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1.  Conjoined twins – twenty years' experience at a reference center in Brazil 
Clinics  2013;68(3):371-377.
OBJECTIVE:
This study reports on the experience of one hospital regarding the surgical aspects, anatomic investigation and outcomes of the management of 21 conjoined twin pairs over the past 20 years.
METHODS:
All cases of conjoined twins who were treated during this period were reviewed. A careful imaging evaluation was performed to detail the abdominal anatomy (particularly the liver), inferior vena cava, spleen and pancreas, either to identify the number of organs or to evaluate the degree of organ sharing.
RESULTS:
There were eight sets of ischiopagus twins, seven sets of thoracopagus twins, three sets of omphalopagus twins, two sets of thoraco-omphalo-ischiopagus twins and one set of craniopagus twins. Nine pairs of conjoined twins could not be separated due to the complexity of the organs (mainly the liver and heart) that were shared by both twins; these pairs included one set of ischiopagus twins, six sets of thoracopagus twins and one set of thoraco-omphalo-ischiopagus twins. Twelve sets were separated, including seven sets of ischiopagus twins, three sets of omphalopagus twins, one set of thoracopagus twins and one set of craniopagus conjoined twins. The abdominal wall was closed in the majority of patients with the use of mesh instead of the earlier method of using tissue expanders. The surgical survival rate was 66.7%, and one pair of twins who did not undergo separation is currently alive.
CONCLUSION:
A detailed anatomic study of the twins and surgical planning must precede separation. A well-prepared pediatric surgery team is sufficient to surgically manage conjoined twins.
doi:10.6061/clinics/2013(03)OA14
PMCID: PMC3611880  PMID: 23644858
Conjoined Twins; Surgical Separation; Ischiopagus Tripus Conjoined Twins; Omphalopagus Conjoined Twins; Thoracopagus Conjoined Twins
2.  Prenatal diagnosis of pygopagus tetrapus parasitic twin: case report 
Background
Asymmetric and parasitic conjoined twins are rarer anomalies of monochorionic monoamniotic twins, consisting of an incomplete twin attached to the fully developed body of the co-twin.
Case presentation
A 30-year-old multigravid woman referred to maternal fetal unit due to polyhydramnios at 28th week of gestation. Sonographic examination revealed a single fetus and polyhydramnios with amniotic fluid index 30 cm. The fetus had normal apparent single head, spine, thorax, abdomen, two upper and two lower limbs, and two relatively well developed rudimentary parasitic lower limbs at sacral region. Lower limbs of the autosite were moving freelly but no movement was detected at the parasite. The parasite contained irregular lower limbs and left foot with three toes. Short and deformed long bones were also present in the parasitic limbs. A Cesarean section was performed at 38th week of gestation and a live female infant weighing 3600 g was delivered. The parasitic lower limbs were totally excised. Post-operative period was uneventful and the newborn was discharged as healthy. Post-natal follow-up was normal at nine-month-old.
Conclusion
Pygopagus tetrapus parasitic twin is a rare form of conjoined twins and in utero diagnosis with ultrasound assists in prenatal management and counselling with parents.
doi:10.1186/1471-2393-4-13
PMCID: PMC481071  PMID: 15251046
3.  Ischiopagus tetrapus conjoined twins: 22 years after separation 
There is no record of both separated ischiopagus tetrapus conjoined twins leading normal lives 22 years after separation. We separated a pair of such twins in 1986 and have followed them up till date. Details regarding the technique of separation and the procedures required to ensure normal defecation and micturition and normal musculoskeletal function have been described by us in earlier communications. In this paper we describe their present status and ability to face the world as independent adult females. The outcome reflects the responsibilities and dedication of pediatric surgeons for infant patients with congenital problems after they have become adults, taking a pivotal role to involve surgeons of other disciplines as and when necessary.
doi:10.4103/0971-9261.54809
PMCID: PMC2809464  PMID: 20177445
Conjoined twins; ischiopagus twins; twins seperation
4.  Cross-sectional illustration on major types of conjoined twins. 
Conjoined twins show varying degree of conjoining in either facing or side-by-side fashion. Cephalothoracopagus janiceps is a prototype of facing anomaly in which the two bodies demonstrated a cross symmetry to the midline, that is axial symmetry. Interfacial and intersternal lines crossed at a right angle and no abnormality of situs was associated. Dicephalus dipus dibrachius is a case of side-by-side union, in which the bodies facing nearly the same direction were symmetrical to the middle sagittal plane. Abnormal situs of one was always associated. Other types of conjoined twins as thoracopagus lie between the two extremes of facing and side-by-side union. The three dimensional architectures of the organs in each type would be explained using cross sectional figures of skull, thorax and pelvis. Although the facing twins share the internal organs without fusion, the organs in the side-by-side component are fused with modification of the situs. We postulate sixteen pairs of situs and four manners of division for the explanation of the midline organs and the presence of a dominant co-twin. The splenic locations in a given cardiopulmonary situs are evaluated for the appraisal and applicability of these hypotheses.
PMCID: PMC3053657  PMID: 3267350
5.  Conjoined twins in West Africa. 
Archives of Disease in Childhood  1980;55(8):626-630.
12 cases of conjoined twins from West Africa were reported between 1936 and 1978. Eight sets were liveborn and were surgically separated either in local hospitals or abroad. Four were stillborn. Two new cases of stillborn conjoined twins were recently delivered at this hospital. The most common type and the ones most likely to be born alive were the omphalopagi. Surgical separation was successful in 5 cases but the twins separated at Zaria died about a month later. Emergency operations were performed on the pygopagus and ischiopagus, and one member of the former but both of the latter died. The thoracopagus and dicephalus twins were stillborn. However, necropsy findings in one of the thoracopagi indicate that surgical separation would have been feasible had the twins been born alive. The internal mechanical factors causing cardiac defects in such twins may be relevant to the study of the pathogenesis of congenital cardiac malformations.
Images
PMCID: PMC1627032  PMID: 7192076
6.  Successful early separation of a premature xipho-omphalopagus conjoined twins: a case report 
Canadian Journal of Surgery  1997;40(2):139-142.
Premature xiphoomphalopagus conjoined twins were successfully separated at 7 days of age. The total body weight of the twins before separation was 3502 g. One twin had persistent patent ductus arteriosus and signs of cardiac failure at 4 days of age. This was managed with indomethacin. Thirty-six hours later the second twin became anuric, necessitating early emergency separation. The twins were joined from the lower sternum to the infraumbilical area. The liver was fused, but there was no major vascular connection. There were no other major anomalies. The babies stood the procedure well and were healthy at follow-up 8 months after separation.
PMCID: PMC3952978  PMID: 9126129
7.  Twin heart with a fused atria and separate ventricles in conjoined twins 
Annals of Pediatric Cardiology  2010;3(2):196-198.
One of the most interesting congenital malformations is that of conjoined twins. We report echocardiographic features of twin heart in dicephalus, tribrachius, dispinous, thoracoomphalopagus twin. It showed two hearts fused at atrial level. Right-sided heart had single atrial chamber with a single ventricle. A single great vessel, aorta, originated from it. Left-sided heart was well developed with two atria and two ventricles. There was a small mid muscular ventricular septal defect and a small patent ductus arteriosus. Great arteries had normal origins.
doi:10.4103/0974-2069.74065
PMCID: PMC3017932  PMID: 21234207
Cardiac malformations in twins; conjoined twins; fused heart
8.  Anesthetic management of conjoined twins undergoing one-stage surgical separation: A single center experience 
Objective: To summarize our experience in the anesthetic management of conjoined twins undergoing one-stage surgical separation.
Methodology: Medical records of conjoined twins admitted to our hospital for treatment and considered for surgical separation from 1996 to present were retrospectively reviewed. Four cases of conjoined twins underwent one-stage surgical separation under general anesthesia. Preoperative evaluation was performed to determine the extent of anatomical conjunction and associated anomalies. Anesthesia was simultaneously induced in all conjoined twins. The intubation procedure was successfully performed with the head slightly rotated to each baby’s side, followed by the administration of vecuronium. Anesthetic agents were administered according to the estimated weight of each baby. One case of conjoined twins underwent surgical separation with cardiopulmonary bypass due to shared hearts.
Results: All conjoined twins were successfully separated. No significant respiratory or cardiac events occurred during surgery except for one twin, which died after separation because of complicated congenital heart disease.
