PALO ALTO, Calif.--(EON: Enhanced Online News)--Conjoined twins Angelica and Angelina Sabuco, joined at the chest and abdomen, will soon be separate little girls. Lucile Packard Children's Hospital at Stanford is preparing a November 1 surgery to separate the two-year-olds, born in the Philippines and now living in San Jose, Calif. The operation, including six hours of work to cut apart the girls and two to three hours of reconstruction, is the culmination of several months of complex planning involving specialists from nearly every part of the hospital.
“The plates will dissolve over about a year and a half”
"This is a major operation, but we really expect both twins to survive and to do well," said pediatric surgeon Gary Hartman, MD.
The surgery will be the second separation of conjoined twins performed at Packard Children's. The first pair was successfully separated in 2007 by a team that Hartman led. The Sabucos’ operation is expected to be less complex because they share fewer organs.
Angelica and Angelina's mother, Ginady Sabuco, was seven months pregnant when she learned her twins were conjoined. "I was asking God: why us, why me?" she said, recalling the day she got the news. It was especially difficult because her husband Fidel was living and working in San Jose while Ginady and their son lived in the Philippines.
After joining Fidel in California in late 2010, Angelica and Angelina were seen at Packard Children's to evaluate their physiology and the risks of separation.
"I want them to live normally, like other children," said Ginady, explaining the separation. In addition to the obvious psychosocial difficulties, remaining conjoined carries risks for the twins' physical health, such as muscular and skeletal deformities that will worsen with time.
The radiology team began the assessment by performing extensive imaging. “CT scans showed that the girls have separate hearts that may touch at their tips. Their livers are tightly fused together. Their intestines touch and may be herniated in some spots, but their digestive systems function separately. Their sternums are joined together; their ribs are separate,” said radiologist Frandics Chan, MD.
The next step in the twins' preparation, performed in July, was surgery to insert tissue expanders in four places under their skin. The expanders are small balloons, gradually inflated with liquid to prompt growth of extra skin that will be used to repair their separation. Each of the four expanders (two per child) was inflated weekly; the expanders are now the size of soft-drink cans.
During the CT scan and the surgical procedures to implant and inflate the tissue expanders, the anesthesiologists kept a close eye on responses to sedation and anesthesia. "We've anesthetized them five or six times now, and they've been very, very stable," said anesthesiologist Gail Boltz, MD. The girls' circulation is mostly unshared, which makes anesthesia safer, she added.
Hartman, Chan, Boltz and plastic surgeon Peter Lorenz, MD, have devised a detailed plan for the surgery, which will involve more than 20 physicians and nurses. They’ve decided where each piece of equipment will stand, and implemented a color-coded plan for keeping straight which personnel and tools are assigned to each twin.
Hartman will make the first incisions in the girls' skin and muscle, and Lorenz will cut through their rib bones. Hartman will separate the girls' diaphragms and livers, which are firmly adhered along their longest sides. The liver separation will be the riskiest segment of the surgery because it is the most likely to cause blood loss. Hartman will then cut any adhesions between the girls' bowels, and cut the last bit of skin that joins the sisters. Then, in separate operating rooms, the reconstruction phase will begin.
Lorenz and his team will rebuild the girls’ chest and abdominal walls. They will implant a thick, custom-made resorbable plate in each girl's chest where the sternum should be, and graft bone pieces removed during the separation onto the plates.
"The plates will dissolve over about a year and a half," Lorenz said. "That gives the grafted bone plenty of time to fuse, so eventually the girls will have normal bones and stable chests."
Afterward, the girls will be in intensive care, where they'll recover for four to five days before being moved to a regular room for another week or so. Then they'll head home to San Jose to start their lives as two ordinary little girls. Ginady anticipates that many things will be easier – she'll finally be able to give the twins breaks from each other when they argue – but that her sweet daughters will still be basically themselves.
"Angelica is more talkative and Angelina's a silent type," Ginady said. The girls love to play "mommy and baby" with each other and listen to stories and music, she added. They know their colors and can count to 10. When Angelica coughs, Angelina gently pats her back.
Now, Ginady and Fidel are preparing the girls for the same ordinary challenges any parent anticipates. "I hope that when they grow up, they go to school, graduate and get stable jobs," Ginady said. "I want them to have a good future."
It’s a future that’s starting to look very bright. “We think the surgery will be quite successful,” said Hartman, “and our team is looking forward to helping Angelica and Angelina live the most normal of lives.”
Please visit http://conjoinedtwins.lpch.org for additional information, artwork, photos and video of Angelica and Angelina.
About Lucile Packard Children’s Hospital
Celebrating its 20th anniversary in 2011, Lucile Packard Children's Hospital is annually ranked as one of the nation's best pediatric hospitals by U.S. News & World Report, and is the only San Francisco Bay Area children's hospital with programs ranked in the U.S. News Top Ten. The 311-bed hospital is devoted to the care of children and expectant mothers, and provides pediatric and obstetric medical and surgical services in association with the Stanford University School of Medicine. Packard Children's offers patients locally, regionally and nationally a full range of health-care programs and services, from preventive and routine care to the diagnosis and treatment of serious illness and injury. For more information, visit www.lpch.org.