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July 8th, 2003, 11:17 PM

SINGAPORE -- They wanted to see each other face to face, they said, and to pursue independent lives. And so Ladan and Laleh Bijani, 29-year-old Iranian twins who were born joined at the head, asked doctors to go ahead with a risky operation to separate them.

Neither survived. The sisters died of blood loss Tuesday afternoon within 90 minutes of one another, doctors said, after a team of surgeons at Raffles Hospital in Singapore worked for 50 hours to separate their two brains.

The operation was the first known attempt to separate adult twins joined at the head.

"When we undertook this challenge, we knew the risks were great," Dr. Loo Choon Yong, the hospital's chairman, said at a news conference.

The Bijani sisters had captured the attention and hopes of much of Singapore, which is still recovering from its battle against severe acute respiratory syndrome, the pneumonia-like disease that killed 32 people here. News of the twins' deaths brought tears to the many well wishers who had gathered for a prayer vigil outside the hospital since the operation began on Sunday.

People also wept publicly across Iran when state-run television announced the Bijanis' deaths. The sisters, who had trained as lawyers, were celebrities there, and President Mohammad Khatami had sent the sisters a message and prayed for their well-being before the operation.

The case raised ethical questions within Singapore's medical community about whether doctors should allow patients to undergo such risky procedures. But the twins had asked doctors to go ahead with the operation even after being warned that there was at least a 50 percent chance that one or both would die or suffer severe brain damage.

Alireza Safaian, the twins' adoptive father, said he knew from the moment he heard about the surgery that both sisters would die.

"I was sure they would die and I told everyone about this but the media did not pay attention to what we were saying," he said.

He said he had taken the sisters to Germany when they were 2, and doctors said that one of them would die if surgeons tried to separate them. He sought advice from Ayatollah Khomeini, who was in exile in Najaf those days.

"He was not a doctor but was close to God," Safaian said. Khomeini said the surgery was not religiously permissible and would be considered murder since doctors knew in advance that one twin might die.

Safaian and his son and daughter, who grew up with the sisters, wept on Tuesday as they watched an old videotape of Ladan and Laleh at the welfare institute in Tehran where Safaian works. Safaian said that the twins had led normal lives before the surgery. They lived alone for the past two years, did their own shopping and cooked for as many as 20 guests, he said.

"They were victims of a big propaganda in Iran and Singapore," Safaian said. "They were used as laboratory mice. I read about the surgery three months ago but the ones who convinced them to go through with it did not let them come see us. Now my girls are gone and there is nothing I can do to bring them back."

The twins' biological father, Dadollah Bijani of Firouzabad village in southern Iran, told an Iranian newspaper that he had tried to talk them out of the surgery but that their minds were made up.

.Similar operations have been reported on 30 to 40 sets of infants and young children since the 1920s. The death rate has been high, about 50 percent, and many survivors have suffered brain damage.

Guatemalan twins, now 2 years old, who were separated last August by surgeons at the University of California at Los Angeles, still require physical and occupational therapy, and one suffered a neurological setback after contracting meningitis after returning to Guatemala, a spokeswoman for the hospital said. Doctors at Medical City Hospital in Dallas are now making plans to separate 2-year-old twin brothers from Egypt.

In 2001, doctors in Singapore succeeded in separating twin infants born in Nepal. That operation helped put Singapore -- and the neurosurgeon who led it, Dr. Keith Goh -- on the map of cutting-edge medical centers.

Complicating the Bijani sisters' case was that their brains had grown closely intertwined over the years and shared a major vein. In 1996, German doctors turned down their request for an operation, saying the shared vein made surgery too dangerous.

Before the operation, Raffles Hospital convened an ethics committee and decided to proceed after determining that the twins were still willing after being made aware of the risks involved. In addition to physiotherapy sessions to prepare them for their surgical ordeal, the Bijanis met with counselors and psychologists to prepare them mentally.

Goh assembled a team of 100 medical professionals and more than a dozen doctors from several countries, including a noted American expert on such operations, Dr. Benjamin S. Carson, director of pediatric neurosurgery at Johns Hopkins Children's Center.

Speaking at a press conference after the twins' death, Carson said: "The women certainly understood the risks and were determined to proceed. I felt compelled to get involved to help give them their best chance at survival and separation, and I have no regrets over my decision. No act is a failure if you learn from it."

At a press conference last month, the Bijanis explained their urgent desire to be separated. "We are hoping the surgery will be successful," Ladan said. "We don't like to think about who will die or who should be saved."

Dr. Mark Siegler, director of the MacLean Ethics Center at the University of Chicago, said, "They were making a choice, it sounds to me like a very informed choice, about what they wanted. "

But he added that a patient's desire alone was not enough to justify a risky operation. He said there also had to be a reasonable chance of success and evidence that the procedure was really being done for the good of the patient and not just to earn money or prestige for the hospital or the doctors. The Bijanis' surgery appears to have met those requirements, Siegler said.

"It seems to me the operation would not have been undertaken by this huge team of surgeons if there were not some prospect for succeeding with the operation," he said.

With the sisters' brains sharing a major vein, surgeons fashioned a duplicate vein from a graft taken from Ladan's right thigh. While that procedure was apparently successful, doctors said the Bijanis' brains were more closely fused than they had expected.

According to a hospital press release, separation of the twins' brains had reached an "advanced stage" by 1:20 p.m. But as the surgeons toiled to separate the many tiny blood vessels connecting the sisters' brains, the twins began to lose blood pressure. Ladan died at 2:30 p.m. At 4 p.m., Laleh was pronounced dead.

The president of Singapore, S.R. Nathan, sent a letter of condolence to Khatami, the president of Iran, and to the Iranian people, saying Singaporeans shared their loss. .

The Iranian government had reportedly offered to pay for the estimated $300,000 cost of the operation. Other reports said Raffles Hospital had waived the cost of the operation. Hospital officials could not be reached for comment.

At their press conference in June, the Bijanis explained how, despite having lived every moment of their lives together, they had developed divergent interests. Laleh liked computer games, newspapers and books. Ladan like to chat on the Internet, read the Quran and pray. The sisters hoped to pursue individual careers after their recovery. While Ladan said she planned to continue in law, Laleh said she hoped to become a journalist.

But one desire remained foremost, they told reporters at their press conference last month. "We want to see each other -- face to face," said Laleh. "We want to see each other," Ladan added, "without a mirror."

One thing can be said for certian, they were two of the bravest women on the planet.

July 9th, 2003, 09:09 AM
One more thing can be said for certain, they were two of the most impatient and risk taking women on the planet.

July 9th, 2003, 02:36 PM
Impatient? They were stuck together for 29 years...

July 9th, 2003, 04:42 PM
I can't say that I'm really sad or that I even care.

July 9th, 2003, 05:20 PM
"People die every day"

-O.J. Simpson

July 10th, 2003, 02:09 AM
lol... funny O.J. quote...

well, i think they were a little impatient... perhaps in 5 more years that operation will be more safe to try and pull off... i think they should have waited a little longer... i dunno'...

July 12th, 2003, 10:22 PM
At least they werent headstrong.


July 12th, 2003, 10:25 PM
Stupid Erbs :cool: