A former Dresden resident led a team of 18 surgeons this month in a historic surgery performed in Toronto. Dr. Steven McCabe led his team to the successful completion of the country’s first transplant of the upper limb.
The Sydenham Current spoke with Dr. McCabe, who went into detail about the hand transplant surgery he helped lead, what it was like for him growing up in Dresden, and much more.
How did you get involved in this stream of work?
“Microsurgery for reattachment of amputated hands has been available since the 1970’s,” Dr. McCabe told the Sydenham Current.
“A lot of improvements in techniques over the last three or four decades. Transplantation of the major organs: liver, kidneys, lungs, heart and others. Those have been increasing in the techniques and immunosuppression has been improving since the 1980’s. Organ transplants became very common through the 1980’s.”
“So really what we are doing is we are marrying those two techniques. Microsurgery to reattach a limb with organ donation and immunosuppression and so what we can do is take a patient that has had an amputation of one or both of their limbs… you have to be very selective, and make sure that the patient has a general suitable situation that will result in a good result. We can then find a donor for that patient, same gender, same limb obviously, colour and size match. The donor and recipient must also be an immunological match, and then we can take that limb from a donor and transplant it onto the recipient and try to restore some function in the limb.”
Dr. McCabe said in the 1990’s, it was pretty obvious that there were some good improvements in immunosuppression medication.
“So the person who has the transplants (their) major organ or the limb’s tissue will have to take immunosuppression drugs for life,” he said. “Those medications carry with them some side effects. So there was reluctance to try it in transplantation but then in the 90’s it became obvious that the immunosuppression could be tolerated well with some patients so there was an interest in this.”
At this point Dr. McCabe and his family were living in Louisville, Kentucky, where there was a big transplant centre located.
“We became interested and we were looking into that problem there and it was obvious that things would be reasonable for transplantation of the limb,” he said.
“We went through a long process. We had a medical ethics review and a lot of discussion with the public and with other professionals and decided that the limb transplantation was a feasible option. We started there and the the first case was in January 1999. Since that time there has been about 110, probably a little more than that, of transplants in the world and because of the lapse of time since 1999 there has been enough follow up of patients to have a reasonable understanding that there can be good functioning results from the surgery.”
Dr. McCabe moved back to Canada about three and a half years ago and surgeons north of the border were already interested in this.
“When I came I joined in and we further developed that so that we would be ready if we got a good patient,” Dr. McCabe said. “Our patient presented herself to us asking about the feasibility of this. We have probably been evaluating her and making sure we were ready for over a year and a half.”
“It is a very careful process. You have to have a surgical evaluation, make sure that the injured limb can be transplanted onto them and then a medical evaluation to make sure the patient can tolerate the surgery and the care. There is also an immunologic evaluation to make sure she is not sensitized to antigen so that she doesn’t have a very ultra responsive immune system. The social aspects are very, very important. Patients will have to have a lot of social support. There may be a lot of stressors after the surgery. So all of those things we have to carefully evaluate before and when everything lines up, then sometimes this procedure can get a reasonable result.”
In this case, Dr. McCabe said they were able to have a donor, whose family graciously donated her left arm, but the donor also donates other organs.
“Potentially eight peoples lives can be saved form one donor,” he said. “Even though the arm has gathered immediate attention now, potentially as many as eight peoples lives would have been saved that day. So that is very important.”
Dr. McCabe said identifying a possible donor was managed by a government of Ontario organization – the Trillium Gift of Life Network
“They have workers in the field at the hospitals, so when a patient is a potential organ donor they will approach the family to discuss that,” he said.
“So hand transplantation is not going to be very common obviously, and so when the Trillium Gift of Life worker is asking a family about a donation, if we have a patient who would be a suitable match for a hand donation, then they would just specifically ask that patients family if they would be willing to donate their upper limb. It is a special situation and they would deal with that on a ‘as need basis’ whereas for other major organs, there is a shortage of organs and it’s all on our drivers licenses etc.”
How did you organize this group of 18 surgeons?
“It is basically a symphony orchestra of people coming and going,” Dr. McCabe said.
“We have the anesthesia specialists who are there, all the operating room nurses and the operating room team. So all in all, we have many times more than that number. We have to have a process of six months of preparation. Everything is detailed. Who is going to come and go when. What pieces of equipment are needed and when, so they are coming and going in and out of the operating room. X-Ray machines, operating machines etc.”
