Editing Conjoined twins (section)

==Treatment==
===Separation===
Surgery to separate conjoined twins may range from very easy to very difficult depending on the point of attachment and the internal parts that are shared.<ref>{{Cite journal |last1=Fallon |first1=Sara C. |last2=Olutoye |first2=Oluyinka O. |date=2018-10-01 |title=The surgical principles of conjoined twin separation |url=https://www.sciencedirect.com/science/article/pii/S0146000518300521 |journal=Seminars in Perinatology |series=Conjoined Twins |volume=42 |issue=6 |pages=386–392 |doi=10.1053/j.semperi.2018.07.013 |pmid=30477661 |s2cid=53767929 |issn=0146-0005}}</ref> Most cases of separation are extremely risky and life-threatening. Though there have been a number of successful separations throughout history, in many cases, the surgery results in the death of one or both of the twins, particularly if they are joined at the head or share a vital organ. This makes the [[ethics]] of surgical separation, where the twins can survive if not separated, contentious. [[Alice Dreger]] of [[Northwestern University]] found the quality of life of twins who remain conjoined to be higher than is commonly supposed.<ref>{{cite book |title=One of Us: Conjoined Twins and the Future of Normal |url=https://archive.org/details/oneofus00alic |url-access=registration |first=Alice Domurat |last=Dreger |isbn=978-0-674-01825-9 |publisher=Harvard University Press |date=2004 }}</ref> [[Lori and George Schappell]] and [[Abby and Brittany Hensel]] are notable examples.

The first recorded separation of conjoined twins took place in the [[Byzantine Empire]] in the 900s. One of the conjoined twins had already died, so the doctors of the town attempted to separate the dead twin from the surviving twin. The result was briefly successful, as the remaining twin lived for three days after separation. The next recorded case of separating conjoined twins was several centuries later, in Germany, in 1689.<ref>{{cite web |url=http://www.medievalists.net/2014/01/the-case-of-conjoined-twins-in-10th-century-byzantium/ |title=The Case of Conjoined Twins in 10th Century Byzantium |website=Medievalists.net |date=January 4, 2014}}</ref><ref>{{cite journal |url=http://denysmontandon.com/wp-content/uploads/2016/01/conjoined-twins.pdf |archive-url=https://web.archive.org/web/20170225215336/http://denysmontandon.com/wp-content/uploads/2016/01/conjoined-twins.pdf |archive-date=2017-02-25 |url-status=live |title=The unspeakable history of Thoracopagus twins' separation |first=Denys |last=Montandon |journal=ISAPS News |volume=9 |number=3 |year=2015 |pages=47–48}}</ref> The first recorded successful separation of conjoined twins was performed in 1689 by [[Johannes Fatio]].<ref>{{cite journal |last1=Kompanje |first1=Erwin J. O. |title=The First Successful Separation of Conjoined Twins in 1689: Some Additions and Corrections |journal=Twin Research |date=December 1, 2004 |volume=7 |issue=6 |pages=537–541 |doi=10.1375/1369052042663760 |pmid=15607002 |doi-access=free }}</ref> Around this same time Dr. Böhm of [[Gunzenhausen]] separated his own children, a pair of omphalopagus or xiphopagus twins; the feebler twin died four days later, but the healthier one was still alive and well at age five, when the case was reported.<ref>{{Cite book |last1=Hirst |first1=Barton Cooke |url=http://archive.org/details/humanmonstrosities04hirs |title=Human monstrosities |last2=Piersol |first2=George A. (George Arthur) |date=1891 |publisher=Philadelphia, Lea brothers & co. |others=University of Connecticut Libraries and Hartford Medical Society Historical Library}}</ref> In 1955, neurosurgeon Harold Voris (1902-1980)<ref>{{cite web |url=http://photoarchive.lib.uchicago.edu/db.xqy?one=apf1-08520.xml |title=Voris, Harold C. |publisher=The University of Chicago Photographic Archive |date=1972 |access-date=2017-07-30}}</ref> and his team at [[Mercy Hospital and Medical Center|Mercy Hospital]] in Chicago performed the first successful operation to separate [[craniopagus twins]] (conjoined at the head), which resulted in long-term survival for both.<ref>{{cite journal |last1=Stone |first1=James L. |last2=Goodrich |first2=James T. | author2-link=James T. Goodrich |title=The craniopagus malformation: classification and implications for surgical separation |journal=Brain |date=May 1, 2006 |volume=129 |issue=5 |pages=1084–1095 |doi=10.1093/brain/awl065 |pmid=16597654 |doi-access=free }}</ref><ref>{{cite web |url=https://www.mercy-chicago.org/mercy-firsts |title=Mercy Care Firsts |website=Mercy Hospital & Medical Center Chicago |access-date=October 14, 2015 |archive-date=May 29, 2019 |archive-url=https://web.archive.org/web/20190529185116/https://www.mercy-chicago.org/mercy-firsts |url-status=dead }}</ref><ref>{{cite news |title=Separate Siamese Twins! |url=http://archives.chicagotribune.com/1955/04/22/page/1/article/separate-siamese-twins |date=April 22, 1955 |access-date=October 14, 2015 |newspaper=[[Chicago Tribune]]}}</ref> The larger girl was reported in 1963 as developing normally, but the smaller girl was permanently impaired.<ref>{{cite journal |last1=Voris |first1=Harold C. |title=Cranioplasty in a Craniopagus Twin |journal=Journal of Neurosurgery |date=February 1963 |volume=20 |issue=2 |pages=145–147 |doi=10.3171/jns.1963.20.2.0145 |pmid=14192083 |s2cid=37985174 |s2cid-access=free|doi-access= }}</ref>

