It was one of the riskiest separation surgeries ever performed.
But now – three months after doctors untangled Eva and Erika Sandoval’s digestive system, a uterus, a liver, a bladder, a pelvis, and a third leg – the girls are leaving their Palo Alto hospital.
On Friday, the hospital released photos of the two-year-old twins eating cakes at a celebration party as they prepared to move to a rehab facility at UC Davis in Sacramento, near their hometown of Antelope.
They will stay there for a few weeks before finally being able to return home.
‘Erika and Eva look really great,’ said pediatric surgeon Gary Hartman, MD, professor of surgery at the Stanford University School of Medicine who led the 50-person team that separated the twins in a 17-hour operation and has closely monitored their recovery.
‘The girls have just blossomed in terms of personality,’ he said. ‘They’re very engaging and chatty.’
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Time to celebrate! Eva and Erika Sandoval celebrate moving closer to home with a princess picnic in their ward on Monday. The two-year-old twins have spent three months in hospital
At a March 6 hospital farewell party, parents Art and Aida Sandoval were excited.
‘I’m over the moon,’ Aida said. ‘It’s still surreal seeing them separate, knowing that it’s still them as two individual bodies. Now we’re just waiting for their next chapter to begin, and the anticipation is indescribable.’
Eva was discharged from Packard Children’s on Thursday, March 9 after a three-month healing period in which her doctors closely watched the condition of the wound at her separation site.
For a while, the plastic surgery team thought she might need a skin graft, but Eva’s wound is now healing well, and a graft will not be necessary.
Erika healed more quickly, allowing her to be discharged from Packard Children’s on February 13, when she left the hospital for the first time since the separation.
However, Erika was readmitted on March 4 to monitor some vomiting that was persisting over several days.
Aside from that bump in the road, for the last few months, both girls have been receiving physical and occupational therapy at Packard Children’s to help them learn new movement patterns that are suited to their individual bodies.
They have also participated in play therapy to help them adapt psychologically to the separation.
‘Neither girl seems to have trouble adjusting,’ said Packard Children’s child psychiatrist Michelle Goldsmith, MD, who has worked with the sisters. ‘They’re both rolling with what’s going on very well.’
The healing process has even had its share of light moments, Aida said.
‘The other day, Eva said “feet”, and I told her “foot”. I said, you have one foot and your sister has the other foot. And then I showed her that she has one leg, and that Erika has the other leg. And she pointed at Erika across the room and said ‘Erika took it! Erika took my leg!’
At UC Davis Children’s Hospital, the twins’ caregivers will focus on helping their mother and home care nurses learn to take care of them safely at home, and will keep building skills the girls still need, such as eating by mouth.
As infants, Erika and Eva required tube feeding. They still receive most of their nutrition via nasogastric tubes.
The team at UC Davis will also use specialized equipment to improve the girls’ mobility.
Before separation, the twins’ anatomy was like that of two people above the sternum, gradually merging almost to one below the diaphragm. They had a total of three legs, one of which was unlikely to ever be functional.
Tissue from the third leg was used as part of Erika’s reconstructive surgery, meaning that each twin now has one leg.
Both girls are now sitting on their own for short periods and will need to learn to use customized wheelchairs to move around.
Because they each lack some pelvic bones on the side without a leg, it is unclear if they will be able to receive prosthetic legs in the future. But whether they use prosthetics or not, physical and occupational therapy will help them gain more independence.
‘Improving their functional mobility will be really important in getting them to continue adapting to their new bodies,’ said Kelly Andrasik, an occupational therapist who has worked with the twins at Packard Children’s.
‘The specialized equipment that an inpatient rehab like Davis offers will really help them with this.’
Erika and Eva will continue to receive regular checkups with Hartman and other caregivers at Packard Children’s after they go home to Antelope.
‘They’re doing really well and they’re ready to go,’ Hartman said. ‘It’s a great thing for everyone on our team to see.’
The girls, from Antelope, California, started on their path to surgery years ago, as they began to suffer countless infections, and Erika was becoming dangerously weak.
On December 6, in one of the riskiest separation operations ever performed, the twin girls were successfully separated.
This is the moment two-year-old twins Erika and Eva Sandoval were reunited after separation
The girls, once joined by the sternum, have suffered no complications since separation
Their parents Aida and Arturo made the painstaking decision to attempt separating them last year, as it became clear that with every month more issues arose.
They had been hospitalized with dozens of urinary tract infections and countless cases of dehydration.
And it was getting worse with time.
LIFE BEFORE SURGERY
In a lengthy profile of the family, the Sacramento Bee last month described how the cost and scale of the operation – and pre-surgery – has taken such a heavy toll on the family.
Aida was urged to abort the little girls when she and Arturo surprisingly fell pregnant two years ago – when she was 44 and he 49.
Without hesitating, the religious couple – who already have three kids in their 20s – went ahead with the pregnancy.
But life was becoming insurmountably difficult for the girls.
Aida was urged to abort the girls when she and Arturo surprisingly fell pregnant two years ago – when she was 44 and he 49. Without hesitating, the couple – who already have three kids in their 20s – went ahead with the pregnancy
Aida said last month that she was confident the surgery would be a success, and that it would allow Erika – the smaller and weaker of the two – to grow into her own person
While Arturo continues his construction work near their home in Antelope, California, Aida has been forced to move to Palo Alto to live close to the hospital with the girls
Like all two-year-olds, twin sisters Eva and Erika Sandoval are excitable, playful, and beginning to develop mentally and physically. But that brings health challenges
Aida has been forced to move to Palo Alto to live close to the hospital with the girls while Arturo continues his construction work near their home in Antelope, California, the Bee reported.
