Miracle surgery

Thirty years after graduating from Christian Medical College (CMC) in Vellore, India, six medical school classmates and their teacher had an unlikely reunion in June. At the request of classmate Rajiv Choudhrie, medical superintendent of Padhar Hospital, a 122-year-old mission hospital in rural Betul, they came together to write medical history: Their team plus 16 other doctors from India and Australia would attempt to separate a pair of conjoined twin girls, an operation never before completed in rural India.

For 12 hours, the surgical team bent over 1-year-olds Stuti and Aradhana, carefully cutting the tissue joining their chest and abdomen together. They saw abnormal anatomy-two hearts stacked on top of each other in a common pericardial sac, each beating at its own rate. A good amount of Stuti's blood was flowing through her sister's body.

They separated the hearts and created two sacs from the existing one, placing a heart into each girl. They then divided the liver, which had two separate blood supplies but were joined by a bridge of liver tissue. Then, with the cutting of the sternum and the closing of the wound, the surgery was complete.

Everyone in the hospital cheered at the successful operation, which many had decried as an impossible medical operation for the mission hospital. For the staff, the successful surgery was much more personal than proving a point: Stuti and Aradhana had become like their own children.

The girls, whose names mean "praise" and "worship" in Hindi, first came to Padhar last May, when their mother was pregnant. She had trouble delivering them at a government hospital, so they sent her to Padhar. During the Caesarian section, the obstetrician jumped back when she realized that the twins were attached at the chest. The young parents felt overwhelmed and unable to care for the girls, and "donated" them to the hospital.

From then on, Choudhrie's wife, Deepa, a 1982 CMC Vellore grad and a radiologist, took on the dual role of mother and doctor for the girls. A number of the nurses and staff also quickly grew attached to the girls, often coming in after hours to play with them.

Despite being conjoined, the girls each developed their separate personalities. "Aradhana, I think, is quicker to smile," Choudhrie said. "Stuti would look at you and wonder whether you were worthy of her smile." Stuti was thinner, while Aradhana was taller and plumper.

The media descended on the hospital, wanting to get pictures and videos of the twins. But the Choudhries and hospital staff worked to protect the girls from the hovering eye of the media: "These are not freaks, this is not a circus. These are humans beings, for us they were God's creation."

Padhar Hospital's decision to spend so much time, money, and energy to save two abandoned girls was news itself. Padhar first opened in 1890 and is affiliated with the Evangelical Lutheran Church in Madhya Pradesh, located in India's central highlands. Its rural site seemed an unlikely place for groundbreaking surgery, but the hospital has a long history of treating polio and AIDS, and of providing dialysis and other specialized services. Recently Padhar has worked with Smile Train to perform cleft lip and palate surgeries.

Another factor weighing on hospital staff: The girls were born right as the national census revealed a serious demographic crisis-for every 1,000 boys under the age of 6, there were only 914 girls. In the past decade, parents have aborted between 3 million and 6 million baby girls, as women are seen as merely a financial burden on the family.

The state's chief minister, Shivraj Singh Chouhan, hoped to reverse the trend by launching a program that provided girls aid for education and food. He was a big supporter of Stuti and Aradhana, donating to the surgery and later visiting them on their first birthday.

From the beginning, the doctors discussed whether separation was viable for the girls. Without the operation, the girls would never lead normal lives and the risk of death was high-if one girl got sick and died, the other would die as well.

Once scans revealed that each of the girls had her own set of internal organs and could be separated, Choudhrie called on his old classmates for help. He contacted Gordon Thomas, a pediatric liver transplant surgeon in Sydney; Sanjeeth Peter, a heart surgeon; Anil Kuruvilla, the head of neonatology at CMC Vellore; and their former anesthesiology professor, Rebecca Jacob. Choudhrie also contacted psychiatrist Prabahkar Thyagarajan to try to reunite the girls with their family.

Choudhrie wanted the team's opinion on whether it were possible to do the operation at Padhar. While larger hospitals in Delhi, Mumbai, England, and Singapore had offered to do the surgery, Choudhrie felt that Padhar could give the girls something the other hospitals lacked-love.

"The children had become ours by then, we were also attached to them," he said.

At first, Jacob thought the Padhar operation seemed like a remote possibility: The hospital was not equipped for two babies, and if anything went wrong, they were four to five hours from the nearest major hospital. But after a November visit to Padhar, she changed her mind: "Seeing the hospital, seeing the devotion of everybody around and in the hospital to the children, the way the children were looked after, they wouldn't have gotten the same love if they were at a big hospital. They'd just be another set of twins."

To perform the surgery in Padhar, the doctors would have to ensure facilities, equipment, and personnel at the same level-or greater-than the best hospitals in the country. So each doctor wrote up a list of needed equipment-from ventilators to monitors to sutures-and the team worked to get them, at times asking companies to donate or lend them expensive machines. As word of the surgery spread, money poured in from hospital supporters and locals. Ten months later, the team had all the equipment it needed.

The classmates also pulled in other specialist doctors, including Albert Shun from Sydney, a pediatric surgeon who had previously done three conjoined twin separations. The team of 23 doctors started, planned, and discussed the operation over Skype and email, motivated by love for the girls but also by a common faith.

"All of us were Christians," Jacob recalled. "All of us had a common goal that we were to give the best care to these children. If we were not assured of the best care we wouldn't go ahead."

Arriving at Padhar from all corners of the world, they joked with one another, recalling the five years spent together in their tight-knit class of 60. But this reunion was about more than memories and storytelling.

The doctors performed the operation successfully on June 20. Twelve days later, the staff celebrated the girls' first birthday with cake, new dresses, and a visit from Chief Minister Chouhan.

By now, Stuti had improved so much that they took her off the ventilator, but Aradhana, who had been sick before the operation, remained on it. Her health fluctuated and Choudhrie noticed that it was taking a lot of effort for her to breathe. She went back to the operating room after an infection, and seemed to get better, but a few days later she fell into cardiac arrest and the doctors could not revive her.

She died July 5.

For the hospital staff, it felt like losing a family member.

"In the hospital, people are dying all the time. ... But we were family, and the rules can be anything, but when it's your own family, it changes the whole thing," Choudhrie said in a Skype interview, tears falling from his eyes.

"It shook my faith a bit when we lost one," he continued. "I never thought in my wildest dreams with all the prayer support that we had that we would lose one. To my mind they were meant to be for the glory of God. But God's ways-you can't explain them, I have not understood it."

Her parents buried Aradhana in early July in their hometown. Three carloads of Padhar staff attended the burial and Choudhrie said a prayer for the girl. The parents had started visiting the girls months before the surgery, and after several meetings with psychiatrist Thyagarajan, had decided to take the girls back after the operation. Stuti will return home after a few more months of recuperation.

While Aradhana's death has hit the hospital staff hard, Choudhrie believes they are starting to heal and move forward."I don't know what God's plans are, I hope I can just trust in them, that He brings us out of this time as the Great Healer."

Despite the grief, the surgery has a widespread impact: While the team of specialists was at Padhar for the operation, the doctors were also able to conduct more than a dozen more surgeries for children with abnormal disorders. Much of the donated equipment and updated infrastructure at the hospital will allow for more surgeries in the future, helping more patients.

Jacob said the separation showed the world that mission hospitals should be taken seriously.

"Most people seem to write off the small hospital as 'Oh you can't do anything there and no one cares,' ... but I think this just proved that everyone cared and that we could do it."