Conclusions : Accurate preoperative evaluation, respiratory and circulatory management, and close cooperation of the multidisciplinary team are important aspects of anesthetic management of conjoined twins surgery.
PMCID: PMC3809258  PMID: 24353566
Conjoined twins; Separation; Anesthetic management; Surgery
9.  Prenatal Diagnosis and Postnatal Findings of Cephalothoracopagus Janiceps Disymmetros: A Case Report 
Case Reports in Medicine  2012;2012:273526.
Conjoined twins are rare variants of monozygotic twins, which result from an incomplete division of the embryonic disk. Cephalothoracopagus is a rare twin pregnancy described as imperfect fusion of the head and chest, but separated columns, limbs, and pelvis. They occur with incidence rates that range from 1 per 50,000 to 1 per 100,000 births; however, the incidence of the cephalothoracopagus variety is 1 per 58 conjoined twins. In the case of identical and symmetric faces caused by the orientations of the 2 notochordal axes that are perfectly ventroventral, they are called janiceps disymmetros. We present a prenatal diagnosis of a typical case of cephalothoracopagus janiceps disymmetros and the diagnostic confirmation by image and pathology exams.
doi:10.1155/2012/273526
PMCID: PMC3368323  PMID: 22690223
10.  Autopsy Findings in Conjoined Twin with Single Heart and Single Liver 
Case Reports in Pathology  2012;2012:129323.
Thoracoomphalopagus is the commonest type of conjoined twin where the bodies are fused from upper chest to lower chest. The autopsy done can help counsil the parents for further pregnancies and determine the prognosis depending upon the type of cardiac anomaly by Seo classification when detected antenatally. We describe the detail pathological autopsy of such a case with single heart and single liver. A detail autopsy was done on the twin fetus. The twins shared a single heart and sometimes the liver and part of digestive system. The combined weight was 4.1 KG. Both were full-term male babies joined from below the nipple till umbilicus. Autopsy in conjoined twins helps in deciding the type of fusion of the body and also of the heart and great vessels. It can help in counseling parents about future pregnancies that there is no chance of recurrence of this abnormality and no need to be scared.
doi:10.1155/2012/129323
PMCID: PMC3432525  PMID: 22957286
11.  Heteropagus Twins—A Tale of Two Cases 
The Indian Journal of Surgery  2011;73(3):217-220.
Heteropagus twinning is a rare occurrence. Parasitic and asymmetric conjoined twins are rarer anomalies of monochorionic monoamniotic twins; which consist of an incomplete twin attached to the fully developed body of the co-twin. We present here two such cases of Heteropagus twinning.
doi:10.1007/s12262-010-0228-8
PMCID: PMC3087066  PMID: 22654336
Heteropagus; Twins; Omphalocele
12.  Early prenatal diagnosis of conjoined twins at 7 weeks and 6 days' gestation with two-dimensional Doppler ultrasound: a case report 
Cases Journal  2009;2:8330.
This case report presents the prenatal diagnosis of conjoined twins at 7 weeks and 6 days’ gestation according to the last menstrual period and 6 weeks and 4 days’ gestation according to crown-rump length in a 32-year-old Turkish woman, using two-dimensional Doppler ultrasound. The twins were fused to each other at the thoracic region (thoracopagus). In the light of previous reports of conjoined twins this appears to be one of the earliest prenatally diagnosed cases in the medical literature.
doi:10.4076/1757-1626-2-8330
PMCID: PMC2740312  PMID: 19830069
13.  A Rare Form of Heteropagus Twinning: Three-Armed Infant with Spinal Dysraphism 
Case Reports in Pediatrics  2012;2012:831649.
An ectopic or accessory limb attached to the back is an extremely rare and strange condition, and there are only a few documented cases in the worldwide literature. The first case was described by Jones and Larkin (1889). There are several theories regarding the origin of this condition. Asymmetric conjoined twinning which is located dorsally in the vertebral column (rachipagus) is the most probable diagnosis of our patient. Conjoined twinning is very rare and the incidence is 1 per 50 000 live births. Rachipagus is even rarer, with no more than 30 case reports so far (Chadha et al. (1993, 2006)). In this report, we present a patient who underwent successful surgical excision of a third arm attached to the back in the midline over the low-dorsal region. Differential diagnoses including teratoma and fetus in fetu are discussed.
doi:10.1155/2012/831649
PMCID: PMC3530761  PMID: 23304600
14.  Absence of the spleen(s) in conjoined twins: a diagnostic clue of laterality defects? Radiological study of historical specimens 
Pediatric Radiology  2012;42(6):653-659.
