Butler-Manual: Journal of Pathology 88:137-140, 1964). We report a description of one new case of fetus amorphus, along with the results of a critical reexamination of 96 cases from the literature. Our findings fail to support the proposed criteria for distinguishing fetus amorphus from placental teratomas. We find that the presence or absence of an umbilical cord does not relate a t all to the developmental state of the specimen. The extent of skeletal development may be a more valid criterion; however, the internal organization in the fetus amorphus forms an anatomical continuum with that of the placental teratoma, making a differential diagnosis meaningless. Additional research is necessary to solve this dilemma.

Two hard cases have generated controversy regarding the application of the principle of double effect in recent years. As regards the first, the case of the conjoined twins of Malta, there has been considerable convergence: most natural law ethicists seem to agree that separation of the twins was morally permissible. By contrast, the so-called “Phoenix case,” involving an abortion at a Catholic hospital for a woman with pulmonary arterial hypertension, has become a touchstone of disagreement between defenders of the so-called “new” natural law theory, and more “traditional” Thomists. I argue in this essay that, contrary to widespread opinion, the two cases were alike in the following respect: in neither need the principal agents have intended the death of anyone.

In this study, we correlated cardiac malformations in the various types of conjoined twins with the proposed site of embryologic union and evaluated the possibility of survival after surgical separation. We conclude that surgical separation is only very rarely successful in twins with united hearts, whereas survival in twins with separate hearts is more dependent on the malformations of other viscera. This report deals primarily with conjoined twins in whom anomalies of the heart are the major factor in deciding whether surgical separation is feasible.

In the early modern period, monstrous births were described in both popular and scholarly publications. Their interpretation as signs from God, often in response to perceived lapses in moral order, is a well-recognized aspect of the use of wonders as evidence of divine providence. This article considers an alternative reading of monsters as signs of complexity and order in the natural world. In sixteenth-and seventeenthcentury France, Italy, Switzerland, and Germany, natural philosophical writers classified monsters according to their causes and morphology. These classifications implied that monsters were part of the plenitude of creation, and it is argued that they were presented to the reader as part of an exemplary order that glorified its creator. In the eighteenth century, the concept of orderly monsters, based on internal anatomy as well as external form, was used in support of the preformation hypothesis.

This thought experiment considers whether Siamese (Conjoined) are allowed to marry according to Halacha. It considers various aspects of the Biblical bans on incest and offers a very contemporary discussion about the meaning of personhood. This paper uses medical journals, works on medical history, and various responsa to find a precedent and paradigm by which this question can be considered.

Introduction We describe our experience with 22 conjoined twins managed from 1974 to 2006. Materials and Methods Records of 22 conjoined twins admitted from 1974 to 2006 were reviewed. Interviews with attending physicians were also conducted. Results There were 11 thoracopagus, 5 omphalopagus, 3 ischiopagus, 2 craniopagus, and 1 pygopagus twins. Five thoracopagus twins were deemed inseparable due to severe cardiac anomalies. One ischiopagus refused separation, and one craniopagus was separated elsewhere. Six twins (three omphalopagus, one each of pygopagus, ischiopagus, and thoracopagus) were separated emergently as neonates; only one twin is a long-term survivor. Mortalities were due to intractable acidosis, sepsis, and hemorrhage. Nine twins (one craniopagus, one ischiopagus, two omphalopagus, five thoracopagus) were electively separated between 9 months and 2 years of age. One set of these thoracopagus twins died of respiratory failure and sepsis post-operatively. A hydrocephalic twin in another thoracopagus twin died intraoperatively. The rest are alive and well. Conclusions Emergency separations yielded dismal results due to poor patient conditions; delay in separation allowed progressive deterioration and resultant poor outcome. Elective separation had more favorable results due to well-planned strategies, team preparedness, and better patient conditions. A multi-disciplinary approach, with parental participation, is integral in the holistic management of conjoined twins.

The total prevalence of conjoined twins (birth + prenatally diagnosed) was 1:68,000 in the study of 1970-1986. Symmetrical cases (the so-called siamese twins) have an obvious predominance (92.3%). Associated major malformations occurred in 80% of conjoined twins and more than 1/5 were discordant. The surviving time of liveborn conjoined twin sets was not more than two days except in two surgically successfully separated pairs. The family study did not indicate a higher recurrence risk. The case group was compared to two control groups and it appeared that the periconceptional use of oral contraception and ovulation induction were mentioned more frequently in pregnancies resulting in conjoined twins.

The Museum Vrolik collection of the Department of Anatomy and Embryology of the University of Amsterdam, founded by Gerardus Vrolik (1775-1859) and his son Willem Vrolik (1801-1863), consists of more than 5,000 thousand specimens of human and animal anatomy, embryology, pathology, and congenital anomalies. Recently, the collection of congenital anomalies was recatalogued and redescribed according to contempory syndromological views. The original descriptions, as far as preserved, were compared with the clinical and radiographical findings. In 13 specimens the following multiple congenital anomalies (MCA) syndromes were diagnosed: acrofacial dysostosis, Apert syndrome, Brachmann-De Lange syndrome, ichthyosis congenita gravis, Jarcho-Levin syndrome, Meckel syndrome, oro-facio-digital syndrome type IV, Roberts syndrome, Smith-Lemli-Opitz syndrome, Treacher Collins syndrome, and trisomy 13. It appeared that the founders of the museum studied and described several of these syndromes many years before they became established as such. In some specimens a reliable diagnosis is still pending. The use of additional diagnostical techniques, such as MRI, CT scanning, and fluorescence in situ hybridization, in these specimens is currently being investigated.

