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Hand Transplantation: Is It Worth A Lifetime Of Immunosuppression?

There was a lovely news article on the first California hand transplant patient in the LA Times earlier this week:  Hand transplant patient speaks (bold emphasis is mine)

Emily Fennell, 26, last month became the first person in California to have the revolutionary surgery. Six weeks and many hours of therapy later, she has no regrets. …..

On March 5, Fennell became the first person to undergo a hand transplant in California and the 13th nationwide to have the revolutionary surgery. . ….

“It’s crazy how good it looks,” she said at her occupational therapy session one morning last week at UCLA, where she spends about eight hours a day working on learning how to move her new hand and fingers. “I knew the match wouldn’t be perfect, but if you didn’t know what happened, you’d think I just had some kind of orthopedic surgery.”  ….

Doctors told her that the biggest risk from the surgery comes from the side effects of lifelong use of strong immunosuppressant medications, which can cause high blood pressure, kidney or liver damage, elevated cancer risks and lower resistance to infections. …..

“I decided the benefits were worth those risks,” Fennel said. She has adjusted well to the medications.  ….

She has no sensation yet in the transplanted hand. The nerves grow about one millimeter a day from the connections the surgeons made to her arm, and it will be several more months before sensations develop.

“The hand is connected to me. It’s mine,” Fennell said. “But until I have feeling in it, it’s not going to feel like mine.”  ……….

Her therapists encourage her to say “my hand” instead of “the donor hand.” It’s a psychological adjustment that runs parallel to the physical challenges she deals with.  ……..

This news article coincides with my reading of the journal article on issues related to face transplantation (full reference below).  Both hand and face transplantation have similar issues to other solid organ transplantation.  One of the big issues with hand transplantation is whether the risks are worth it as a hand transplant is not a live-saving procedure as a heart or liver transplant is.

From the article

Two of the world’s first four face transplant recipients acquired cytomegalovirus viral infection by means of their donated facial organs. Also, the French experience, and our own, has been challenged by cytomegalovirus reactivation and graft rejection, therefore necessitating a critical evaluation. The authors have also learned, from their own experience, that facial composite tissue allografts containing mucosa and paranasal sinuses present a distinct challenge with regard to their accompanying flora.

Conclusions: Although the risk of donor-derived cytomegalovirus is acceptable in life-saving solid organ transplantation, for face transplantation patients, the scenario is different. When the authors’ team performed the first nearly total face/maxilla transplantation (December of 2008), there was little known regarding the consequences of cytomegalovirus-related donor transmission in face transplantation. Therefore, the authors now recommend that all candidates be fully informed as to the risks of cytomegalovirus/infectious transmission and that aggressive viral, bacterial, and fungal prophylaxis be instituted.

As with the young women who would give a year of life for a perfect body, it is a question for the individual (I am coming to believe) to decide.  But for them to decide, we surgeons/doctors must do a better than good job at educating them as to what the risks are AND as to the reality of the limitations that will remain.  The new hand will never work as well as the non-injured one did.

Read Wolf’s comment on my blog post regarding the Florida student who had a hand transplant.

REFERENCE

Cytomegalovirus and Other Infectious Issues Related to Face Transplantation: Specific Considerations, Lessons Learned, and Future Recommendations; Gordon, C R; Avery, R K; Abouhassan, W; Siemionow, M; Plastic & Reconstructive Surgery. 127(4):1515-1523, April 2011; doi: 10.1097/PRS.0b013e318208d03c

*This blog post was originally published at Suture for a Living*


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