Surgical team pushes limits to separate twins

Surgeon David Dunaway Surgeon David Dunaway's voice briefly shook with emotion as he explained how it was his team's hope that Rital and Ritag Gaboura would go on to lead normal lives.

"I can't say what a joy it has been," said the cranio-facial specialist. "It is hard to say what it feels like to have been involved in the team that managed to do this.

"It has been a wonderful experience. A few weeks later and they are smiling and developing properly. It has been wonderful for us."

It is a fleeting indication that, far from being a miracle, the separation of Sudanese conjoined twins was the culmination of months of work by a team of more than two dozen experts who pushed themselves to their surgical and medical limits.

"We feel very lucky that our girls have been able to have the surgery that they needed, but we also know other children who need complete sponsorship and families who are searching for someone to help them," says the girls' father, Abdelmajeed.

Rital and Ritag weighed just 6kg together when they were born by caesarean section in Khartoum, Sudan, in September 2010, joined at the top of their heads.

Their parents Abdelmajeed, 31, and Enas, 27, both doctors, knew the odds against them were terrible.

Only a fifth of conjoined craniopagus twins make it to their first birthdays, while 90 per cent of them die by the time they reach 10 years old. Even fewer get a chance to lead a normal life.

The two little girls would be confined to lying down but, worse still, Ritag was supplying half of Rital's blood, keeping her twin alive, but slowly her heart was failing.

For the girls' parents, it was the beginning of a fight to find the funding and the expertise to separate them safely. They approached one organisation after another in vain.

Eventually, they were put in touch with Facing the World, a charity that was set up by some of the UK's leading craniofacial surgeons almost a decade ago to provide hope for youngsters with terrible disfigurements.

The charity managed to raise almost £300,000 ($580,000) to cover costs, while experts donated their time free.

Sarah Driver-Jowitt, Facing the World's executive co-ordinator, who travelled to Sudan to make arrangements when the girls were two months old, says: "Even bathing them was difficult. Mum was really struggling to carry them both while supporting their necks. But they got around it in the most graceful way. They had large pillows to put them on.

"One twin would sleep while the other was crying. Just watching their mum cuddle one while the other sister was asleep, you forgot they were conjoined."

Armed with new toys and clothes, the family arrived in London in April to begin a mammoth round of medical treatment. The team immediately fell for the pair. Rital, the stronger one, was "the boss", while Ritag was chattier.

"They have always been little laughing girls. They just giggle. They would beam and start laughing even before I would talk to them," says Driver-Jowitt.

The two little girls' brains were separate but touched and shared a single dural layer (a thick fibrous membrane enveloping the brain). Parts of Rital's brain were also supplied by her sister's blood.

The surgeons were faced with a dilemma, says team leader Dunaway, as they wanted to complete the surgery in "slow, steady" stages.

The initial plan had been to wait until the twins were around a year old, but the doctors knew that Ritag's high blood pressure and failing heart were putting her in mortal danger.

Medication, he explained, was also causing a major problem, as one twin had high blood pressure while the other's was low - a tremendous challenge for the anaesthetists.

The team included craniofacial and plastic surgeons, neurosurgeons, anaesthetists, neuro-radiologists, paediatricians, cardiologists and a host of specialist nurses.

On May 9, the first operation began. Over 10 hours, the medical team separated one third of the brains through limited cuts to the skulls. A silastic sheet was placed partially between them to replace the joint dura.

The surgery went well, but it seemed that Ritag's heart problems were getting worse.

Seven days later, the twins went through another 10-hour operation when the surgeons separated the common vein in their brains, giving it to Rital, and extended the silastic sheet across the rest of the heads.

"This was a small 3cm blood vessel in a whole set of vessels, so the chance of making an error was high," explains leading neurosurgeon Owase Jeelani. But the surgery was successful and both twins were functioning well. The strain on Ritag's heart was also beginning to lift.

Then on July 4, when the girls had recovered enough and put on some weight, they went back into surgery yet again. This time, over six hours, tissue expanders were inserted under the scalp.

These were inflatable silicone balloons which over the coming weeks would be gradually inflated with injections of saline. As they expanded, they stretched the scalp so that both girls would have enough to cover their heads when the separation came.

Then on August 15, they went through the final major operation. Over 13 hours the surgeons worked to separate the girls. A new skull was made by splitting the inner and outer layer of their bone to cover both heads.

Doctors had worked for months on three-dimensional models to try to ensure that any scarring or disfigurement would be kept to a minimum. The skin was replaced so the direction of hair growth was normal.

The girls appeared to be doing well. Ritag, who had always had to fight harder to survive, had blossomed, while Rital was progressing a little bit more slowly, the surgeons explain.

"It is a delight to see how well the girls are doing," says craniofacial surgeon Simon Eccles. "Rital was up and holding her own milk bottle again within days of surgery. Ritag took a day or two longer but she, too, is back to her laughing self."

They will both need further reconstructive surgery to ensure normal shaped heads, says Dunaway, and they will need physiotherapy to make their neck muscles stronger, but the prognosis is good for both girls: "It is for the family now to be able to settle down and lead a normal life."

The twins turned 1 this week, but Driver-Jowitt says: "Their mum and dad have already said that they will have two birthdays, one to mark their birth and one to mark their separation. The parents always said that all they ever dreamed about was to have two healthy girls to go home with and that is now about to happen."

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