Double arm transplant beats odds

Surgeon Andrew Lee describes: challenge, action, result

The challenges were grave.  Iraq War veteran Brendan Marrocco was riding in a vehicle directly hit by an explosive fire projectile while returning to his base north of Baghdad on Easter Sunday, 2009. The projectile pierced through the vehicle, and sent pieces of shrapnel and bits of metal flying into the passengers. Sitting right where the projectile hit, Marrocco sustained severe injuries throughout his body — a severed carotid artery, broken nose, fractured facial bones, burns and lacerations, and most tragically, wounds that led to the amputation of all four limbs.

After undergoing emergency treatment in three hospitals, Marrocco was entrusted to a group of surgeons at Hopkins Hospital to explore the possibility of a hand transplant. Andrew Lee, lead surgeon on the ultimate procedure, discussed the case in an event at Hopkins last Thursday.

CHALLENGE 

The surgeons’ dilemma was whether or not to pursue the hand transplant. The procedure would not only subject the patient to hours of a physically exhausting operation, but would also require the patient to take potentially harmful drugs for the rest of his life to combat transplant rejection.

“When the first hand transplant was performed in the U.S., it was very controversial,” Lee said. “One of the people objecting to hand transplant at that time was myself. I didn’t think that the risk-benefit balance of the first arm transplant was in favor of the patient. I didn’t think the triple immunosuppression was really justified to improve their quality of life.”

The operation posed numerous other challenges as well. For instance, the surgeons could not use the traditional cuff blood pressure monitor since the arm itself was being operated on. Also, the tremendous expense associated with such a transplant is not currently covered by medical insurance companies.

ACTION 

The surgical team at Hopkins did not back down to the challenge. Instead, it facilitated collaboration between physicians and surgeons of different specialties and various organizations.

In order to finance the operation, the Department of Defense and Hopkins Hospital stepped in.

“For [Marrocco], we were able to receive not only research grants, but also some grants to cover the clinical expense from the Department of Defense. The Johns Hopkins Hospital was also generous in absorbing any additional cost associated with the research and the operation.”

Once the source of funding was secured, the surgical team acquired the resources to deal with the other difficulties.

To accurately monitor Marrocco’s blood pressure while operating on the arm, the Hopkins surgeons took a page out of the biomedical engineer’s book, and installed an innovative pressure monitor within the patient’s bloodstream.

To reduce the number of drugs Marrocco would have to take to combat transplant rejections, the Hopkins surgeons experimented with new immunological therapies and successfully reduced the number of drugs required from three to one.

When the operation began, the orthopedic surgeons were up first to connect the bones of the patient to those of the donor, establishing the foundation. Next, the plastic surgeons, aided by microscopes, connected each and every muscle fiber, nerve and blood vessel.

RESULT

The operation was a truly collaborative effort among specialists from diverse disciplines of medicine. Only through such teamwork did the surgeons overcome all the odds stacked against this procedure. Speaking about the future of hand transplants, Lee expressed optimism.

“I think the attitude is changing,” Lee said. “The resistance towards hand transplantation is turning around.”