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Hands, faces -- and it’s a success

Special to The Times

A team of surgeons gave 32-year-old Dave Robert Armstrong of Upland a hand, last July -- literally.

Just 10 years earlier, that wouldn’t have been possible. But in September 1998, the first hand transplant was performed in Lyon, France, and since then more than 30 people around the world have received such a transplant -- sometimes, two.

Other patients have received arms, faces and abdominal walls -- varied types of composite tissue allotransplantation, or CTA, meaning multiple tissues are involved (skin, muscle, tendon, bone, cartilage, fat, nerves, blood vessels) and the body part comes from a brain-dead donor.

These CTA procedures are being done with “a very, very high success rate,” says Dr. L. Scott Levin, professor of orthopedic and plastic surgery and chief of plastic surgery at Duke Medical Center in Durham, N.C. (So far only hand and abdominal wall transplants have been done in the United States.)

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Additional types are considered possible. “We’re on the frontier of this field,” says Dr. Gordon Lee, a plastic surgeon and director of microsurgery at Stanford Hospital.

And some of the field’s pioneers believe it has vast potential. “We feel we can help many more people than we’re helping now,” says Dr. Stefan Schneeberger, director of the University of Pittsburgh CTA Program.

To date, though, CTA is expensive, risky and possibly shortens the lives of those who undergo it.

Gauging success

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A successful hand transplant is one in which the hand survives and is functional, says Dr. Warren Breidenbach III, who led the team in Louisville that performed Armstrong’s transplant in July.

Breidenbach and his team from the Kleinert Kutz Hand Care Center, in partnership with Jewish Hospital and the University of Louisville School of Medicine, have performed all four hand transplants that have been done in the U.S., including the world’s first successful one in 1999.

(The 1998 hand transplant in France was considered successful until the recipient asked to have it removed, saying he felt “mentally detached” from it.)

Function doesn’t happen overnight. The surgeons join at least three nerves in the transplanted hand -- two large and one smaller branch -- to ones in the recipient’s arm, and the nerves in the transplant die. Then the recipient’s nerves grow down into the transplant, and function grows with them.

In full arm transplants, the nerves have farther to grow, so function is slower to develop, and there’s a greater chance that it might not.

On a test of functionality, the Carroll test, Breidenbach’s four patients score from the high 50s to the low 70s on a scale of zero to 99. Lee has met one of these patients and says he can pick up coins, take a pen apart and put it back together, and identify an object by touch with his eyes closed. He can play with his kids and hold hands with his wife.

Still, the decision to perform a hand transplant -- or CTA of any kind -- requires a difficult risk-benefit analysis.

CTA is very expensive: $250,000 for hand-transplant surgery and the first three months of treatment, followed by drugs that can cost thousands of dollars a month.

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The surgery is complicated, requiring a large team and long hours. The hand transplant in July took 14 hours and involved a 20-member team, including six hand surgeons. More people were involved in planning, preparation and after-care.

The surgery, however, is similar to that of “replantation” -- reattaching a hand that has been cut off in an accident, says Lee, who does that kind of surgery routinely. “Technique is not the limiting step.”

Finding a suitable donor and keeping the transplant alive long enough to perform the transplant further complicate matters. But doctors are unanimous that the biggest challenge in CTA comes from immunosuppression.

Transplant recipients generally have to take drugs for the rest of their lives to suppress their immune systems. These drugs have severe side effects, such as making patients prone to infection: “A common cold can turn into something serious,” says Dr. James Bradley, professor of plastic surgery at UCLA Medical Center. They also raise the risk of cancer. By some accounts, Lee says, “Life expectancies are 10 years shorter.”

These same issues arise with organ transplants, but those are performed as life-saving measures. Lowering life expectancy by 10 years may not seem like such a bad deal when the alternative is dying now. CTA, on the other hand, is performed to improve the quality of life. And though the improvement it offers may be dramatic, a shortened life span is a serious trade-off. Many physicians don’t feel the risk is justified.

Safer alternatives exist, such as reconstructive surgery (transplanting tissue from one part of the patient’s body to use in creating a missing part) and prosthetics. “But whenever you take tissue from another part of the body, there’s the potential for complications,” Lee says.

And these substitutes are never as good as the real thing, he adds. “If you had a choice between a robotic hand, and a hand that would let you feel and touch and pick things up, which would you take?”

Safer methods

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So scientists are looking for ways to make CTA safer. “They want to induce tolerance, trick your body into thinking the new hand is a part of you,” Lee says. “That’s the holy grail of transplant immunology.”

Only trouble is, researchers have been looking for it for 30 or 40 years and haven’t found it. Some believe that by the time they do -- if ever -- better methods will have been developed to replace body parts, perhaps via stem cell research.

Others counter that great progress is being made. Ten years ago, Schneeberger says, the standard drug treatment consisted of three drugs, including one steroid, taken at high doses for the patient’s entire life. But studies by researchers at the University of Pittsburgh have shown that for kidney transplant patients, it’s possible to reduce the number and dosage of these drugs. The latest study, published in May, showed that one drug -- not a steroid, and taken at a lower level than before -- can prevent transplant rejection as well as the three-drug treatment.

Breidenbach has tried to implement what is known about immunosuppression in organ transplants, where data on thousands of patients are available, in his own program -- where the patients can be counted on fingers of one hand.

He used the standard three-drug treatment on his first two patients, but starting in 2006 -- after both had taken the three drugs for years -- he weaned them off the steroid. Now they take only two drugs, and he says they are doing fine.

Breidenbach used “steroid sparing” on his last two patients, meaning that, except for the first day, they have taken only two nonsteroid drugs. Now he’s hoping to try “spaced weaning” on them -- giving them only one drug, as the Pittsburgh study showed was possible with kidney transplant patients. “I don’t know if it will apply to hands, but I believe it will,” he says.

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health@latimes.com

Read about prospects for CTA surgery at latimes.com/cta.


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