Limb Transplant Pioneer Establishing New Program at Emory

The only physician in the United States formally trained in hand surgery and transplant surgery is establishing a new program at Emory University School of Medicine to train other experts and to conduct research on what is still an extraordinary procedure.

Linda Cendales, MD, assistant professor of surgery at Emory University School of Medicine, helped organize the team that performed the first hand transplant in the United States in 1999 in Louisville, Kentucky.

At Emory, she wants to train the next experts in composite tissue allotransplantation (CTA)--the re-transplantation of limbs and other intact body parts.

That means having surgeons with the skills to repair bone, vessels, muscle, tendon, skin and nerves in marathon ten-hour operations as well as an understanding of the immune system after transplantation.

Dr. Cendales began work at Emory in November as director of the Laboratory of Microsurgery and Composite Tissue Transplantation. She is affiliated with the Emory Transplant Center and the Atlanta Veterans Affairs Medical Center.

"The future of this field relies on surgeons who understand the immune biology as well as the technical and rehabilitation aspects of CTA," says Dr. Cendales. "We need to start training surgeons in CTA."

The first hand transplant in the world was performed in 1964 in Ecuador, before the development of modern immunosuppressive medications. The recipient, a sailor, had to have the transplanted hand amputated two weeks after surgery because of tissue rejection.

The next hand transplant was performed in France in 1998 and endured more than two years before the recipient stopped taking immunosuppressive medication and asked to have the hand removed.

The Louisville team's hand transplant is currently the longest surviving hand transplant in the world. Dr. Cendales was also involved in the team's second hand transplant in 2001. A third patient had the same surgery in Louisville in 2006, and all three are still able to use their transplanted hands.

The primary cause of amputations in the United States is trauma. The first two U.S. hand transplant recipients lost their hands in a fireworks explosion and a work-related machine press accident.

Surgeons have already tackled many of hand transplantation's technical challenges, Dr. Cendales says. Issues involved in reattaching a severed limb, such as dealing with crushed bone or mangled connective tissue, can make "replantation" more technically demanding than an organ transplant, she says.

But the difficulty unique to transplantation comes from the regimen of drugs patients must take to prevent their immune systems from attacking their new tissues. Side effects from immunosuppressive medications can include diabetes, heart disease and an increased risk of cancer.

"We have an opportunity now to combine our continuing efforts to prevent graft rejection with Dr. Cendales' unique training and skills," says Christian Larsen, MD, DPhil, professor of surgery, director of the Emory Transplant Center and vice-chair of research at Emory. "Together we could really propel the field."

Composite tissue transplantation continues to advance by leaps and bounds, with recent reports from around the world of transplants involving donors' faces, knees, tracheae and even a uterus, performed in 2000 in Saudi Arabia.

Because of the risks and side effects and because these procedures can be seen as primarily "quality-of-life"-driven, some critics of these procedures say transplantation should be avoided if not life-saving.

"There is always a balance between the risks and the benefits of a quality-of-life procedure," says Dr. Cendales. "Recipients have to balance the benefits of having a transplanted hand against potential complications and side effects from the medications."

Limb transplantation also opens up considerations of body image, because the transplants are visible to the recipient and observers, she notes. Study of limb transplantation could provide insight into how the brain reorganizes after both injury and surgery and the phenomenon of "phantom limb pain."

Originally from Colombia, Dr. Cendales attended medical school in Mexico City. She credits her mentors, her colleagues and her collaborators for the advancements that her team has achieved in this new field. She joined the Christine M. Kleinert Institute for Hand and Microsurgery in Louisville, KY in 1997 and moved to the National Institutes of Health (NIH) in Bethesda, MD, in 2001, completing two fellowships.

While at Emory and the Atlanta VA Medical Center, Dr. Cendales plans to build the study of composite tissue allotransplantation systematically. She will continue the work she began at the NIH on forearm tissue transplantation in monkeys and a classification system for the severity of skin rejection after transplantation.

"We intend to establish a complete program leading from the laboratory bench to the bedside," she says.
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