Brigham and Women’s to offer hand transplants

At least six people already screened

By Elizabeth Cooney

Globe Correspondent / August 24, 2010

The Boston hospital that last year performed the country’s first face transplant now plans to offer hand transplants under an experimental program announced yesterday.

Brigham and Women’s Hospital has screened at least half a dozen people who have lost one or both hands and may be eligible for the complex surgery, Dr. Matthew Carty, a reconstructive plastic surgeon, said in an interview.

“We’re extremely excited about being able to offer this to patients,’’ he said. “There’s a huge potential pool of candidates in our soldiers returning from the front lines who have had severe limb injuries.’’

Fewer than 50 hand transplants have been performed worldwide, and only three US hospitals, in Louisville, Ky., Pittsburgh, and at an Air Force base in Texas, have undertaken the procedure. UCLA Health System launched a program last month.

Face and hand transplants are considered more complex than transplants of organs such as livers or kidneys because surgeons must also fuse bones, tendons, muscles, ligaments, nerves, and blood vessels, requiring delicate microsurgery.

The first modern hand transplant using microsurgery techniques was performed in France in 1998. Previous hand transplants took place in the 1960s. But without the use of drugs to keep the body’s immune system from rejecting donated tissue, the operations were failures.

Patients now must commit to taking immunosuppression drugs for life and to doing intensive rehabilitation for months after their operations.

The operations also raise complex ethical issues. Because people can survive losing hands or faces, the tradeoff between risk and benefit is different than for life-saving transplants, said Art Caplan of the University of Pennsylvania, an ethicist who has studied the issue for many years. Quality of life must be weighed against the side effects of taking antirejection drugs that weaken the immune system and make people more vulnerable to cancer and infection.

“Those drugs all have serious risks,’’ he said. “They can cause cancer at a high rate, and they can cause kidney failure.

“If I’m getting a heart transplant, I’m going to die’’ without it, he said. “If I get a hand or a face transplant, that could shorten life.’’

But Caplan added: “On the whole, I’ve been a defender of trying this. The [subjects] can make the choice if they are informed.’’

The alternatives to hand transplants have been reconstructive surgery or artificial hands. While prosthetic hands can function much better than they once did, thanks to vastly improved technology, they still do not act or look like hands, Carty said. Hands fashioned by surgery from other parts of the body may have some sensation but only rudimentary function, he said.

The goal of a hand transplant is to restore both appearance and function. That means giving a patient sensation — feeling the difference between hot and cold or soft and rough — as well as the ability to hold objects or shake hands, for example. “Transplants may give the best of both worlds,’’ Carty said.

To be eligible for the Brigham program, patients must have had their dominant hand or both hands amputated. The program also asks that patients try a prosthetic hand for six months before seeking a transplant.

Those guidelines could conceivably be broadened, Carty said, just as the protocol for face transplants evolved. When the Brigham first declared its intention to perform face transplants, candidates needed to already be taking immunosuppression medications for another reason, such as a kidney or pancreas transplant. But the rules were loosened to include other patients.

The nation’s first hand transplant recipient is doing well 11 1/2 years after he received his new hand at Jewish Hospital in Louisville, said hospital president Marty Bonick.

Among the five transplants performed there, one transplant has failed, but the man who had to have his donated hand amputated is eager to have another transplant, Bonick said.

“It’s very complicated surgery, but those techniques are reproducible,’’ he said. “The challenge with transplant has really been focused around the immunosuppression. Rejection is what you fear in any transplant, whether an internal organ or the hand.’’

The Louisville hospital has received $13.4 million from the US Department of Defense for hand transplantation.

The Brigham also received federal funds. It won $3.4 million to pay for face transplants for injured veterans.

There are different issues for matching donors and recipients for hand and face transplants than there are with organ transplants, Caplan said. Family members may be uneasy about donating their loved ones’ hands or face, he said.

“Hands are the other part of the body that are always exposed,’’ he said.

People may not anticipate donating these body parts when they sign an organ donor card.

“At this point the general public, when they register as organ and tissue donors, have a general understanding of what they consented to donate: organs and corneas or heart valves,’’ said Sean Fitzpatrick of the New England Organ Bank.

For hand donation to go forward, he said, “this is a separate decision and one made by the family.’’

To be considered as donors, people must have indicated their willingness by signing an organ donor card or conveying their wishes to their family members. If the potential donor has been declared brain dead, is on a ventilator, and is a potential match, the family will be approached, Fitzpatrick said.