Background
Laterality defects are quite common in thoracoileopagus and parapagus dicephalus but rare in other types of conjoined twins.
Objective
To present the presumed laterality defects in cephalothoracoileopagus and prosopothoracoileopagus conjoined twins, based on the unilateral or bilateral absence or duplication of the spleen.
Materials and methods
Three human anatomical specimens of craniothoracoileopagus (CTIP) twins and one of prosopothoracoileopagus (PTIP) twins were investigated. The specimens were part of the Museum Vrolik collection of the Department of Anatomy and Embryology of the Academic Medical Centre, University of Amsterdam, The Netherlands. The specimens were taken out of their jars and scanned with multidetector CT and volumetric T2-weighted MRI at 1.5 T.
Results
The internal anatomy of the specimens was largely in accordance with previous reports. However, there was no recognisable spleen in the right twin in one CTIP specimen, in the left twin in one other CTIP specimen, and in both twins in the third CTIP specimen and in the PTIP specimen.
Conclusion
Asplenia and polysplenia are considered reliable indicators of right and left isomerism, respectively. However, three of our four specimens had laterality patterns that did not correspond with those previously reported. Since no other parameters of laterality defects could be verified in these specimens, we concluded that asplenia was unlikely to be caused by laterality defects.
doi:10.1007/s00247-011-2316-8
PMCID: PMC3366290  PMID: 22237480
Conjoined twins; Laterality defects; Imaging; Historical specimen
15.  Differences between the events preceding spina bifida and anencephaly. 
Journal of Medical Genetics  1981;18(1):17-21.
It is usually held that there is a time continuum in the formation of monoxygotic (MZ) twins which is indexed by their placentation, running from dichorionic to monochorionic diamniotic to monochorionic monoamniotic and conjoined pairs. There is good evidence that this continuum is characterised by a continuum of predisposition to anencephaly, slightly raised in dichorionic pairs but very high in some sorts of conjoined pairs. Although MZ twins, especially monoamniotic and conjoined pairs, are peculiarly liable to anencephaly, they are not particularly susceptible to spina bifida. Among twin pairs concordant for anencephaly or spina bifida, there are strikingly few concordant in the sense of one twin having anencephaly and the other spina bifida, in contrast with the numbers of pairs concordant for the same malformation. The prevalence of anencephaly in double monsters varies with the type of monster, being high in diprosopus. These findings may be explained by the timing of embryonic events.
PMCID: PMC1048651  PMID: 7019447
16.  Multimodality Imaging in the Assessment of Thoraco-Omphalopagus Conjoined Twin: Lessons to Learn 
Case Reports in Radiology  2012;2012:564036.
Conjoined twins are rare and present a unique challenge to pediatric surgeons and radiologists. An imaging strategy to accurately define anatomic fusion, vascular anomalies, and other associated abnormalities is important for surgical planning and prognostic information. A conjoined female twin with a combined weight of 2.8 kg was born by emergency caeserean. Hence, a computed tomography scan of the thorax and entire abdomen at 1.25 mm slice thickness was performed to delineate the internal structures of the twins. CT-angiography defined specific vascular supply which determined the distribution of shared structures between the twins. An echocardiogram showed four heart chambers with atrioventricular septal defect. To further evaluate the heart chambers, the twin was planned for gated cardiac magnetic resonance imaging. Unfortunately, they succumbed 6 hours apart due to complication of septicemia. Magnetic resonance imaging and CT scan provide excellent anatomic detail, demonstrating organ position, shared viscera, and limited vascular anatomy, whilst angiography defined specific vascular supply, useful in determining the distribution of shared structures between the twins in planning for surgery.
doi:10.1155/2012/564036
PMCID: PMC3390032  PMID: 22792503
17.  Anaesthetic Management of Conjoined Twins' Separation Surgery 
Indian Journal of Anaesthesia  2009;53(3):294-301.
