Emergency separation of conjoined twins in a tertiary hospital in Indonesia: three case reports

• Published in: BMC medical ethics Vol. 24; no. 1; p. 16
• Main Authors: Ramlan, Andi Ade Wijaya, Zahra, Raihanita, Rinaldhy, Kshetra, Kapuangan, Christopher, Rahendra, Ferdiana, Komang Ayu, Yani, Ahmad
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 25.02.2023; BioMed Central; BMC
• Subjects: Abdomen; Anatomy & physiology; Anesthesia; Babies; Cardiac arrhythmia; Care and treatment; Case Report; Case reports; Children; Conjoined twins; Decision-making; Emergency separation; Ethical aspects; Ethics; Fentanyl; Genetic aspects; Health aspects; Health Status; Hemodynamics; Hepatectomy; Hospitals; Humans; Indonesia; Infant; Infant, Newborn; Liver; Medical ethics; Mortality; Multidisciplinary teams; Parents & parenting; Pediatrics; Physiology; Sepsis; Surgery; Tertiary Care Centers; Twins, Conjoined - surgery; Ventilators; Indonesia; Conjoined twins; Ethics; Case report; Emergency separation
• ISSN: 1472-6939; 1472-6939
• DOI: 10.1186/s12910-023-00895-z

Emergency separation of conjoined twins is performed when one twin is already dead or dying and threatens the survival of the other. The particular decision to perform an emergency separation of conjoined twins provides an ethical dilemma that needs special attention. Adding to the complexity of surgical and postsurgical management in emergency separation, ethical and sociocultural aspects further complicate decision-making. From 1987 to 2022, 18 conjoined twin separations were performed in our centre. This paper describes three conjoined twin emergency separations. In the first case of thoracoomphalopagus babies at nine days of age, one baby was diagnosed with necrotizing enterocolitis with frequent desaturation and seizures, and the other baby was healthy. Emergency separation was performed on the twelfth day of age; unfortunately, neither baby survived the surgery. In the second case, emergency separation was performed on the 110th day of life due to sepsis in one baby. The nonseptic twin passed away six hours after surgery, while the septic twin died 12 days after surgery due to wound dehiscence and abdominal sepsis. The third case was of an omphalopagus conjoined twin with a parasitic twin. The healthy baby was deemed nonviable but found to be healthy upon birth. Immediate emergency separation was performed at 2 h of age. The living baby survived the surgery but passed away two months later. When separation is deemed necessary to save one twin, it becomes difficult to apply standard ethical medical reasoning. The decision to separate results in most cases in very high-risk surgeries with poor outcomes during surgery and postsurgery. Compounded by the complexity of the case, sociocultural and religious aspects further add to the dynamics of decision-making. A multidisciplinary team must work together with a health ethics committee and navigate through this ethical conundrum with the patient and family at its decision-making centre to decide on the best plan of care.