Hand Transplantation is major surgery and has many risks associated with it. As a potential patient you have to decide whether these risks are worth taking.
Along with discussing how hand transplant may benefit you, we will also talk at length in the clinic what risks you may be exposing yourself to and how these may affect you.
Risks associated with this surgical procedure include those that are present in any surgery. These risks include, but are not limited to the following:
- Infection as a result of the operation or being on immunosuppression
- Bleeding during or after the operation
- Risks of anaesthesia
Specific consequences of this surgery in particular will include:
- Scarring from the operation or scars that may occur while your hand is healing.
- Possible nerve injury from the operation itself or from local anaesthesia injection.
- Scarring or injury to tendons or joints causing stiffness in the new hand.
- Failure of the blood vessels to join satisfactorily resulting in loss of the new hand.
The anaesthetist will discuss anaesthesia with you. Anaesthesia is generally very safe.
Risks of Medication
As the tissue type of the donor hand is never a complete match for your own (only an identical twin shares perfect tissue match), your body will try to reject the new hand unless medications are taken to prevent rejection. These medications are known as immunosuppressants.
The medications used are very similar to those used in the transplant of solid organs (such as kidney, heart, or liver). A hand transplant is different because it involves the transplantation of skin, muscle, nerves, blood vessels, bone, and tendon, as well as fat and tissue present under the skin.
The possible complications associated with hand transplant may be similar to complications already studied and known to occur in solid organ transplants. With time and more experience, we may find that this is not exactly true.
It is likely that you will need to take several medications every day. At the beginning of surgery, you will be given a strong immunosuppressant, the effects of which will last for several months. After surgery you will begin taking tablet medications to dampen your immune system. You will remain on immunosuppressants for as long as you have the transplanted limb.
In addition to reducing your body’s response to the transplanted hand, the tablets will also reduce your body’s response to common infections. Because of this, you will be given extra tablets to reduce the chance of infection.
You may require extra tablets should you develop infection or suffer from rejection.
In order to make sure that you receive the correct dose of medication, frequent blood tests will be needed. Once the correct dose is established, blood tests will be performed less frequently.
Side effects are more common when your dose is higher and they usually get better as your dose is lowered over time. If you notice any side effects, you are to report them to us, but you must not stop taking the medicine.
Long Term Risks
Long-term problems related to transplantation are specific to the organ transplanted. Currently long-term data does not exist for those having undergone hand transplantation as only small numbers have been performed and few individuals have had their new limb long enough to display possible problems that may happen in the future.
Data from solid organ transplant recipients is therefore used as a guide. It is important to realise however, that the frequency of long term problems can vary by as much as 5 times depending on which organ has been transplanted. Because people considered for hand transplant are fit and healthy, the chances of you developing long-term problems may be less than those who have had a kidney transplant for example, because their non-functioning kidney already affects their health.
Immunosuppressive or anti rejection medication can produce various changes in your body. You may develop high blood pressure or diabetes (high blood sugar) from the medications that are given to you to prevent rejection of your transplanted hand. Additionally, there is a chance that the amount of lipids or unneeded fats may be increased in your blood stream.
These bodily changes usually can be controlled with extra medications.
Toxicity to the nervous system, kidneys, or liver may result from the administration of these medications. You might experience mood swings which may be difficult to control.
There is a possibility that you may develop an infection at the site or near the transplanted hand. The immunosuppressive medicines may place you at an increased risk of bodily infection caused by bacteria, fungus, or virus (particularly during ﬂu season), amongst others. This increased risk may require lifestyle changes. Transplant recipients are recommended to receive a pneumovax vaccine and a yearly influenza vaccine. We may recommend regular use of additional medication to reduce the chances of developing certain infections.
Your risk of developing cancer whilst taking immunosuppression will change. The risk of some cancers is likely to increase (such as skin, mouth, oesophagus, blood and Kaposi’s sarcoma).
In patients who have had a kidney transplant for 20 years, 80% will develop a skin cancer. Most of these cancers are likely to be treatable. The risk of cancer is also increased in people whose kidneys do not work, yet have not received a transplant. So, this increased risk may be due to the fact that their kidneys do not work as well as the effect of immunosuppression.
