Transplantation

This summarizes the development and structure of the Hand and Upper Extremity component of the Vascularized Composite Allograft (VCA) program at the University of Toronto.

University of Toronto Hand and Upper Extremity Program

The Hand and Upper Extremity Program at the University of Toronto is ready to proceed with clinical cases of upper extremity transplantation. The University of Toronto has a high volume multi-organ transplantation program, a strong hand and microsurgery infrastructure, and experience to proceed with upper extremity transplantation. For the past several years, we have developed our program and observed the advancements in this field. We have worked extensively with Trillium Gift of Life Network to develop an upper extremity transplantation program for the Province of Ontario. We have a large faculty of hand and microsurgeons who are committed to this program. Our faculty includes Dr. McCabe who was an active member of the Louisville team that developed the first program in the United States introducing the procedure in 1999. Dr. McCabe and Dr. Zuker are members of the American Society for Reconstructive Transplantation and the International Hand and Composite Tissue Allotransplantation Society. We have the surgical, medical, transplantation immunology, ethical, psychological, and therapy resources in place and organized to proceed. We have an application to the Ministry of Health and the Ontario Drug Benefit program for funding for this program for Ontario residents.

History

The first successful transplantation of the hand was performed in Louisville, Kentucky in 1999. Two unsuccessful attempts were made prior to this, in 1963 and in 1998. Since that time more than 80 upper extremity transplants have been performed in Australia, Austria, China, Germany, France, Italy, Poland, Spain, England, Turkey, Mexico and in several centers in the United States. To date there have been no upper extremity transplantations in Canada. The success rate has been 95% for survival of the transplanted limbs. An international registry has been tracking outcomes which has shown widespread patient acceptance and satisfactory sensory and motor outcomes.

Indications

Transplantation of the upper limb has been recommended for patients who are in good health with amputation of one or both upper limbs suitable for transplantation and who have not been successful adapting to prosthetics. Useful functional recovery can be expected, however the patient must take life long immunosuppressant medication similar to that used for solid organ transplantation.

Logistics

Indications and contra-indications for the recipient and the donor have been developed in conjunction with Trillium Gift of Life Network. Briefly the following logistics are in place. Potential patients are evaluated in a structured manner by the surgeons, transplant immunologist, internist, and psychiatrist. If there is unanimous approval, the patient is presented to the VCA committee to determine if they are a possible candidate for transplantation. If yes, the patient is referred to the hand therapist to develop a post-operative therapy plan. The process of informed consent begins. If the patient requests the procedure they will be put on the transplant list and Trillium Gift of Life Network is informed. A donor is identified through the current process in place for the Province of Ontario.

The transplantation procedure will be performed at Toronto Western Hospital, a component of UHN in Toronto. The estimated in-patient stay will be two weeks. Physicians from the multi-organ transplant team will manage the immunosuppression. After discharge, the patient will require ongoing therapy and surveillance for rejection. Patients are followed by the Hand Transplant team at the Toronto Western Hospital. Depending on the level of amputation, ongoing assessment and therapy may continue for more than a year. The patient will then be followed at the UHN multi organ transplant clinic for medication management and monitoring for rejection. We anticipate a combined upper extremity transplantation follow up clinic at UHN.

Immunosuppression

Immunosuppression will be managed by the physicians in the Multi -Organ Transplant Program at UHN. The immunosuppression regimen is similar to that required for renal transplantation.

Conclusion

We are prepared to offer upper extremity transplantation for carefully selected patients with upper extremity amputations who have been unable to adapt to prosthetics. Our primary objective is recovery of useful function in the transplanted limb to improve the patients’ quality of life and reduce suffering while reducing risk to a reasonable level.


Steven McCabe MD MSc FRCS(C) Dec.4, 2013

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