Conjoined Twin Separation and Reconstruction -An Anatomic Classification System, Techniques and Outcomes at a Tertiary Pediatric Care Center

Purpose: Conjoined twin separation is highly complex. Existing taxonomies describe morphology but not extent of sharing across regions—a key determinant of feasibility, planning, and outcomes. We introduce the Texas Children’s Hospital (TCH) Classification System and report our institutional experience supplemented by a structured literature review. Methods: Retrospective review of conjoined twins (2014–2024). The TCH system assigns one point per domain (skin/soft tissue, deep viscera, major vascular, central neurologic, bone) within four regions (cranium, thorax, abdomen, pelvis); region scores yield composite fusion score (CFS). Two reviewers scored cases. We described outcomes and compared CFS between separated and non-separated twins. PubMed review identified cases with anatomic detail for scoring. Results: Seventeen cases were identified; 12/17 (70.6%) were viable at birth, and 4/12 (33.3%; 4/17, 23.5% overall) underwent elective separation. Tissue expansion (TE) preceded separation in 3/4 pairs (75%); hepatic artery embolization in 1/4 (25%). Device complications occurred in 2/3 TE pairs; sternal hardware complications in 2/3 plated patients. Infection and seroma each occurred in 2/8 patients (25%). Three of eight (37.5%) required tracheostomy and three (37.5%) gastrostomy. All separated twins survived (follow-up 9–117 months). CFS was lower in separated versus non-separated twins in both institutional (mean [SD] 5.2 [2.8] vs 9.3 [3.2]; p =0.041) and literature cohorts (4.7 [1.9] vs 7.1 [1.8]; p =0.010). Conclusions: The TCH classification offers an adjunctive, anatomy-based framework capturing the burden of shared structures and correlating with separation feasibility. While not predictive, it provides a common language to align teams, structure operative strategy, and support counseling.