It was in a Chicago bakery that
faculty member Ernest Manders, MD (pictured), Professor of Surgery, University of Pittsburgh, first saw Sarah Mues. Dr. Manders was in Chicago for the annual conference for the American Association of Tissue Banks. Sarah and her sister were in the Windy City on vacation and eating lunch. As reported in The Bulletin, Dr. Manders just had to interrupt and introduce himself.
“We noticed Sarah didn’t have any arms or hands,” Dr. Manders said, recalling the bakery encounter during a telephone interview. “...We saw her pick up a fork and feed herself a salad. I do hand surgery, and I’ve never seen anybody do this in my life.”
During their conversation, Dr. Manders explained to Sarah that a team of doctors in Pittsburgh perform arm and hand transplants, and two of them were at the conference — McGowan Institute faculty members Stefan Schneeberger, MD, and Vijay Gorantla, MD, PhD. Together with their colleague, Andrew Lee, MD, they are one of the pioneers in this field. Impressed by Ms. Mues’ ability to complete the mundane — to eat a salad, for example — Dr. Manders invited her to the conference.
“It was so surreal,” Ms. Mues said. “I felt like I was living in someone else’s life.”
She met the doctors the next day at the conference and within a few weeks, Sarah was in Pittsburgh undergoing a round of blood tests. While there, Dr. Manders and his wife, Sandra, took Ms. Mues and her father to dinner. Dr. Manders again watched in amazement — and with a bit of embarrassment — as Sarah made her way through a dinner of soup and pasta. She never spilled a drop, he said. Dr. Manders, however, with two hands had to tuck a napkin into his collar to keep drops of food from staining his shirt.
“For somebody who has a problem, seeing Sarah will force you to readjust how significant a problem you really have,” Dr. Manders said. “It’s unbelievable.”
If the blood tests show Sarah is a potential transplant candidate, she will move on to another round of intensive tests: CAT scans, bone marrow tests, and psychological exams, among others. One test will check her brain’s ability to move her hands. Medical staff will need to check if her brain still remembers how to, for example, wiggle a finger. If all the tests go well, Ms. Mues will have to move to Pittsburgh and wait until a suitable donor could become available at any time, so that she can receive hand transplants.
Once a donor is found in the U.S., everything happens at a hyper pace. Dr. Manders compared it to ski jumping, where the athlete must stay in control to keep from falling into chaos. Once the donor’s blood stops flowing, doctors and nurses have 9 hours to get to the body, draw bone marrow, and amputate the arms, return to Pittsburgh and attach the limbs to Ms. Mues.
“You have everything planned,” said Dr. Manders, who will likely travel to the donor site. “You start the clock. You walk out of the hospital in the transport vehicle. There are four teams in place when you get back. You walk in the door and say, ‘Let’s get to work.’”
But for someone who Dr. Manders describes as “highly functioning,” the risk-reward equation has to be balanced. Why would Sarah — who can brush her teeth, feed herself, comb her hair — risk such a grueling operation? She doesn’t hesitate to give her answer.
“I want to give my kids a hug; I want to hold their hand; I want to feel my life,” Sarah said. “I think about being able to run my fingers through my kids’ hair.”
UPMC Clinical Study on Human Hand Transplantation
Based on groundbreaking research and experience in solid-organ transplants, the University of Pittsburgh Medical Center (UPMC) is beginning a novel clinical study on human hand transplantation that seeks to reduce the use of immunosuppressive drugs and their damaging side effects for patients.
Although surgeons from around the world have performed hand transplants successfully for almost 10 years, they have used multiple immunosuppressive medications to prevent rejection of the grafts, increasing the risk of diabetes, hypertension, and other disorders.
In contrast, researchers and surgeons at UPMC propose to implement an immunomodulatory approach known as the “Pittsburgh Protocol,” which entails antibody therapy, donor bone marrow cell infusion, and treatment with a single immunosuppressive drug to reduce toxicity for patients.
“We will be offering another, potentially safer alternative for those who have lost a hand,” said Dr. Lee. “With our focus on reducing the need for multiple immunosuppressant drugs typical of this procedure, we believe that we can restore what many amputees have lost without the risk of devastating side effects.”
Surgeons at UPMC will adapt a two-phase protocol that involves initial antibody treatment followed by bone marrow cell therapy. The goal is not merely to suppress the immune system but to change the way it functions. Transplant patients will receive antibodies to help overcome the initial overwhelming immune response. That will be followed by a bone marrow infusion. The bone marrow cells target specific cells that could reject the hand and help “re-educate” the immune system into thinking that the transplanted hand is not a foreign object. Patients will be treated with tacrolimus, a drug that was first used in liver transplants by Thomas Starzl, M.D., Ph.D., over two decades ago, to maintain the low-grade immunosuppression needed to prevent long-term graft rejection.
“Unlike a solid-organ transplant, which is needed to prolong life, a hand transplant improves only the quality of life,” said Dr. Lee. “We take very seriously the long-term health of our patients. We have devoted many years of research to developing an immunomodulatory protocol that will reduce the risks of the procedure. We believe our new protocol will achieve this goal, allowing more amputees to be considered for hand transplants in the future.”
UPMC researchers are seeking patients between the ages of 18 and 60 with amputation at the forearm or below who are interested in receiving a hand transplant. Selected patients will undergo intensive medical screenings and psychological evaluation. Eligible subjects will be invited to undergo a comprehensive informed consent process and placed on the transplant list to await a potential donor. Those who receive transplants will be expected to stay in the Pittsburgh area for 3 months after the surgery to undergo extensive physical therapy and careful monitoring and assessment by physicians.
Dr. Manders is Residency Program Director for the Division of Plastic Surgery, Medical Director of the Facial Nerve Center, Chief of Plastic Surgery at the Oakland VA Hospital, and Plastic Surgery Chief of the University of Pittsburgh Cranial Base Surgery Program. Dr. Schneeberger, is Director of the Composite Tissue Allotransplantation (CTA) Program in the Division of Plastic Surgery at UPMC and a Professor of Surgery. Dr. Gorantla is currently a Research Assistant Professor of the Department of Surgery in the Division of Plastic Surgery at the University of Pittsburgh and Administrative Director of the CTA Program. Dr. Lee is a Professor of Surgery and Chief of the Division of Plastic Surgery at the University of Pittsburgh; he is also the director of the Hand Surgery Fellowship at the University’s School of Medicine. All of the doctors are faculty members of the McGowan Institute.
Illustration: McGowan Institute for Regenerative Medicine.
The Bulletin (10/16/08)
MSNBC Today Show (video)
UPMC Media Relations News Release (10/28/08)
Bio: Dr. Ernest Manders
Bio: Dr. Stefan Schneeberger
Bio: Dr. Vijay Gorantla
Bio: Dr. Andrew Lee