Hyderabad, Oct. 16: On Saturday, staff at the Niloufer Hospital here brought a cake for conjoined twins Veena and Vani to cut on their 13th birthday.

They have been doing it every October 15 since the twins, joined at the head, came to live with them in April 2006. But unlike other years, the jollity was tinged with sadness yesterday - for this year's celebration could be the last.

Next October 15 may have to be marked at a state-run home, where the girls are likely to shift in a couple of months.

"We have heard that we are going to be shifted from here soon, either to a state home or a hostel," Veena said during a brief interaction with The Telegraph. "Given a choice we would have liked to stay here. The doctors and nurses take good care of us and we are happy here."

At the heart of the problem lies the government hospital's hesitancy in carrying out the high-risk head-separation surgery amid conflicting assessments of success from expert medical teams.

With the girls now turning 13, the hospital - where doctors and staff adore the twins, a colour TV entertains them and a special tutor arrives daily to teach them - thinks they now need a new environment.

In answer to a recent letter from the hospital, the state government has advised the shift to a home run by the women and child development department.

"We are not trying to wash our hands of the girls. The twins have been here for over a decade and we treat them as our kids," Dr Ramesh Reddy, head of paediatric surgery at Niloufer Hospital, told this newspaper.

"But they are becoming mature and this is the time they should interact with girls of their age and get used to a normal atmosphere. They should experience a proper life; a hospital with sickness and deaths is not the place for them to stay in forever."

A team of specialist surgeons from London had examined the twins in February last year and said the surgery could be a success. The girls' parents, auto-rickshaw driver Maragani Murali and day labourer Nagalakshmi, too consented to the risk involved - of disability or the death of either girl or both.

But in June this year, a team from the All India Institute of Medical Sciences suggested the risk was too great, and a nervous Niloufer Hospital backed out.

"This is an ethical issue. In our desperation to relieve them of their misery we cannot expose them to greater harm," Dr Reddy said.

But he added that the hospital hadn't ruled out surgery in the future.

"We are continuing our exploration globally for options of advanced expertise and technologies. We are now in touch with the Melbourne Children's Hospital, which is showing an interest in the case," he said.

Paediatric surgeons say the twins share a key vein that carries blood from their brains to their hearts and that attempts to sunder the twins will put them at the risk of dying.

"If surgical separation is attempted, blood circulation in the brain of one of the twins may stop," said Minu Bajpai, professor of paediatric surgery at AIIMS who has helped separate at least four Siamese twins. "No one will want to take such a risk."

Dr Sunita Ojha of Jaipur and Dr Pavai Arunachalam of Chennai, members of the Indian Association of Paediatric Surgeons, said they did not recall any attempt to separate cranially conjoined twins in India.

A small room in Niloufer's paediatric ward is where the girls live. A cot and a table on which their books are kept occupy most of the space. It's a room that has attracted doctors from many countries such as Singapore and Britain, curious about the twins' rare condition.

The girls are aware of their parents' financial constraints and know that returning home is not an option. Veena and Vani have two more sisters at their home in Beersettygudem, Warangal, which they have never seen.

Born on October 15, 2003, at a hospital in Suryapet, a nearby town in Nalgonda, they were taken to a hospital in Guntur the following day. Two-and-a-half years later they were brought to Niloufer, which specialises in maternal care and childcare.

The parents occasionally visit their children but say they cannot provide for their special needs. It's the state government that has been paying the girls' bills.

"We have agreed to the risky surgery but if the operation is ruled out, we request the government to provide us with a job and a house in Hyderabad to take care of Veena and Vani," Murali, the father, said.

Rajeshwar Tiwari, principal secretary, health, said the state government was making arrangements for the twins' shift to the state home.

"We are convening combined meetings of the health department and the women and child development department to work out the details. The girls will need special care and facilities," he said.

"One or two nurses from Niloufer may be sent there on deputation for a few months so that they can train the staff to look after Veena and Vani."

Tiwari said the Telangana government would assume responsibility for the twins throughout their lives.

"Whenever the opportunity comes, we'll go for surgery. We'll bear all the costs. This is the least we can do for the unfortunate girls and their family," he said.

Surgeons say such operations are relatively easier when the twins are conjoined along the chest or the abdomen, although even those surgeries are challenging and take anywhere from eight to 14 hours.

Cranially conjoined twins represent two to six per cent of conjoined twins, according to a medical paper by doctors from the Sri Ramachandra Medical College, Chennai.

A day before the girls' birthday, twin boys Anias and Jadon McDonald, born joined at the head 13 months ago, were separated after 27 hours of surgery at the Children's Hospital at Montefiore Medical Center in the Bronx, New York.

Doctors at Niloufer said they were not aware of the McDonald case. "But we are approaching hospitals worldwide for the possibility of a separation surgery on Veena and Vani," Dr Reddy said.

A nurse's eyes welled up as she patted Vani's shoulder affectionately.

"Since I joined this hospital in 2008 I have been looking after them. We wish all happiness to them wherever they are," she said.