A revolutionary transplant

An arm transplant is extremely rare but a double-arm transplant was unheard of until just last month.

Five teams totalling 20 surgeons fill the operating theatre at the Munich hospital Klinikum Rechts der Isar, where the first complete double-arm transplant took place.

It has become routine for surgeons to transplant kidneys, livers, even hearts, but transplanting arms is rare in the extreme. So there was excitement in Germany late last month when a 54-year-old farmer who had lost his arms in an accident had a new pair attached in a 15-hour operation. Five teams of doctors were involved in the painstaking surgery at the Technical University of Munich's Klinikum rechts der Isar.

Separate teams prepared each arm from the donor, while different groups attached each limb. A fifth team transplanted a blood vessel to the patient's left arm, where his circulation was poor. One of the 20 doctors involved was Prof Hans-Guenther Machens, the clinic's head of plastic and hands surgery, who jointly led the team that attached the left arm. The main difficultly, he said, was co-ordinating the work of the five teams.

There was only "a very short time" between when the arms could be removed from the donor and attached to the recipient to prevent the limbs from deteriorating. "We were able to solve this problem. We had relatively short times - one-and-a-half hours for the right side and two hours for the left," he said. Rejection was also a major issue. A large number of immunocompetent cells - cells that can produce an immune response following exposure to foreign material - were contained within the skin and bone marrow of the arms. That means the arms could reject the body as well as the other way around.

There were no major problems the first week after the operation - the most critical time for rejection - and doctors were able to reduce the levels of drugs the patient took to prevent rejection. While the operation was technically a success, the recipient is a long way from having fully functional arms. Nerves are expected to grow down the arm at a rate of just 1mm per day. "It might take two years before the patient finds sensation in his fingers, if ever," said Prof Machens.

"He is prepared to wait a long time before he can move part of his arm. The first movement will probably be part of the muscles of the upper arm." The arms were attached well above the elbow, which makes the surgery slightly less problematic as the nerves are less dispersed there than they are further down the arm and there is just one bone. The operation came about five years after the first arm transplant - one of many firsts in the transplant world in recent years. A decade ago doctors performed the first hand transplant, while a woman in France received most of a new face three years ago after being mauled by a dog.

Prof Machens believes a full leg transplant is also possible, although how successful it would be is not clear. "It's nice to have a technical success, to show you can do it, but that's not the aim. The aim is to help," he said. A head transplant, however, is likely only ever to happen in people's imagination. "Cell death occurs very soon - after seven to 10 seconds brain cells start to lose function if there's no blood circulation. Any operation would certainly take longer than 10 seconds," Prof Machens said.

"Head transplants are so far off reality and so much into science fiction. Not only at the moment [are they not possible], but not ever." Prof Machens is similarly dismissive of suggestions that recipients take on the characteristics of donors, saying "there's not much science" to such claims. The UAE could also be seeing more transplants. The country's first dedicated transplant unit was opened in Sheikh Khalifa Medical City in February. And yesterday The National reported calls for a donor registration scheme to allow people to carry a donor card indicating that they were willing for their organs to be used.

While technical issues - and a shortage of donor organs - can limit transplants, there are also psychological factors involved in being given a part of someone else's body. In 2001, the first hand transplant proved unsuccessful not for technical reasons, but because the New Zealand recipient described his new hand as "hideous and withered" and asked for it to be removed. Similarly, a penis transplanted onto a Chinese man in 2005 was taken off when the recipient and his wife decided they did not like the organ.

Fortunately, such psychological rejection seems unlikely in the case of the farmer who received the transplanted arms. "We knew the patient had a very sound process coming into this and a very supportive family background. We were very optimistic the patient would accept," said Prof Machens. "It was a very emotional moment when the wife said, 'They look like yours.' She instinctively took his hands."

According to Dr Raymond Hamden, a clinical and forensic psychologist at the Human Relations Institute in Dubai, there is a big psychological difference between accepting an organ in a life-or-death situation and having other types of transplants. Also, the potential psychological problems of accepting a kidney from a dead person are likely to be less than those from having one from a living person, when guilt could be an issue. On the other hand, when an organ is transplanted from a living donor, a bond is formed for life.

"If you need a pancreas and someone dies, then you are grateful to the [donor's] family, but it can stop there," Dr Hamden said. "If I choose to give my kidney, that means you and I will have a long-lasting relationship psychologically." The psychological and the physical are tied up with each other, Dr Hamden said, because if a patient is feeling anxious and guilty about receiving an organ, their immune system could be weakened and recovery hampered.

"Psychological input is essential, both pre-surgery and after surgery, not just for the individual but for family members as well," he said. For example, if someone who has been disabled for years receives a transplant and is no longer dependent, then their caregiver faces a huge upheaval in their life. "If the family member no longer has that role as a carer, they may not have another role. That individual has to develop a new purpose in life, a new mission statement for living," he said.

"They may have had no fun or recreation, no social network, they were fixated on [looking after] the member of their family rather than developing their own interests." @Email:[e-mail]