Siamese twins separated in South Africa 1 dies

June 16, 1994|By Michael Hill | Michael Hill,Johannesburg Bureau of The Sun

PRETORIA, South Africa -- Johns Hopkins neurosurgeon Benjamin S. Carson called it "the most complicated procedure I have ever been involved with" -- a 20-hour operation to separate Siamese twin girls that turned into an emergency procedure when one of the 9-month-old patients went into cardiac arrest.

Nthabiseng Makwaeba died hours after the operation ended. Her sister, Mahlatse, with whom she had been joined at the back of her head, was in "very, very critical condition" after being placed on life support systems to relieve pressure on her heart and lungs.

The operation brought together the handful of doctors who had tried such a procedure before, including Dr. Carson, Hopkins' chief of pediatric neurosurgery.

"I can say that most likely the outcome would have been the same had this operation taken place [at Hopkins]," the doctor said.

Members of the surgical team "did everything they could to save that baby," he said. "They even performed open heart surgery. But once I got a look at the heart, it was clear there just wasn't the tissue there to support life."

Dr. Carson was invited to join the team by its chief, Dr. Sam Mokgokong, chief neurosurgeon at Ga-Rankuwa, a hospital built on the far outskirts of Pretoria to serve non-white patients and students when South Africa was ruled under apartheid.

The twins were born to a couple who lived in rural Lebowa, the former homeland of the Pedi tribe, near the city of Pietersburg north of Pretoria.

Siamese twins joined at the head occur less than once in 2 million births. Complicating these twins' separation was the fact that they shared vessels supplying blood to their brains.

Dr. Mokgokong was involved in a similar separation attempt at Soweto's Baragwanath hospital six years ago, about the time Dr. Carson headed a team at Johns Hopkins that separated the Binder twins from Germany. In both of those cases, the twins survived but suffered serious brain damage.

"Everything was going so well, I thought we were going to have a real good result," Dr. Carson said of the surgery that began shortly after dawn Tuesday.

As Dr. Mokgokong explained, hours into the operation, after anesthesiologists had sedated the twins and plastic surgeons had prepared the skin flaps that would cover their surgical wounds, Nthabiseng, the weaker of the twins, went into cardiac arrest.

"At that point, the entire operation became an emergency procedure," Dr. Mokgokong said.

If one of the twins were to die before separation, the other would soon follow. Both twins were quickly placed on heart-lung machines and their body temperatures were lowered, slowing their metabolism, to reduce the loss of blood during the separation and reconstruction of blood vessels.

As the neurosurgeons worked, cardiac specialists struggled to save Nthabiseng's heart. But after the long separation procedure, the heart failed to re-start when the girls were taken off the life support machines.

Shortly after birth, Nthabiseng had undergone an operation for a congenital heart defect effecting her arteries. Dr. Mokgokong said the extent of that defect was more than anyone had realized.

Both doctors agreed that if the operation had not been performed when it was, Nthabiseng's heart would have failed and Mahlatse would have also died.

The operation was originally scheduled for mid-April, but the twins developed chicken pox.

Neither doctor would give a firm prognosis of the surviving twin's chances. They agreed that, given the extent of blood loss -- caused in part by the amount of anti-clotting agent needed when the twins were hastily put on the heart-lung machine -- and other trauma during the operation, some brain damage was inevitable.

"This post-operative period is going to be very difficult and complicated," said Dr. Carson, who will fly back to Baltimore tomorrow night. "Only the first step has been taken.

This will go on for weeks."

Dr. Mokgokong said that Dr. Carson donated his services, with Ga-Rankuwa paying only his expenses. "It would have cost us about $1 million to take the twins to Baltimore for the operation," he said. "We could not afford that, so Dr. Carson came to us."

At Ga-Rankuwa, the operation cost less than $100,000, which will be paid by the state. The hospital is collecting money to help with the costs of after-care.

The twins' father, Juard Makwaeba, a parks ranger, makes $200 a month.

He and his wife, Elizabeth, who speak no English, sat stoically through the news conference, as they had during much of the night.

Shortly after the twins' birth, the Makwaebas were moved from their rural village of mud huts to a more urban location.

In part this was to put them near a clinic, but it was also to safeguard their lives.

A belief in witchcraft runs deep among the Pedi people. Giving birth to Siamese twins might have made the Makwaebas suspect in their village, and they could have been among the dozens of people burned as witches every year in Lebowa.

"This is another reason these twins had to be separated," Dr. Mokgokong, also a Pedi, said. "It would have been impossible to have raised them in Lebowa."

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