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NEW YORK CITY, NY (November 24, 2003) -- In a five and a half hour procedure today, surgeons at The Children’s Hospital at Montefiore (CHAM) successfully completed the second stage in a planned series of operations to separate Carl and Clarence Aguirre, 19-month-old craniopagus twins from the Philippines.
“It went extremely well and there were no surprises,” said James T. Goodrich, MD, director of Pediatric Neurosurgery at CHAM, who performed much of the surgery. “We are right on target. We are about 50-60 percent of the way through now,” said Goodrich. The twins are expected to remain at CHAM for several days and will return to Blythedale Children’s Hospital for continuing physical and nutritional therapy. Depending on how well the brothers respond to the therapy, they could be ready for the next surgery in late January 2004.
Today, the highly specialized surgical team tied off four large veins that the twins shared, including part of the sagittal sinus, the largest vein responsible for draining blood from the brain to the heart. Tying off the shared veins is a necessary step prior to physically separating the twins, at which time they will need completely independent blood vessel systems.
In addition, David A. Staffenberg, MD, chief of Pediatric Plastic Surgery at CHAM, placed one tissue expander on the left side of Carl’s head. Tissue expanders are small pouches that are gradually filled with saline and stretch the overlying skin, which will finally be used to reconstruct the scalp in each twin.
While the twins’s skulls are conjoined, doctors say their brains are not. The brains, however, directly abut each other and, during the procedure, Dr. Goodrich and Dr. Willy Lopez, a member of the twins’ surgical team from Manilla, used instruments called “brain retractors” to gently pry apart about 50 percent of the surface areas that abutted.
“After today’s operation, more than half of the veins that need to be tied off prior to separation have been tied off,” said Dr. Goodrich. “These veins are located mostly in the front and side areas of the brain.”
“The most difficult part of the operation may lie ahead,” said Dr. Goodrich. “This will involve cauterizing, suturing and then separating a large complex of veins at the back of the brain, especially the abnormally shaped sagittal sinus vein.” This complex of veins runs along the plane where the twins’ heads are joined. Separating them will involve at least one or two additional operations, he said.
The four large veins that were tied off today included the anterior segment of the superior sagittal sinus and three cortical veins that run from the brain’s cortex to the sinus vein. One of the boys will receive the sagittal sinus vein, the other will not. Clarence, the smaller twin, may be the best candidate for keeping the sagittal sinus, doctors said.
Robert Marion, MD, director, Center for Congenital Disorders, CHAM, and the twins' pediatrician, said that caring for the twins will be a long-term process. “They will continue to receive physical, occupational and speech therapy, as well as nutritional care to ensure that when they are separated, they will be strong and able to walk,” he said. Because the twins have been tube-fed, they have gained 8 pounds since they arrived in September,” he said.
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