Summary
Anaesthesia for conjoined twins, either for separation surgery, or for MRI or other evaluation procedures is an enormous challenge to the paediatric anaesthesiologist. This is an extra challenging surgery because we the anaesthesiologists need to care for two patients at the same time instead of just one. Anaesthesia for conjoined twins ‘separation surgery mainly centered on the following concerns: 1.Conjoined Twins’ physiology like crossed circulation, distribution of blood volume and organ sharing with their anaesthetic implications. 2.Long marathon surgery with massive fluid shifts and loss of blood & blood components and their rapid replenishment. 3.Meticulous planning for organized management of long hours of anaesthetic administration in two paediatric subjects simultaneously with multi surgical specialties' involvement and their unique requirements. We report the anaesthetic and intensive care management of one pair of Pygopagus separation surgery and also the review of literature and world statistics.
PMCID: PMC2900119  PMID: 20640136
Conjoined twins; Separation surgery; Anaesthesia; Monitoring
18.  Ultrasound diagnosis of cephalopagus conjoined twin pregnancy at 29 weeks 
The authors report a case of a cephalopagus conjoined twin that was diagnosed at 29 weeks of gestation despite the mother having had two ultrasounds done previously. The fetus had one head and face, fused thoraces, common umbilicus but had two pelvises and two sets of genitalia. The fetus had four normally formed legs and arms.
Antenatal ultrasound images are supplemented by post natal photographs. A review of literature, clues to ultrasound diagnosis and possible causes of missing this significant abnormality until the 3rd trimester are discussed.
doi:10.2349/biij.6.4.e38
PMCID: PMC3097803  PMID: 21611074
conjoined twins; ultrasound; missed diagnosis; false negative; cephalopagus
19.  Parapagus dicephalus dibrachus dipus: A case of conjoined twins 
In this report, we describe the case of a woman with a prenatal diagnosis of parapagus dicephalus dibrachus dipus conjoined twins at 14–15 weeks of gestation via two-dimensional ultrasonography. The parents elected to terminate the pregnancy and the patient delivered a 15-cm 130-g male fetus. There were two heads and necks which appeared grossly normal. The thoracic and abdominal cavities were shared. The fetus had four normal limbs. On internal examination, there were two separate structurally normal hearts. There were two larynges and four lungs. Two esophagi fused to enter a single stomach. The diaphragm was common and separated a single abdominal cavity. Distally, the alimentary system including the liver and gallbladder was single.
PMCID: PMC3939174  PMID: 24591881
Conjoined twins; parapagus twins; ultrasonography
20.  Prenatal diagnosis of conjoined twins: four cases in a prenatal center 
Objective
To assess the findings in conjoined twins diagnosed prenatally.
Material and Methods
Between January 2002 and June 2009, we reviewed the database and medical records of 857 twin pregnancies, including 140 monochorionic twins. Nineteen monochorionic-monoamniotic twin pregnancies were detected, four of which were complicated by conjoined twins.
Results
Of these 4 cases, 2 were complicated by thoracopagus and one had thoraco-omphalopagus; these three cases underwent termination at 16, 11, and 19 weeks gestation, respectively. The last case was diagnosed as a pygopagus tetrapus parasitic twin at 28 weeks gestation. The family decided to continue the pregnancy, and achieved a successful outcome with elective surgery postpartum.
Conclusion
Conjoined twins are an uncommon and complex complication of monozygotic gestations, which is associated with high perinatal mortality. The early prenatal diagnosis of conjoined twins allows improved counseling about the management options, including maintenance of pregnancy with surgery after delivery or termination of pregnancy.
doi:10.5152/jtgga.2010.32
PMCID: PMC3939146  PMID: 24591931
Conjoined twins; prenatal diagnosis
21.  Conjoined twins: what ultrasound may add to management 
Introduction
Conjoined twins occur in approximately 0.2:10,000 births; the obstetrician and sonographer only rarely examine them. In Western countries, discovery of conjoined twins is often made by the end of the first trimester; however, in the third world, conjoined twins are often discovered only at birth.
Objective
To evaluate how ultrasound techniques, when possibly available, may improve management and counseling when conjoined twins are confirmed.
Material and Methods
The authors report two different cases of union of two equal twins with sole umbilical cord.
