Forum for Science, Industry and Business

Sponsored by:     3M 
Search our Site:

 

The world's first transplant of both arms at the “Klinikum rechts der Isar” of the TU in Munich

04.08.2008
From the 25th to the 26th July, the “Klinikum rechts der Isar” of the Technical University of Munich saw the first transplant of complete arms after several years of preparatory work

The patient is doing well under the circumstances. This operation was managed by the Clinic for Plastic Surgery and Hand Surgery (Director Prof. Hans-Günther Machens). The operation, with a team of 40 people participating, was headed by PD Dr. Christoph Höhnke (Head of the transplant team, Senior Physician of the Clinic for Plastic Surgery and Hand Surgery) and Prof. Edgar Biemer (long-standing ex-board member of the plastic surgery division).

Case history

Six years ago, the 54 year old farmer lost both his arms at upper arm level during an accident. Thus the man had to heavily rely on help - a condition which he wanted to change as quickly as possible. After two attempts with various artificial limbs had proven unsuccessful, his desire for arms consisting of live tissue became ever bigger. He therefore approached the Clinic for Plastic Surgery and Surgery at the “Klinikum rechts der Isar” for help.

He thus came into contact with a team of physicians with the ideal prerequisites for the globally hitherto unprecedented operation: apart from a decade long tradition in microsurgery and replantation surgery, the employees of the Clinic also have long-standing experience in interdisciplinary surgical preparation and planning - indispensable for such complex surgery.

The “Klinikum rechts der Isar” also contains a Liver, Kidney and Pancreas transplantation centre, so that even larger know-how in immuno-suppression was on hand. With PD Dr. Christoph Höhnke, who accepted the overall management of the transplantation team, and the former Head of Plastic Surgery at the “Klinikum rechts der Isar”, Prof. Edgar Biemer, he also met two physicians who have not only clinically but also scientifically dealt with problems concerning transplants or microsurgery for many years. In addition, the current Director of the Clinic, Prof. Hans-Günther Machens, had himself been active in transplant surgery for many years and, when he began office in December 2007, was prepared to actively support this project and take on medical responsibility.

The physicians of the Clinic for Plastic Surgery now had to initially clarify whether the future patient was physically and psychologically suitable for the difficult surgical procedure. The man was examined from head to foot, for in order to be prepared for the suppression of the immune defence system required after transplantation, he had to be perfectly healthy. One also had to ensure that he had a stable personality and a stable social environment. The last phase of operative preparation was represented by an explorative operation on the upper arm stump, during which the physicians tested to see where and how they would be able to seal off nerves and vessels during transplant. During this procedure they ascertained that the main artery in the left shoulder was occluded; this would thus require several bypasses.

Now it was solely a matter of waiting for a suitable donor, matching the host in sex, age, skin colour, size and blood group and would have no injuries to the upper extremities.

The Operation

It all happened on the evening of the 25th July, around 10 p.m.: five teams started simultaneously in two operating theatres - one group each on the left and right side of the donor and host and an additional team removing a leg artery from the donor. First they had to expose each of the muscle ends, nerves and the vessels and prepare them for connection. Before the donor's bones were severed, the blood vessels in the arms were filled with cooled preservation solution (perfusion). Both arms were then removed in such a way, that they accurately corresponded to the patient's arm length.

Now both surgical teams connected the new body parts to the body of the host on both sides in a step-by-step procedure. First they joined the bones together with an 8 hole plate. They then connected the arteries and veins in order to recreate circulation of the transplanted arms as quickly as possible. The left side had already been prepared with three venous bypasses. Before completion of the anastomoses, the arms were rinsed with a special liquid to remove the preservation solution.

Then the blood was released at intervals of 20 minutes; because from an anaesthetic point of view it must be ensured that the patient does not suffer acute damage from the blood flowing back from the transplants. The arms quickly took on their rosy colour. There was no significant swelling - proof for a well-functioning circulation and a short ischemia period (lack of tissue circulation). The surgeons then sewed the muscle and tendon strands back together and finally reconnected all the nerves (nervus musculocutaneus, nervus radialis, nervus ulnaris and nervus medianus). Now the skin could be sewn back together. Finally, a cross-joint fixateur externe was attached with pins to the lower and upper arm. This allows the arms to be suspended to avoid pressure marks. The operation was successfully concluded after 15 hours.

Current situation and further care

Not only the operation itself but also the first days thereafter continued optimally for the patient. His condition is very good under the circumstances. Now it is a matter of avoiding future wound healing disorders, infections, strong side effects caused by the drugs and, in particular, any rejective reaction (see below). Quite a number of measures were taken to this effect: close monitoring, antibiotic prophylaxis, drug monitoring and immuno-monitoring. To avoid degeneration of the muscles, these are regularly stimulated with physiotherapy, among others. The patient is also given psychological support.

Worldwide, not many hands and lower arms have been transplanted to date. The transplantation, performed in Munich, represents an even greater challenge: it also encompassed the elbow joint as well as the upper arm, signifying significantly larger regeneration areas and a more difficult immunological situation.