A set of dicephalous parapagus twins was born at 36 wk gestational age. Twin A had complex congenital heart disease in the form of a single ventricle that would be fatal without surgical intervention. Twin B had normal intracardiac anatomy. The twins were deemed surgically inseparable and the parents requested palliative open-heart surgery on Twin A. The twins shared a common circulatory system to the lower half of the body so that physiological manipulations in one twin adversely affected the other's hemodynamic condition. Twin A underwent successful single ventricle palliation; however, after a prolonged hospitalization, the infants died secondary to severe respiratory disease in Twin B.

Conjoined pygopagus twins are very rare. They represent about 17% of all conjoined twins and commonly share the gluteal region, terminal spine, and lower gastrointestinal, urological, and reproductive tracts. Meticulous preoperative investigations and planning as well as a multispecialty team approach contribute to the success of surgical separation. We report a case of successful surgical separation of pygopagus conjoined twins. D

Introduction: Conjoined twinning is an extremely rare anomaly. Very few diagrammatic descriptions are provided for the various hepatobiliary anomalies seen in these twins. We aimed to review our experience with the various subtypes of hepatobiliary anomalies and their association with the inability to separate as well as provide diagrammatic descriptions of these anomalies. Methods: We retrospectively reviewed our experiences within separating twins. We reviewed patterns of hepatobiliary anomalies and the required investigations and intraoperative workups. Results: Of the 60 cases we evaluated, 28 were successfully separated. The reasons for nonseparation were possession of: a single heart, major communicating hearts, or major chromosomal anomalies. The liver was involved in 17 cases (60.7%) in the operative group and 23 cases (71.8%) in the nonoperative group. All cases had a computed tomographic scan and ultrasound as preoperative workup. Only 2 cases required a magnetic resonance cholangiopancreatography for preoperative evaluation. Intraoperative ultrasound was not used, and only 3 cases required an intraoperative cholangiogram. Diagrammatic depictions of the various categories of anomalies are presented. Conclusion: In our experience, we did not find hepatobiliary anomalies to be the sole reason for inseparability in any of the conjoined sets. Hepatobiliary anomalies seem to be more frequent in the nonseparable group.

Bodily experiences, such as pain, hunger, thirst, tickles, etc., intuitively have a characteristic: they can have only one owner. However, conjoined twins, also known as Siamese twins, call the initial intuition into question: it may be possible to share bodily experiences.

A case of congenital duplication (monocephalus dipygus) in a goat is described. Two pelvis and four pelvic limbs were observed in the kid. Conjoined or fused symmetric twins were diagnosed. Associated abnormalities were cleft palate and anal atresia. Most of the classically recognized teratogens were ruled out by history and serology. However, progenitors were related in the second degree. Thus, genetic factors could be suspected in this case. To the authors' best knowledge, this is the first report of monocephalus dipygus in a goat.

This is a case report in which the diagnosis of conjoined twins was made in a woman by ultrasonography in her eighth month of pregnancy. With this diagnosis, the mother-to-be was transported to a hospital with sophisticated obstetrical, neonatal, and pediatric surgical facilities. The twins were delivered by elective caesarian section and were seen to have anomalies requiring immediate surgery. Following stabilization and basic investigations, surgery was performed on the infants at 3 hr of age. This resulted in a condition that permitted a thorough postoperative work-up and elective separation several months later. INDEX WORDS: Conjoined twins; ultrasound in antepartum diagnosis.

Anatomical features are described in a case of cephalothoracopagus female twins with laterally fused heads. There was a single foregut, shared equally by the two individuals. The tracheae, lungs, hearts, livers, and gallbladders were also shared by the two individuals. They were located in the anterior and posterior regions of the joined bodies. These peculiarities occur in other cases of cephalothoracopagus twinning reported in the literature, and may have been caused by spatial problems in the developing twin embryos. In particular, each heart is considered to be a composite organ, formed by tissue from both individuals. The occipital region of the skull was double, but the remainder of the cranium was single. The oral cavity was divided in two by a midline mandibular body thought to represent the fused medial portions of two mandibles. Each compartment so formed contained a tongue. This midline body is considered responsible for a cleft lip and palate. Finally, we propose that anencephaly in this and other cases of laterally fused heads is associated with mechanical difficulty in closing the rostra1 neuropore.

The incidence of conjoined twins is approximately 1/100,000 births and 70% of the twins are female.' Approximately 40 to 60% of conjoined twins are stillborn and an additional 35% survive only 1 day. These early deaths generally occur in the most severely malformed twins, especially those with thoracopagus joining and major cardiopulmonary malformation. Approximately 35% of the twins are the omphalopagus type, which comprises a wide spectrum ranging from shared liver, intestines and bladder to a mere skin bridge.* We report the anatomical findings and separation of the eighteenth reported case of minimally conjoined omphalopagus twins.3 Accepted for publication July 19, 1996 FIG. 1. Preoperatively twins have shared cloaca and 2 umbilical cords.

In this article I consider the case of the surgical separation of conjoined twins resulting in the immediate and predictable death of the weaker one. The case was submitted to English law by the hospital, and the operation permitted against the parents' wishes.