Results
The two cases presented with non contributive medical history and no prior teratogen exposure and an unfavorable prognosis.
Early discovery of viable conjoined twins permits assessment of the best route of delivery and a planning for serial sonography and fast MRI to plan eventual separation surgery or fetus after-birth surviving possibilities.
PMCID: PMC3414243  PMID: 22905303
conjoined twins; ultrasound
22.  One into two will not go: conceptualising conjoined twins 
Journal of Medical Ethics  2004;30(3):279-285.
This paper is written in response to controversial judicial decisions following separation surgery on conjoined twins "Jodie" and "Mary". The courts, it is argued, seem to have conceptualised the twins as "entangled singletons" requiring medical intervention to render them physically separate and thus "as they were meant to be", notwithstanding the death of the weaker twin, "Mary". In contrast, we argue that certain notions, philosophical and biological, of what human beings are intended to be, are problematic. We consider three compelling conceptualisations of conjoined twins and advocate a model that conceives them as two psychologically separate individuals who happen to share a body, the sharing of a body being integral to the individuality of each twin. While we reject an "essentialist" view of the conjoined state, a view which might render separation surgery unthinkable in all cases, we nevertheless argue against an "adversarial" interpretation of conjoined twins' respective best interests. We maintain that the physical entanglement should be regarded as a shared problem rather than one posed by one twin to the other. And if, after deliberation, separation surgery is deemed the "least detrimental alternative" or the "lesser of two evils", then there should be recognition of what conjoined twins will lose, as well as gain, through separation. The current drive to separate twins at all costs may evince a deeper unease with bodily configurations that appear to threaten the premium that the Western ethical and legal tradition places on personal sovereignty, and the physical circumscription that such sovereignty assumes.
doi:10.1136/jme.2002.001289
PMCID: PMC1733862  PMID: 15173363
23.  Conjoined Twins in a Triplet Pregnancy: A Case Report 
Background. Conjoined twins are a rare complication of monozygotic twinning and are associated with high perinatal mortality. Case. Here we present a case of conjoined twins in a triplet pregnancy diagnosed at 13 of weeks gestation. With the aid of 3D ultrasound and MRI images, the parents were counseled regarding the management options, including continuation of pregnancy, termination of pregnancy, or selective fetocide. They chose selective fetocide of the conjoined twins and went on to deliver the remaining triplet at term. Conclusion. This case represents to our knowledge the only MRI images of conjoined twins in a triplet pregnancy and demonstrates how 3D imaging can be used to better counsel patients about management options.
doi:10.1155/2011/235873
PMCID: PMC3335527  PMID: 22567498
24.  Thoracopagus Conjoined Twins: A Case Report 
ISRN Obstetrics and Gynecology  2010;2011:238360.
Objective. Conjoined twin is a rarely seen congenital anomaly together with severe mortality and morbidity. The more common types of conjoined twins include the thoracopagus type, where the fusion is anterior, at the chest, and involves the heart. We are reporting one case of conjoined thoracopagus twins diagnosed by ultrasonography at 11 weeks. Case Report. In a multigravid pregnant woman who has been admitted to our clinic with a diagnosis of conjoined twins, thoracopagus, by ultrasonography at an 11-week gestation, termination of the pregnancy was performed. Conclusion. Making an early diagnosis with ultrasonographic examination gives the parents a chance to elect pregnancy termination.
doi:10.5402/2011/238360
PMCID: PMC3099464  PMID: 21660094
25.  Dicephalic Parapagus Tribrachius Conjoined Twins in a Triplet Pregnancy: A Case Report 
Dicephalic parapagus tribrachius conjoined twin is a very rare condition.
We present a case of 5-days-old male dicephalic parapagus conjoined twins. The conjoined twins were diagnosed in 4th month of pregnancy by ultrasonography. The pregnancy terminates at 36 weeks by cesarean section and triplets were born. The babies were male conjoined twins and another healthy male baby. Many congenital defects of interest can now be detected before birth. Sever form of this malformation precludes postpartum life. It is supposed that with advances in screening methods for prenatal diagnosis these cases are terminated in first or second trimester of pregnancy.
PMCID: PMC4064765  PMID: 24971140
Dicephalic Parapagus Tribrachius; Conjoined Twins; Triplet Pregnancy

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