Iranian
twins Laleh and Ladan Bijani, joined at the head for 29 years, died
within 90 minutes of each other Tuesday after doctors separated
them but were unable to control their bleeding in the unprecedented
surgery.
In their homeland, people cried out in shock or wept as state television
broke into normal programming to announce their deaths during the
third day of surgery in Singapore.
"Is my beloved Ladan really not with us anymore?" Zari
Bijani, an elder sister of the twins, said after Ladan's death was
reported. Seconds later, she fainted.
Hospital officials said Ladan died 90 minutes ahead of her sister
Laleh, with both deaths because of blood loss. They died while still
under anesthesia.
"Everyone upstairs is crying," said the nurse, speaking
on condition of anonymity. "We treated them like family because
they had been here for seven months."
It was the first time surgeons tried to separate adult craniopagus
twins - siblings born joined at the head. The surgery has been performed
successfully since 1952 on infants, whose brains can more easily
recover.
The twins had gone into the surgery saying they knew the risks
but wanted to achieve their dream of living independent lives -
Laden wanted to continue as a lawyer, Laleh wanted to switch
to become a journalist. Speaking in English to journalists last
month, their joined heads wrapped in a single scarf, the smiling
and laughing sisters said they wanted for the first to look at each
other face-to-face.
"We have different ideas about our lives," Laleh said.
"Actually, we are opposites," Ladan interrupted, laughing.
"If God wants us to live the rest of our lives as two separate,
independent individuals, we will," Ladan said before the final
tests Saturday ahead of the surgery.
The risky, marathon separation procedure began about 10 p.m. EDT
Saturday. Before the operation, doctors warned that the surgery
could kill one or both of the twins, or leave them brain-dead.
"When we undertook this challenge, we knew the risks were
great. But we were hopeful. Ladan and Laleh knew the risks too,"
said Dr. Loo Choon Yong, chairman of Raffles Hospital. "As
doctors there is only so much we can do as the rest we have to leave
it to the Almighty."
From the start, doctors ran into unexpected obstacles not found
in the infants that the operation has until now been performed on.
It took longer to cut through portions of the sisters' skulls because
their older bones were denser than previously believed.
And though the Ladan and Laleh's brains were separate, they had
adhered to each other after years of growing and sharing the same
space. That forced doctors to meticulously cut the organs
apart, "millimeter by millimeter," Raffles hospital spokesman
Dr. Prem Kumar said.
"As the separation was coming to a close, a lot of blood was
lost. The twins were subsequently in a critical state,"
said Kumar.
Working in two groups, surgeons gave each twin blood transfusions,
but in the end they were unable to cope with the unusual blood flow
patterns, he said.
"I was concentrating very hard on Laleh at the time,"
lead neurosurgeon Dr. Keith Goh said, recounting the moment when
he knew the operation had gone wrong. "I was very saddened
when I looked over and saw them struggling, of course at the same
time, we were struggling too."
A crucial part of the surgery had been to deal with a finger-thick
vein shared by the sisters that drained blood from the brain. In
1996, German doctors had told the twins that shared vein
made surgery too dangerous.
During the operation, the surgeons grafted a similar sized
vein from Ladan's right thigh to her brain, then rerouted the shared
brain to her sister.
But Ladan's new vein became congested, and surgeons Monday night
considered wheter to call off the rest of the operation and leave
the twins joined or "continue with final stage of the surgery,
which we knew would be very, very risky," Loo said.
"The team wanted to know once again what were the wishes of
Ladan and Laleh," Loo said. "We were told that Ladan and
Laleh's wishes were to be separated under all circumstances."
For more than 50 hours, the team of 28 doctors and about 100 medical
assistants worked in tight spaces in front of and behind the twins,
who were in a sitting position in a custom-built brace connected
to IVs and monitors. Classical music played softly, and surgeons
whose expertise was not needed at the moment would slip out of the
room for rest.
In the final hours, the surgeons had to contend with unstable
pressure levels inside the twins' brains just before they worked
to uncouple the sisters' brains and cut through the last bit of
skull joining them, Kumar said.
"I am very sad, as all of us are," Goh said. "Over
the last six months, everyone who came in contact with them was
touched by their personalities and the kind of people they were."
The courage of the twins won them a place in the hearts of Iranians.
Television devoted many programs to the twins. Newspapers published
page after page about their life and the protracted operation.
Parents of the twins, Dadollah Bijani and Maryam Safari, thanked
the Iranian nation for praying for their children, the state-run
Tehran radio reported.
"It's a national tragedy," said Ahmad Mahmoudi, a photographer
in Tehran.
Housewife Noushin Nowrouzi promptly parked her car after she heard
the news on the radio so she could cry in peace.
The sisters were born into a poor family of 11 children in Firouzabad,
southern Iran, but grew up in Tehran under doctors' care.
The Iranian government said Monday it would pay the nearly 0,000
cost of the operation and care for the twins.
Participating neurosurgeon Dr. Benjamin Carson, director of pediatric
neurosurgery at Johns Hopkins Children's Center in Baltimore, has
separated three sets of craniopagus twins.
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