In 1957, Bertram Katz and his surgical team made international medical history performing the world's first successful separation of conjoined twins sharing a vital organ.<ref>{{cite web |url=http://www4.vindy.com/extra/tributes/905419781.html |title=Dr. Bewrtram Katz, 83 – Obituary |website=Vindy.com |access-date=2014-08-03 |archive-url=https://web.archive.org/web/20131110222735/http://www4.vindy.com/extra/tributes/905419781.html |archive-date=2013-11-10 |url-status=dead }}</ref> Omphalopagus twins John Nelson and James Edward Freeman (Johnny and Jimmy) were born in Youngstown, Ohio, on April 27, 1956. The boys shared a liver but had separate hearts and were successfully separated at North Side Hospital in Youngstown, Ohio, by Bertram Katz. The operation was funded by the Ohio Crippled Children's Service Society.<ref>[http://www.twinstuff.com/component/content/article/26-twin-facts/119-conjoined-twins-1950s?directory=27 <!-- accessed April 11, 2013 -->]{{dead link|date=June 2016|bot=medic}}{{cbignore|bot=medic}}</ref>

Recent successful separations of conjoined twins include that of the separation of [[Ganga and Jamuna Shrestha]] in 2001, who were born in [[Kathmandu, Nepal]], in 2000. The 97-hour surgery on the pair of [[craniopagus twins]] was a landmark one which took place in Singapore; the team was led by neurosurgeons Chumpon Chan and Keith Goh.<ref>{{cite news |url=http://www.channelnewsasia.com/cna/analysis_prog/incon/incon_doc2.htm |work=Channel News Asia Singapore |title=In Conversation with Medicine's Miracle Workers – Dr Chumpon Chan and Dr Keith Goh |date=April 19, 2001 |access-date=March 27, 2010 |url-status=dead |archive-url=https://web.archive.org/web/20110114212842/http://www.channelnewsasia.com/cna/analysis_prog/incon/incon_doc2.htm |archive-date=January 14, 2011}}</ref> The surgery left Ganga with brain damage and Jamuna unable to walk. Seven years later, Ganga Shrestha died at the Model Hospital in Kathmandu in July 2009, at the age of eight, three days after being admitted for treatment of a severe chest infection.<ref>{{cite web |url=http://www.monstersandcritics.com/news/southasia/news/article_1420406.php/Nepali_twin_dies_7_years_after_97-hour_separation_surgery |title=Nepali twin dies 7 years after 97-hour separation surgery |website=Monsters and Critics |date=July 30, 2008 |archive-url=https://web.archive.org/web/20081101095900/http://www.monstersandcritics.com/news/southasia/news/article_1420406.php/Nepali_twin_dies_7_years_after_97-hour_separation_surgery |archive-date=2008-11-01}}</ref>

