Successful separation of twins, conjoined from the breastbone to the groin, has occurred only 20 times in the world and never before at Children's Hospital of Pittsburgh of UPMC.
But in December, a team of 50 doctors and nurses from Children's -- including general and orthopedic surgeons, anesthesiologists and experts in plastic surgery, urology and organ systems -- separated 2-year-old twins Dagian and Danielle Lee of Cleveland during a 24-hour surgical marathon.
Two months later, the two are brimming with personality and intelligence. Both playful, Danielle is outgoing, while Dagian can display a temper.
"They are happy, healthy and will be discharged soon," said Dr. Joseph E. Losee, chief of the Division of Pediatric Plastic Surgery at Children's.
Dr. Losee, who led the effort, said the operation required professionals to work together in smooth, orchestrated fashion to ensure the best outcome "for these two beautiful little girls."
Future reconstructive surgeries will be necessary, but the girls seem happy to be separated while remaining close in spirit. Each has only one leg, without the hip or leg-bone structure necessary for the typical prosthetic leg. Doctors said their chances of getting a prosthesis is 50-50. Until that decision is made, they'll use wheelchairs.
"They are typical little girls," their mother, Catherine Nickson, 26, said.
While conjoined, they'd grab each other's pacifiers, bop each other on the head with toys, and fight, play and laugh together. Now on intravenous treatments in separate beds, they interact from afar and talk to each other on cell phones.
"I think they are happy they can go to sleep without the other punching her in the face," said Ms. Nickson, who has lived since October 2007 with her 3-year-old, Dayloni, at the Ronald McDonald House.
She said she decided on the separation surgery because she "wanted three kids, not two or one."
Doctors prepared for the separation for 18 months, with the twins undergoing 10 advanced procedures, including insertion of tissue expanders to stretch the torso skin so it could cover the surgical openings half the size of their torsos and pelvises. Because the rib cages were connected, the girls also had respiratory problems that had to be resolved before the separation surgery.
The University of Maryland Medical Center says one in every 200,000 births involves conjoined twins. Up to 60 percent are stillborn, and up to 25 percent survive.
Conjoined twins usually are identical and the same sex, most often female. Their individual embryos conjoin three or four weeks in utero and often develop common internal organs. Commonly called Siamese twins, they can share brains, hearts, limbs and various internal organs.
Dagian and Danielle were ischiopagus twins, which accounts for 6 percent of all conjoined births. Such twins are joined at the pelvis, which means they can share a gastrointestinal tract, genitalia and urinary tract organs.
"Only 20 in the world like this have been separated," said Dr. Timothy Kane of Children's Division of Pediatric General and Thoracic Surgery.
Surgery to separate them began at 6:30 a.m. Dec. 13 and was completed about the same time Dec. 14, the day before their second birthday. Separation took 16 hours, then they went to separate rooms for eight hours of reconstructive surgery to close the body cavities.
While each had a heart, lungs and stomach, their livers were attached but did not share blood vessels or bile ducts. They shared a colon, with individual urinary tracts that also required separation. Danielle received the colon, and Dagian underwent an ileostomy, which extends the small intestine to a hole in her side to a colostomy bag. Tissue from a nonfunctioning third leg was used as a sling to reconstruct the pelvis and support internal organs.
"The biggest risk was infection," Dr. Kane said. "For a long time their body cavities were open and a large area needed to be covered."
Ms. Nickson said she was told she couldn't become pregnant after giving birth to Dayloni, so her pregnancy was a surprise. Knowledge that she was having twins added suspense. But the biggest surprise occurred six hours before giving birth at the Metro Health Medical Center in Cleveland, where she was told the twins were conjoined.
When the twins are discharged from Children's, Ms. Nickson said, she'll return to Cleveland and "have a gigantic party."
Her experience, she said, has convinced her to return to nursing school. For now, her focus is Dagian and Danielle, who wore white bows in their hair with matching pink and green dresses yesterday.
Ms. Nickson said agreeing to the separation surgery"was such a difficult decision to make, and I knew the separation involved very complicated surgery. I was scared."
"I just wanted them to have the best life they could possibly live."
David Templeton can be reached at firstname.lastname@example.org or 412-263-1578.