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Conjoined Iranian Twins Die After Two-Day Surgery

Failure of the separation effort, the first of its kind on adults, leaves a nation in mourning.

July 09, 2003|Azadeh Moaveni and Allison M. Heinrichs | Times Staff Writers

Tehran — In a nation where the disabled are often viewed more with disdain than compassion, Laleh and Ladan Bijani became unlikely heroes.

Joined at the head since birth, the Iranian twins' plight had long been followed by the public with impertinent curiosity. But the 29-year-olds' decision to embark on an extremely risky separation operation in Singapore for the chance at independent lives provoked an outpouring of sympathy for the women and transfixed their homeland.

When the operation -- the first attempt ever to separate adult twins joined at the head -- failed Tuesday after more than two days of surgery, the news plunged Iran into mourning.

Many Iranians who had come to see the women as symbols of perseverance in the face of extraordinary physical and emotional hardship reached for their mobile phones to share their grief with family and friends.

"Their whole story struck a chord with me, though I can't explain why it's more sad than anyone innocent dying," said Maryam Hosseini, a travel agent in Tehran.

Despite the challenges of the operation, Iranian media reports had suggested that at least one sister would survive. Newspapers filled pages with stories and photos documenting how the twins coped with their lives, and state TV broadcast a home video of the two behind the wheel of a car, both lodged in the driver's seat. Radio stations aired updates on the hour.

Before the operation began Sunday at Singapore's Raffles Hospital, Iranian President Mohammad Khatami offered his best wishes. "I hope to see the dear and patient Laleh and Ladan healthy and happy among us very soon," he said. Khatami's office said it would cover the approximate $300,000 cost of the surgery.

The sisters struggled to lead a normal life throughout their 20s, attending college and eventually living on their own. They wore makeup, socialized and talked about their professional goals. Wearing the mandatory Islamic veil posed a physical challenge, which they met by wrapping a scarf around both their heads and securing it underneath with a clip.

Although they had adapted to their situation, the women had for years been seeking doctors who would be willing to try to separate them. Such surgery has been successfully completed on infants -- whose brains are considered more malleable than adult brains and recover from injury better -- but it had never been attempted on adults.

In 1996, the twins consulted German doctors but were turned down. Although they had separate brains, they shared a major blood vessel, the venous sinus, which drains blood from the brain. The doctors felt the shared vein made the surgery too risky.

The women sought out doctors in Singapore after conjoined Nepalese infants were separated there in 2001. Following a long battery of tests and psychological examinations, the Bijani sisters were accepted once doctors determined that there was a reasonable chance they could survive -- and that remaining fused could pose other health risks.

Before the surgery, the Singapore team -- a group of 28 specialists from Singapore, the U.S., Nepal, Japan, France and Switzerland -- knew it would have to give the venous sinus to one of the twins and construct a second blood vessel for the other twin.

In their last public statement before the surgery, the twins said, "If God wants us to live the rest of our lives as two separate, independent individuals, we will."

But from the start, the surgery proved more difficult than expected. The section of skull that joined the twins was thicker and more compact than doctors anticipated, and the six-hour surgery to cut away the skull and reveal the brains ran longer than surgeons projected.

After cutting away a thick strip of bone from the front of the shared skull, surgeons were able to closely examine the brains and blood vessels and determined that Ladan would receive the new blood vessel. They began constructing a new vessel for her using a vein removed from her right thigh.

The procedure was completed Monday at 4:30 p.m. Singapore time, and the surgery to separate the brains began. Doctors found that while the brains were separate, they had adhered to each other. Surgeons had to separate them millimeter by millimeter, a process that lasted through the night.

At 1:20 p.m. Tuesday, the separation was nearly complete, and the twins were declared to be in stable condition. However, the loss of blood in the concluding hours of the surgery proved too great. Ladan died just after 2:30 p.m. Laleh was listed as critically ill and, though doctors fought to stabilize her, she died an hour and a half later.

Dr. Steven Chang, an assistant professor of neurosurgery at Stanford who did not take part in the operation, said that although the loss of blood was the main problem, it probably led to swelling, which was most likely the cause of death.

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