Infants Rose and Grace Attard, conjoined twins from Malta, were separated in the United Kingdom by court order ''[[Re A (conjoined twins)|Re A]]'' over the religious objections of their parents, Michaelangelo and Rina Attard. The twins were attached at the lower abdomen and spine. The surgery took place in November 2000, at [[Saint Mary's Hospital, Manchester|St Mary's Hospital]] in [[Manchester]]. The operation was controversial because Rose, the weaker twin, would die as a result of the procedure as her heart and lungs were dependent upon Grace's. However, if the operation had not taken place, it was certain that both twins would die.<ref>{{cite news |url=http://news.bbc.co.uk/2/hi/health/1292681.stm |work=BBC News |title=Siamese twin Jodie "to go home soon" |date=April 23, 2001 |access-date=March 27, 2010}}</ref><ref>{{cite journal |last1=Appel |first1=Jacob M. |title=Ethics: English High Court Orders Separation of Conjoined Twins |journal=The Journal of Law, Medicine & Ethics |date=September 2000 |volume=28 |issue=3 |pages=312–313 |doi=10.1111/j.1748-720x.2000.tb00678.x |pmid=11210387 |s2cid=36191724 }}</ref> Grace survived to enjoy a normal childhood.<ref>{{cite news |url=http://www.thefreelibrary.com/We+don%27t+know+how+to+tell+Gracie+her+sister+died+so+she+could+live%3B...-a0166174616 |title=We don't know how to tell Gracie her sister died so she could live |via=Free Online Library |date=July 9, 2007 |work=The Mirror |access-date=2014-08-03}}</ref>

In 2003, two 29-year-old women from Iran, [[Ladan and Laleh Bijani]], who were joined at the head but had separate brains (craniopagus), were surgically separated in Singapore, despite surgeons' warnings that the operation could be fatal to one or both. Their complex case was accepted only because technologically advanced graphical imagery and modeling would allow the medical team to plan the risky surgery. However, an undetected major vein hidden from the scans was discovered during the operation.<ref>{{cite magazine |url=https://www.wired.com/wired/archive/11.10/twins_pr.html |title=Wired 11.10: Till Death Do Us Part |magazine=Wired |date=2001-04-11 |access-date=2014-08-03}}</ref> The separation was completed but both women died while still in surgery.

In 2019 Safa and Marwa Ullah were separated at [[Great Ormond Street Hospital]] in London, England. The twins, born January 2017, were joined at the top of the head with separate brains and a cylindrical shared skull with the twins each facing in opposite directions to one another. The surgery was jointly led by neurosurgeon Owase Jeelani and plastic surgeon Professor David Dunaway. The surgery presented particular difficulties due to a number of shared veins and a distortion in the shape of the girls' brains, causing them to overlap. The distortion would need to be corrected in order for the separation to go ahead. The surgery utilized a team of more than 100 including bio engineers, 3D modelers and a virtual reality designer. The separation was completed in February 2019 following a total of 52 hours of surgery over three separate operations. As of July 2019, both girls remained healthy and the family planned to return to their home in Pakistan in 2020.<ref>{{cite web |url=https://bbc.co.uk/news/extra/PLNMqvmycN/conjoined-twins |title=The battle to separate Safa and Marwa |website=BBC News |access-date=2019-07-18}}</ref><ref>{{cite web |url=https://www.gosh.nhs.uk/news/separating-conjoined-twins |archive-url=https://web.archive.org/web/20190717081048/https://www.gosh.nhs.uk/news/separating-conjoined-twins |url-status=dead |archive-date=July 17, 2019 |title=Separating conjoined twins |website=www.gosh.nhs.uk |language=en |access-date=2019-07-18}}</ref>