Dr. McCabe added: “For the surgical procedure, we have what we call the skills laboratory here at University of Toronto. We actually practiced that procedure probably four or five times before, so we would know exactly how things would go and when things would be needed. The other thing was that we really don’t need 18 surgeons, but it just so happened that everybody on our team was in town. Since this was the first operation like this, of course everybody wanted to participate. So we had some of the best surgeons in each of the sub-special areas doing various things. Fixing the bones, doing the microsurgery, doing the nerves. So we were very lucky to have all of those surgeons all in town.”
Are you able to do this type of surgery again?
“For patients with amputation we want to first of all make sure that they try the trial of having prosthesis first,” Dr. McCabe said.
“So we don’t want to try a transplantation if a person can do very well with a prosthetic limb. In our protocol, we ask people to wait at least a year after an injury before we think about it. We do have the set up where we have everything in place for proceeding. I think the Ontario government is reviewing the whole process to make sure it fits with their vision of health care in Ontario.”
Dr. McCabe said he believes there will be a few select patients that have the situation that’s “just right” to make this a worthwhile operation.
“Certainly for older folks, the nerves wont have a chance to regenerate and it wont work,” he said.
“People that are too ill or have injuries that aren’t amenable to this type of surgery, that wouldn’t be possible of course but there are probably some patients with and injury pattern and the health situation that would make this possible.”
Does it look like the person receiving this transplant will have a useful hand?
“The nerves are the key features here,” Dr. McCabe said.
“So the nerves have to regrow into the transplanted arm. They grow about 1mm per day. So it takes a month or so to get started at a mm per day. We won’t really see any active motion for a few months, maybe three to five months. It will take about two years maybe for the nerve to get down to the hands to see how the feeling is.”
There is a registry of transplanted limbs, Dr. McCabe said.
“We have an organization because there is 110 and we try to follow every body’s results just to make sure we understand. Most patients do get some of the useful feeling and useful motion. Far from normal, but hopefully useful. Our first patient from Louisville, Matt Scott, he is the one reported in the media. He is now 16 years since the transplant in Louisville, he estimates his function is about half the other side which is much better than nothing of course. We are always comparing that to what people could expect from a prosthetic limb. There is a lot in play and a lot of moving parts to keep in mind.”
The person receiving the limb is a 49-year-old woman, who lost her arm in an accident.
Could these transplants apply to legs or feet? Or is that possible?
“So we have this field called Vascularized Composite Allograft and we just say VCA and that means composites of skin, muscle, bone, nerves etc. So a few areas of the body have been tried,” Dr. McCabe said.
“The hands have been the most successful. There is also a lot of media about a face transplantation and parts of the face. There has been about 34 full facial transplantations around the world. We are getting very interested down here in Toronto. I won’t be a participant in that but some of my colleagues could be. That’s one area that is developing.”
Dr. McCabe said lower extremities transplantation has been tried and it has been a uniform failure.
“There is large muscles, large bones,” he said.
“Patients have done very poorly, there has been some fatalities after that. There has been no success. So right at this moment in time there is probably no one that is going to try to do legs. The other thing is that with the leg the prosthesis work a lot better. If you think of some of the folks like the (man)Â who was in the Olympics with the prosthetic legs. So prosthetic legs do better than the transplant in all likelihood.”
Dr. McCabe added: “There is the face, there has been some interest in uterine transplantation in Sweden and the United Kingdom. There has been transplantation of the uterus. Another one is the abdominal wall. When someone has a lot of abdominal surgery and they lose a lot of their intestines, very easily an intestinal transplantation is required. That is a very specialized use, but it falls under this area of VCA.”
Tell us how you feel about Dresden, and how it shaped where you are now
“I grew up in Dresden,” Dr. McCabe said.
“My father was the principal of the elementary school. So he would always know about our exam results before we did. If we were sitting down at dinner and all the sudden it got very silent, we knew the boom was going to fall there.”
He said it was always a battle between school and ice hockey while he was growing up.
“I remember in high school participating in a run from Dresden to Wallaceburg for some sporting day,” he said. “It was an 11 mile run with 11 people running. It was a big relay. That was quite a fun day I remember.”
Dr. McCabe added: “I still think fondly of Dresden. I was a lifeguard at the community swimming pool and interestingly, I see a lot of my former lifeguard friends on Facebook. We are Facebook friends, we don’t get together in person but Facebook is really remarkable in that way for us to catch up with people. Those are the things I remember. Our life growing up was basically ice hockey in the winter and swimming and baseball in the summer. I remember it very fondly obviously. It was a great place to grow up.”