Nonetheless, Aida told the paper she maintains her faith: ‘You just have to remember that doctors tell you the worst.
‘I have faith in God, and I know that if it’s meant to be, it will be.
‘They want life, and they’re going to fight for it.’
She said she was confident that the surgery would be a success, and that it would allow Erika – the smaller and weaker of the two – to grow into her own person.
The Bee called Eva ‘the larger and more dominant twin’ and describes how she carries them both around.
Eva and Erika were attached from the sternum to the pelvis. They shared a digestive system, a uterus, a liver, a bladder, and a third leg with a seven-toed foot. Now they are separate
As they grew, they were experiencing more and more health concerns. They were hospitalized with dozens of urinary tract infections and countless cases of dehydration
‘She thrust forward with two arms and one thick leg, while her sister scrambled to support herself on spaghetti-thin limbs, sometimes giving up entirely and letting herself be dragged along,’ reporter Sammy Caiola writes.
Aida told the paper: ‘In moments where one is tired or she’s sick, and the other wants to go play, I want her to be able to do that.
‘That’s something they’ll get when they’re separated – their individual limelight.’
PREPARING TO SEPARATE
Prior to the surgery, Dr Hartman said Eva would likely keep their bladder, while Erika would get a colostomy bag.
Erika, the weaker twin, was expected to keep their third leg while Eva would get the other two.
Both were expected to be missing vital body parts; and both needed significant reconstruction of their lower bodies.
The surgeons estimated the operation carried a 30 percent risk that one or both of them would die – largely due to the fact that they shared a tangled skeletal system, with many shared and tangled blood vessels.
‘This is a worrisome number because in most cases doctors only perform with a tenth of a percent chance of fatality,’ their parents Aida and Arturo wrote on their Facebook page before the surgery.
These are the intricate 3D-printed models showing the girls’ entangled skeletal structures, which the surgeons used to make a game plan ahead of the surgery. The pelvis (left) was the biggest obstacle, since it was entwined and tangled with many shared blood vessels
It was one of the most complicated procedures surgeons at Lucile Packard Children’s Hospital Stanford have ever faced – so complicated that the operation kept getting pushed back
‘It’s hard to see the numbers and find comfort on the odds.
‘But … from the beginning our girls have superseded the doctors expectations of life and will continue to show us their strength.’
Ahead of the operation, Dr Hartman told the Sacramento Bee the biggest concern was preventing blood loss when severing the liver and the pelvic bone.
Their operation is one of the most complicated procedures surgeons at Lucile Packard Children’s Hospital Stanford have ever faced – so complicated that the operation keeps getting pushed back.
Going to hospital: Arturo, 51, carries the girls as Aida, 46, and their relatives follow en route to Lucille Packard
Before surgery: Erika and Eva look at each other before their operation
Before surgery: Eva (left) and Erika (right) pictured arriving at the hospital last week
After originally planning to perform the surgery in January this year, the team decided on the first week of December.
Surgeons spent the last few months inserting tissue expanders, a common tactic in separation of conjoined twins.
It was a way of stretching the skin gradually so that, when it came to the reconstruction surgery, they have more to move and manipulate.
The team released photos from inside the operation, and pictures of the 3D-printed models of the girls’ shared body parts, which they used to practice for months.
‘We’re so happy they did well during the actual separation procedure and it went smoothly,’ Gail Boltz, clinical professor of anesthesiology, said.
Matias Bruzoni, Dr Hartman’s co-surgeon who made the final cut of the skin in the separation, explained how the team working ‘little by little’ from the upper chest down to the shared leg.
The surgery was challenging because they shared much of their lower body and had one liver, one bladder and three legs.
During surgery: ‘The twins did very well,’ lead surgeon Dr. Gary Hartman said (pictured during the operation last week)
Ready for reconstruction: One of the girls is wheeled out of the OR for hours of reconstruction
Mammoth task: The 50-strong team had been preparing for more than a year (pictured during the surgery last week)
The team said they could not have effectively separated the pelvis without such advanced radiological scans, used during surgery (pictured) and also before to make 3D plastic models
In the procedure conducted last Tuesday into early Wednesday, the team divided the bladder into two separate organs. It also split their liver to give half to each child.
The girls each have one leg, with doctors using a third leg for reconstruction, taking its skin and muscle to close one child’s abdominal wall.
And it was the reconstruction that really determined whether the girls would recover well.
Dr Hartman explained: ‘It doesn’t matter if you get them separated if you cant get them reconstructed and get them closed.
‘Matias and Jim [Gamble, the orthopedic surgeon who guided the separation of the pelvis] got us through the pelvis and cut the skin.
‘As Matias says, it’s the most anticlimactic thing. You’ve been through the whole separation then you just have to cut that last bit of skin, and they’re the heroes.
It doesn’t matter if you get them separated if you cant get them reconstructed and get them closed. The reconstructive guys are really the heroes
Lead surgeon Dr Gary Hartman
‘The reconstructive guys are really the heroes.
‘And the proof of that is Erika, who was and is the smaller twin. We were very concerned about her pre-surgery because she kept getting smaller. The more calories we gave her, Eva would get bigger.
‘But because of the way she was reconstructed, she is getting stronger and moving faster than her sister.
‘That is down to the creativeness of the reconstructive surgeons.’
After surgery: Aida, Arturo, and two of their three adult children embrace with joy after the operation
‘It’s been a dream come true’: Aida Sandoval wept next to her husband last week as they thanked the surgical team that separated their two-year-old daughter Eva and Erika