Last month, Dr. Linda Cendales— associate professor of surgery at Duke University School of Medicine and director of Duke’s hand transplant program—led a team that performed the first hand transplant surgery in North Carolina by attaching the limb to a patient from Laredo, Texas, who lost his hand in a childhood accident. Cendales discussed the surgery and the future of the procedure with The Chronicle via email.
The Chronicle: What is a hand transplant surgery? In other words, from a biological perspective, what exactly was surgically added and removed?
Linda Cendales: Hand transplantation is an innovative therapy under the umbrella of a field called vascularized composite allotransplantation. VCA is the transplantation of vascularized tissues such as skin, bone, muscle, tendon and nerve as a functional unit to reconstruct defects unable to be repaired with one’s own tissue. VCA is the result of advances in transplantation and microsurgery.
In the case of our first patient at Duke, the patient lost his left hand at the age of four and received his new left hand at the age of 54. He was placed on the waiting list matching for skin pigmentation, sex, size and blood type. The surgery was performed as planned. The donor hand was procured at the level of the elbow and transported to the operating room. At the time of the transplant, the skin of the patient’s residual limb was opened. Multiple teams including surgeons, nurses, operating room staff, anesthesiologists, radiology technicians and our research team worked together to complete the transplant. During the procedure, the tendons, muscles, nerves, arteries, veins and bones from both the patient and the donor limb were dissected and their ends connected. The official time of the transplant was when the connection of the artery was performed and the hand received blood again. A remarkable moment. The patient was placed in a large dressing for post-operative monitoring. We completed the 12-hour procedure on May 27.
TC: Besides the obvious complexity of a hand transplant, what other challenges are there in completing this surgery, from start to finish?
LC: Hand transplantation has more unknowns than knowns and is complex at many levels. Hand transplantation is similar to other organ transplants in that it requires immunosuppression for as long as the recipient has the transplant. But in contrast to other organ transplants, it is a visible transplant adding the dimensions of body image and quality of life. I think that most of the challenges in this field are related to immunosuppression and the immunogenicity of the different tissues transplanted.
TC: How did Rene Chavez qualify for the surgery and how was his arm medically prepared for the procedure?
LC: Mr. Chavez contacted me at my prior institution over three years ago and opted to continue in constant communication with me since then. When our Duke hand transplant clinical research program was actively recruiting participants, Mr. Chavez flew to Duke to be evaluated. Our evaluation process is thorough and includes lab work, imaging and psychological, social and occupational therapy evaluations. There are assessments by physicians, pharmacists and surgeons. After each participant’s evaluation, our multidisciplinary team decides if the candidate is approved to move forward with Phase 2 of the clinical trial, which is placement on the waiting list to receive a transplant.
TC: How did you and the 17 other physicians coordinate such a complex surgery?
LC: Our program is based on a strong multidisciplinary and team approach. This procedure is the result of years of preparation by scores of individuals including surgeons, physicians, nurses, anesthesiologists, therapists, organ procurement professionals, social workers, pharmacists, psychologists, administrators, researchers and many others all coming together to help Mr. Chavez regain better quality of life and improved upper extremity function.
TC:You were the first surgeon in history to lead a hand transplant at the University of Louisville and continued with your work in hand transplants later at Emory University. What have you learned about this procedure over the years?
LC: I was fortunate to have the opportunity to help organize the first VCA program in the United States in Louisville and to establish additional programs in the country. For me, preparation, scientific and multidisciplinary approaches and focus on the population in need are key components in the development of this emerging field. Our first hand transplant at Duke exemplifies this. It exemplifies how key components of academic science are codependent and how success in one augments opportunity for success in another. Our hand transplant is an achievement for the entire Duke Health system, from the partnership in pre-clinical science with Duke’s Division of Laboratory Animal Resources to the strong multidisciplinary collaborations in clinical science and patient care. We came together across departments and disciplines to accomplish something few have done before, and we opened a new domain of possibility to our patient population in need. And we can all be proud of that.
TC: How will you and your team help Mr. Chavez begin to make use of his new hand? Is there a general plan in place for physical therapy or do you tailor rehabilitation based entirely on the patient?
LC: Mr. Chavez, as well as all subsequent hand transplant recipients in our program, will follow a rigorous occupational therapy regimen and receive close monitoring of the immunosuppression regimen. For the former, the program includes daily therapy and the transition to activities of daily living at a later time. For the latter, we are, for the first time in hand transplantation and in VCA, testing the systematic use of the immunosuppression medication called belatacept.
TC: Although it has only been a little more than a week since the procedure, it seems as though North Carolina’s first hand transplant was a success. Where do you plan to go from here with Duke’s hand transplant program?
LC: While our first hand transplant at Duke could be considered an end-product or accomplishment, we prefer to consider it the beginning of a comprehensive vascularized composite allograft clinical program backed up by a very deliberate investigational program that we hope will help advance this field. Our program received $4 million from the U.S. Department of Defense for the development of a VCA program to support limb transplantation, which is a procedure that may help benefit soldiers who lose limbs during combat.
We also established a VCA collaborative initiative with five outstanding institutions nationwide for the development of VCA. In addition, we held the first International Workshop on VCA Histopathology in May 2016 with leaders from 11 national and international institutions where clinical VCA—hand, face and abdominal wall—has been performed. It is our goal to bring reconstructive transplantation to deserving individuals such as Mr. Chavez who have limb loss or other un-reconstructible tissue defects.
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