The relief in the Raffles hospital foyer overflowed when news broke at 2.30pm yesterday that Ladan and Laleh Bijani had been successfully separated after 51 hours of pioneering surgery. The two dozen Iranians and Singaporeans who had held a vigil for the twins broke into spontaneous cheering and applause.
Their joy lasted only seconds. The hospital spokesperson, Dr Prem Kumar, held up his hand for silence. In a sombre tone, he said: ”But they’ve both lost a lot of blood and they’re actually in a critical state. Please pray very hard for them.”
Unlike previous press conferences, he left without taking any questions. No one knew whether to celebrate or panic. Only an hour previously Dr Kumar had appeared relieved when he said the separation was almost complete and the twins, joined together for 29 years, were stable.
Now there was confusion. ”What is happening?” one Iranian woman asked. ”I know not what to think.”
Her question was answered an hour later. Kumar returned to the lobby and read from a prepared text that Ladan, the more extrovert of the twins, had passed away. Again he took no questions.
The men and women who had been keeping a vigil wept, while Singaporeans, who had never met the twins but had grown fond of them during their six months in the island republic, rushed to the hospital and joined in the grieving.
”I was having my lunch when I heard,” said Armila Teo as tears ran down her cheeks. ”I’m nobody to them but I’m still a human being. It’s awful.”
Despite the despair, there was optimism that Laleh — her name in Persian means fragile flower — would pull through. But just before 6pm rumours spread that she had also died from massive loss of blood.
Within minutes hospital executives confirmed that the first attempt to separate adults joined at the head, known as craniopagus twins, had failed.
”When we undertook this challenge, we knew the risks were great. But we were hopeful. Ladan and Lelah knew the risks too,” said Dr Loo Choon Yong, chairman of Raffles hospital. ”As doctors there is only so much we can do; as for the rest we have to leave it to the almighty.”
Days before the operation Ladan had explained that she and her sister were also counting on divine intervention as well as medical science: ”If God wants us to live the rest of our lives as two separate, independent individuals, we will.”
The surgeon who led the team of 28 doctors and more than 100 support staff, Dr Keith Goh, was clearly upset as he tried to explain how the sisters’ circulation had failed after an apparently successful separation.
”The patterns of blood flow through such abnormally joined brains is hard to predict and when we went through all the final studies on Saturday, we certainly did not see some of the features which we encountered during surgery,” he said.
”These changes in blood flow patterns occur, and they can occur in any patient and in any operation, sometimes the way the human body behaves in surgery is not one can entirely predict. And that is what happened.”
In a dramatic revelation Dr Loo Choon Yong said the surgeons had almost terminated the operation on the cheerful women who were brought up by doctors far away from their home and nine siblings in Firouzabad, southern Iran.
The grafted vein had become blocked on Monday evening and the surgeons debated whether to continue or to stop, remove the twins to intensive care, bring them out of their anaesthetised state and discuss the options.
After consulting with the next of kin, who said the twins wanted to gamble on separation, however risky, the doctors continued operating, cleared the blockage and an air of optimism returned to the theatre.
An American expert on separating twins conjoined at the head, Dr Benjamin Carson, from Baltimore, who took part in the surgery, said that while he was upset he did not see the episode as a complete failure because doctors could learn a lot for a similar situation, particularly over how strongly the two brains had stuck to each other.
The surgery was only considered possible because the sisters, who were given a joint scholarship to study law at Tehran University after the authorities realised they could not stop them cheating in exams, had separate brains.
Even though they were conjoined, Ladan and Laleh had noticeably different personalities. Friends remember them trying to walk in opposite directions from as early as the age of eight. The resulting pain often left them in tears.
They often fell over as young children, resulting in scratches and bruises.
They also had different interests. The talkative Ladan enjoyed cooking while Laleh, a quiet thinker, preferred the company of animals.
As they grew up they tried to lead normal lives. They both could drive and played ball games together.
”We have different ideas about our lives,” Laleh told reporters last month. ”In fact we are opposites,” Ladan added. ”When we first opened our eyes to see the light, we wanted to be separated.”
These opposing forces prompted the sisters to visit Germany in 1996 to try to persuade doctors there to operate on them. They returned empty-handed.
Ironically, the sisters said if the operation had succeeded they planned to stay together in their Tehran apartment.
The mood in Iran yesterday was of despair and some recrimination. ”I wished those doctors had not operated at all if either of them would die. But I suppose they did their best to save them,” said Shahrbanoo, a 28-year old housewife.
”This makes me so sad. I’ve been watching television constantly and looking at the internet to find out what happened.”
The president, Mohammad Khatami, had offered to pay for the £180,000 operation and sent personal messages to the twins and their family.
The Iranian doctor who adopted the twins as children and brought them up accused Singapore doctors of killing the pair. ”We shared a house for 27 years and I feel a great emptiness,” Alireza Safaian said. ”When they took them to Singapore I knew they would bring back their bodies; they took them there and killed them.”
Their real father, Dadollah Bijani, a poor farmer, earlier explained how the sisters had been cared for by American doctors in a local hospital for years.
They went missing during the confusion of the 1979 Islamic revolution. He eventually tracked them down to Karaj, near Tehran, where Mr Safaian had adopted them.
The struggle against time
Saturday July 5
Twins undergo tests for six hours, during which doctors determine they would face serious difficulties if operation did not proceed
Sunday July 6
8.30am Final scan to confirm everything OK
10am Surgery begins with harvesting of vein from Ladan’s leg to use as a bypass in her brain for drainage after separation
5pm Cranium opened up, bypass connected, brain dissection begins
Monday July 7
6.30pm Bypass becomes occluded, surgery stopped to debate whether to continue. Next of kin insist surgery continues
Tuesday July 8
1.30pm Separation completed, surgeons work on twins individually
2pm Ladan’s circulation starts to fail
2.30pm Ladan dies
3.45pm Laleh’s circulation starts to fail
4pm Laleh dies – Guardian Unlimited Â