Calif. Doctors Separate 2-Year-Old Twins

Two year-old twin girls who were conjoined at the chest and abdomen have been successfully separated, doctors at Lucile Packard Children's Hospital announced Tuesday.

The 9-hour surgery performed Monday on Yurelia and Fiorella Rocha-Arias of San Jose, Costa Rica went ''much better than anticipated,'' but the odds of survival for both girls are only 50 percent, according to their lead surgeon.

''There's a lot of relief, but it's not really over,'' Dr. Gary Hartman said in a phone interview with The Associated Press. ''The point where we would relax significantly would be when they're off the breathing machines.''

Yurelia and Fiorella are in the Palo Alto-based hospital's critical care facility. Neither is conscious. Both have ventilators and feeding tubes.

Yurelia is heavily sedated and receiving intermittent paralyzing agents because she's going back to the operating room later this week, where a cardiothoracic surgeon will try to correct a serious heart defect. Yurelia was born with a double outlet right ventricle and other congenital defects.

Fiorella has been heavily sedated since surgery, but anesthesiologists will lighten her sedation Tuesday or Wednesday, Hartman said. She doesn't appear to need follow-up surgeries.

The girls' parents, Maria and Jose Luis Rocha-Arias, have requested privacy and declined to comment.

The procedure was considered complicated, in part because the twins shared a blood supply. The girls were connected at the right atria of their hearts, the chamber that receives blood from the rest of the body, and they appeared to share a liver.

Shortly after dawn Monday, when surgery began, doctors clamped off valves to see what would happen if neither girl shared blood with the other. Before the surgery, doctors said they couldn't figure out if Yurelia was supporting Fiorella, or vice versa.

But both girls' hearts performed better than doctors expected during the five-minute clamp test. Fiorella's blood pressure, which was high before the surgery, came down. Yurelia's oxygen level, which was low before the surgery, went up.

''We expected that either one of them could have problems by clamping the connection, but neither one did — in fact, each of them in some manner improved,'' Hartman said. ''We thought it was just great.''

The shared liver turned out to be two individual livers fused at the widest point. Doctors successfully separated the oversized, highly vascular organ — ''a very bloody process,'' Hartman said.

The girls arrived in San Francisco on July 25 and received weekly injections of sterile saltwater into balloons placed under their skin. The procedure stretched their skin to compensate for the holes surgeons cut into their abdomens.

At their age, Yurelia and Fiorella may be stronger and able to recover more quickly than younger conjoined twins; before coming to California, they were only hospitalized a few times for colds and respiratory infections in Costa Rica. (Their parents moved from Nicaragua to Costa Rica, which has world-class medical facilities, after an ultrasound showed conjoined twins.)

But their muscle and skeletons had more time to fuse than younger twins who undergo surgery, complicating the separation, Packard doctors said.

Packard doctors are donating their time to treat Yurelia and Fiorella, who have nine older siblings. Mending Kids International, a faith-based nonprofit based in Santa Clarita that helps sick children, arranged transportation and housing.

The hospital is donating medical and clinical care. The Nicaraguan embassy helped pay for the twins' care in Costa Rica.

Earlier this fall, Hartman estimated the cost of the surgery to be $1 million to $2 million. Cedars-Sinai Medical Center in Los Angeles rejected the case, and Packard's ethical board approved it only by a narrow margin.

Researchers estimate the incidence of conjoined twins to be between 1 in 30,000 to 1 in 200,000 worldwide. Most do not survive pregnancy, and most born alive die within 24 hours.

Researchers theorize that conjoined twins result when a single fertilized egg does not totally split during the process of forming identical twins. Another theory holds that two fertilized eggs fuse early in development. There's no definitive environmental or genetic cause.

About five separation surgeries are performed annually in the United States.

On Aug. 29, doctors at Children's Hospital of Philadelphia separated 1-year-olds Matthew and Andrew Goodman, who shared a liver, pancreas and other organs. In early August, doctors in Cleveland called off the long-planned surgery on 3-year-old girls joined at the head, saying the risk to both twins was too great.