Background Emergency separation of conjoined twins is performed when one twin is already dead or dying and threatens the survival of the other. The particular decision to perform an emergency separation of conjoined twins provides an ethical dilemma that needs special attention. Adding to the complexity of surgical and postsurgical management in emergency separation, ethical and sociocultural aspects further complicate decision-making. Case presentation From 1987 to 2022, 18 conjoined twin separations were performed in our centre. This paper describes three conjoined twin emergency separations. In the first case of thoracoomphalopagus babies at nine days of age, one baby was diagnosed with necrotizing enterocolitis with frequent desaturation and seizures, and the other baby was healthy. Emergency separation was performed on the twelfth day of age; unfortunately, neither baby survived the surgery. In the second case, emergency separation was performed on the 110th day of life due to sepsis in one baby. The nonseptic twin passed away six hours after surgery, while the septic twin died 12 days after surgery due to wound dehiscence and abdominal sepsis. The third case was of an omphalopagus conjoined twin with a parasitic twin. The healthy baby was deemed nonviable but found to be healthy upon birth. Immediate emergency separation was performed at 2 h of age. The living baby survived the surgery but passed away two months later. Conclusions When separation is deemed necessary to save one twin, it becomes difficult to apply standard ethical medical reasoning. The decision to separate results in most cases in very high-risk surgeries with poor outcomes during surgery and postsurgery. Compounded by the complexity of the case, sociocultural and religious aspects further add to the dynamics of decision-making. A multidisciplinary team must work together with a health ethics committee and navigate through this ethical conundrum with the patient and family at its decision-making centre to decide on the best plan of care.

BackgroundPost-operative systemic inflammation response syndrome (SIRS) is an event that results from surgical trauma, white blood cells contact activation, and intra-surgical bacterial translocation, which is difficult to distinguish from sepsis. Presepsin is a novel biomarker that is increased since the early stages of bacterial infection and can be used to confirm the diagnosis of post-operative infectious complications. This study aimed to investigate the diagnostic performance of presepsin for post-operative infectious complications compared to other well-known biomarkers.MethodThis cross-sectional study included 100 post-operative patients admitted to Cipto Mangunkusumo National Hospital and Bunda Hospital in Jakarta, Indonesia. The objective was to identify the optimal cutoff and trend of plasma presepsin concentration on the first and third day after surgery and to compare them with other biomarkers.ResultPlasma presepsin level was higher in the infection group compared to the non-infection group (median 806.5 pg/ml vs. 717 pg/ml and 980 pg/ml vs. 516 pg/ml on the first and third day, respectively). Presepsin levels tended to increase on the third post-operative day (median + 252 pg/ml) in children with infection. The opposite trend was observed in the non-infection group from the first to the third day (median -222.5 pg/ml). Presepsin delta, a three-day difference between the first and third post-operative day, had the best diagnostic performance compared to other biomarkers (Area Under the Curve 0.825). The optimal cutoff for presepsin delta to diagnose post-operative infection was +90.5 pg/ml.ConclusionSerial assessments of presepsin levels on the first and third days post-surgery and their trends are helpful diagnostic markers for clinicians to detect post-operative infectious complications in children.

Introduction: Congenital prepubic sinus (CPS) is a rare congenital abnormality in the urinary tract in the form of remnant ducts that extend from skin openings near the pubic symphysis to various areas. Due to its anatomical and pathological variation, the clinical manifestation of this condition has a wide spectrum. This paper shows one of the youngest reported cases of CPS that was successfully treated with surgery. This paper aims to elucidate and provide the current literature review in order to increase awareness towards CPS diagnosis in general practitioners, pediatricians, and surgeons. Case report: Here we present a 2-months-old female baby with a CPS that presented a purulent discharge and recurrent abscess from an opening since birth. Prior to surgery, the patient had visited multiple health care provider until a definitive diagnosis of CPS could be established, which was followed by the administration of topical antibiotic prior to surgery. The condition was diagnosed through abdominal CT imaging and treated with a simple surgical technique aided with methylene blue dye. Conclusion: Clinicians should consider the differential diagnosis of congenital anomaly such as CPS in a patient presenting with purulent discharge or erythema from accessory meatus in the pubic region.