We do not know the exact risk of cancer in those who have had a hand transplant. It is likely to be no greater than the risk following kidney transplant and may possibly be lower.
Amongst all hand transplant recipients, so far, only one patient has developed a relatively minor cancer of the skin, which was easily treated with surgery. It may be, as time goes by, that we see more hand transplant patients develop certain types of cancer.
Immunosuppression, when used long term may also increase the chances of organ failure, particularly affecting the kidneys. From data available from solid organ transplants, somewhere between 5 and 25% of those immunosuppressed will develop kidney failure after 10 years. This likelihood depends very much on which organ has been transplanted. It is expected that organ failure amongst hand transplant recipients will be less frequent than is seen in those having undergone solid organ transplantation.
The acceptance of the hand or limb by your body is not guaranteed. Even if the transplant procedure is an operative success, your body may still reject the hand that is transplanted. If this occurs, the limb may not work as well or the transplanted limb may need to be surgically removed and you may then be left without a hand or limb.
The post amputation arm might not function as well as your arm functions today. If the hand is completely rejected, your chances of having a future, successful hand transplant may be reduced.
Complete Limb Loss
Both the long and short-term survival of your transplant cannot be guaranteed. In rare situations, your transplanted limb could be lost completely. This may result from a lack of blood flow into the transplanted limb or due to immune rejection.
If the blood flow to the limb is uncertain, then an additional operation may be required to improve the flow. Complete loss of blood flow may lead to loss of the transplanted limb and its surgical removal. The likelihood of this, is however, expected to be low (less than 2%).
Immune rejection causing complete loss of the transplant has so far been rare. Most patients (about 8 in 10) will experience an episode of rejection but usually these episodes are readily treated with increases in medication dosages. Amongst the 72 hands so far transplanted in the western world, only one has suffered a rejection severe enough to cause complete loss of the limb whilst taking their prescribed medicines. It is certain however, that the limb will be rejected completely should you choose not to take your prescribed medication as directed.
One limb worldwide has been lost as a result of severe bacterial infection.
Should you experience a complete loss of the transplanted hand or limb then further surgery will be required. This surgery would involve removal of the transplanted part. Additionally, tissue would need to be borrowed from one part of your body to cover over the area where your transplanted limb previously was. This operation, although not as complex as the transplant itself, also has risks such as bleeding, infection, wound healing problems and loss of the transferred tissue.
There are several psychological risks associated with this procedure. These risks include fear that your body will reject the transplant or react adversely to the procedure or medication. Such fear may lead to anxiety and preoccupation with the transplant or your health. There is a risk of disappointment in the appearance or function of the hand transplant because it may not look as good, or perform as well, as you hoped. If your body rejects the transplant, you may be very upset. Such fears, disappointment, or upset, could lead to agitation, difficulty concentrating and working, disruption in your relations with other people, or emotional depression.
Symptoms of depression include sad mood, loss of energy, disruption in eating and sleeping, irritability with other people, and withdrawal from other people. In its most severe forms, depression can lead to thoughts of suicide, or attempts to take your own life. If you feel depressed or suicidal, you are required to immediately notify the Hand Transplant Team.
Other psychological risks include guilt feelings about the death of the donor, difﬁculty conforming to the treatment regimen and its side-effects, and a sense of personal responsibility for the success of the procedure.
In addition, you may feel uncomfortable or disoriented when you look at the new hand, which (unlike with solid organ transplantation) is always on view. You may feel a loss of your identity. It may be difficult to adjust to the reality of a hand transplanted from someone else, and there may be issues with intimacy.
There is a chance that your family may not respond positively to your new hand, or show signs of resentment because of all of the care that you need. You will also need to be prepared for and able to cope with intrusive media attention, and interest and reactions from others (both those known to you and strangers), which may not always be positive.
Psychological tests and psychiatric interviews will be given at intervals both before and after surgery to monitor your thoughts and feelings about these risks.
If rejection necessitates re-amputation with loss of some further tissue of the original stump, there may be additional psychological reactions to this additional loss, similar to feelings at the time of the original loss of your hand.