Allogenic upper arm transplant: an immunological challenge
In contrast to the transplant of solid organs (liver, kidney, pancreas, etc.), an extremity histologically represents heterogeneous tissue, consisting of various components with varying immunogeneity. From an immunological point of view, the focus is on
1)the skin, containing cells with high immunogeneity

2)bone marrow, which is also transferred within the scope of an upper arm transplant

The highly immogeneous cells of the skin lead to a strong immuno-reaction in the host. During an upper arm transplant, approximately 20% of the body's entire skin surface is transplanted. At least initially, this requires a strong immunosuppressive therapy with all the possible side effects (e.g. infections Furthermore, the skin lacks a simple lab-chemical parameter (such as creatinine during a kidney transplant) to enable the recognition of an immunological reaction in the host. The diagnosis of an immunological defence reaction is thus based on the clinical assessment of the skin, regular skin biopsies and different immunological tests. This type of monitoring is far more complex than after transplantation of solid organs.

The hollow bones in the upper arm contain large volumes of bone marrow (in contrast to a hand transplant, during which hardly any bone marrow is transplanted). Bone marrow consists of immuno-competent cells, which could trigger a so-called graft-versus-host-reaction (GvHD). This means, that these cells are able to attack the host. Such an attack denotes a life-threatening situation for the host. The extent of the risk after an upper arm transplant is difficult to assess, as it has been shown that preclinical data cannot be directly transferred to the human situation. This also requires different immunological examinations in order to recognise and treat the occurrence of such a reaction at an early stage.

In principle, upper arm transplantation combines the immunological problems of bone marrow transplantation with those of solid organ transplantation. In the long run, this is joined by possible side effect caused by immuno-depressors. From a transplantation surgeon's point of view, upper arm transplantation thus represents an interesting challenge, which also offers the opportunity of making a contribution to understanding immunological processes after transplantation.

Tanja Schmidhofer | alfa
Further information:
http://www.med.tu-muenchen.de

More articles from Health and Medicine:

nachricht Researchers find trigger that turns strep infections into flesh-eating disease
19.02.2019 | Houston Methodist

nachricht Loss of identity in immune cells explained
18.02.2019 | Technische Universität München

All articles from Health and Medicine >>>

The most recent press releases about innovation >>>

Die letzten 5 Focus-News des innovations-reports im Überblick:

Im Focus: Light from a roll – hybrid OLED creates innovative and functional luminous surfaces

Up to now, OLEDs have been used exclusively as a novel lighting technology for use in luminaires and lamps. However, flexible organic technology can offer much more: as an active lighting surface, it can be combined with a wide variety of materials, not just to modify but to revolutionize the functionality and design of countless existing products. To exemplify this, the Fraunhofer FEP together with the company EMDE development of light GmbH will be presenting hybrid flexible OLEDs integrated into textile designs within the EU-funded project PI-SCALE for the first time at LOPEC (March 19-21, 2019 in Munich, Germany) as examples of some of the many possible applications.

The Fraunhofer FEP, a provider of research and development services in the field of organic electronics, has long been involved in the development of...

Im Focus: Regensburg physicists watch electron transfer in a single molecule

For the first time, an international team of scientists based in Regensburg, Germany, has recorded the orbitals of single molecules in different charge states in a novel type of microscopy. The research findings are published under the title “Mapping orbital changes upon electron transfer with tunneling microscopy on insulators” in the prestigious journal “Nature”.

The building blocks of matter surrounding us are atoms and molecules. The properties of that matter, however, are often not set by these building blocks...

Im Focus: University of Konstanz gains new insights into the recent development of the human immune system

Scientists at the University of Konstanz identify fierce competition between the human immune system and bacterial pathogens

Cell biologists from the University of Konstanz shed light on a recent evolutionary process in the human immune system and publish their findings in the...

Im Focus: Transformation through Light

Laser physicists have taken snapshots of carbon molecules C₆₀ showing how they transform in intense infrared light

When carbon molecules C₆₀ are exposed to an intense infrared light, they change their ball-like structure to a more elongated version. This has now been...

Im Focus: Famous “sandpile model” shown to move like a traveling sand dune

Researchers at IST Austria find new property of important physical model. Results published in PNAS

The so-called Abelian sandpile model has been studied by scientists for more than 30 years to better understand a physical phenomenon called self-organized...

All Focus news of the innovation-report >>>

Anzeige

Anzeige

VideoLinks
Industry & Economy
Event News

Global Legal Hackathon at HAW Hamburg

11.02.2019 | Event News

The world of quantum chemistry meets in Heidelberg

30.01.2019 | Event News

Our digital society in 2040

16.01.2019 | Event News

 
Latest News

New therapeutic approach to combat African sleeping sickness

20.02.2019 | Life Sciences

Powering a pacemaker with a patient's heartbeat

20.02.2019 | Medical Engineering

The holy grail of nanowire production

20.02.2019 | Power and Electrical Engineering

VideoLinks
Science & Research
Overview of more VideoLinks >>>