By calling in talent from other medical institutions and performing pre-transplant amputation to preserve structures and better prepare the recipient's limb, Kodi Azari, MD, is aiming to change the paradigm of hand-transplantation surgery.
In March 2011, Kodi Azari, MD, surgical director of UCLA's Hand Transplantation Program, led a team that successfully transplanted the right hand of a 26-year-old woman, making UCLA the first medical center west of the Rockies to perform a hand transplant. After that procedure, Dr. Azari theorized that if he could do the amputation as well as the transplantation of the hand, he could improve the outcome by preserving more of the tendons, nerves and vessels. But it would be rare to find such a candidate, as most already would have had the hand removed to be fitted for a prosthetic. Then he met entertainment executive Jonathan Koch, who nearly died from a mysterious septic illness. Koch survived the ordeal, but both his feet and hands were severely damaged — his left hand beyond repair but not yet amputated. (Koch wrote about his experience in the Fall 2017 issue of U Magazine.) In October 2016, Dr. Azari and a team from UCLA and other Southern California medical institutions transplanted Koch's left hand. Dr. Azari, whose UCLA office is decorated with sculptures, paintings and photos of hands, spoke with U Magazine contributor Lyndon Stambler about advances in the hand-transplant procedure.
Dr. Kodi Azari: Each one is incredibly unique. Regardless of how much preparation you do, each one throws you huge curve balls. That's why we expanded the program to not just UCLA, but also to other institutions from Southern California. We recruited surgeons who I thought would be spectacular and whom I knew personally. These surgeons from competing institutions were asked if they would be willing to join us in performing one of these operations. I am truly grateful for their collegiality, as none of them asked for any recognition or reimbursement; they all were happy to participate because they knew it was going to help someone. That's the spirit that drew me to medicine. It shows that we can put aside our competitive and financial differences for the greater good of helping a patient. When patients come to UCLA with a difficult problem such as this, we can build a team, regardless of institutions, to help that person.
Dr. Azari: The hand is unique because of the complex balance between the tendons in the palm and the back of the hand. That's what makes the hand and fingers flex and extend. It's about setting a balance between push and pull, and those forces need to be precisely balanced. If they are not balanced, it won't work well. There is no cookbook showing how to do this. It is something that is as much art as it is science. It is about surgical intuition and experience. There's a saying that I love: “The only shortcut in surgery is preparation.” If you've ever watched Olympic divers or gymnasts, they're visualizing every little step and turn in their minds. I do the same almost every night as I am preparing for a surgery. The entire sequence goes through my mind. Every single detail of each step. When you watch a good surgeon, his or her hands aren't moving fast; they're moving efficiently. They make the difficult parts look easy.
Dr. Azari: It is critical to have a team that you can trust and that can work in harmony with one another. When you are engaged in the operation, it's like you have tunnel vision, as each step requires full concentration. It is hard to think of things globally or holistically. You have to trust that the others who are helping you can see the other steps that are required and keep you from getting into trouble, or they can make the otherwise huge speed bumps you inevitably will encounter along the way into smaller ones.
Dr. Azari: What made Jonathan's case different from others I've done was that I also was the surgeon who did the amputation. Usually, patients will have had their limb amputated to be fitted for a prosthetic. But an amputation for a prosthetic fitting is different than an amputation for a transplant. For a prosthetic fitting, one removes about one-third of the forearm. That helps you to best fit the prosthetic. To prepare a limb for transplantation, it's the opposite. You want all the structures to be as long as they can be, as close to the fingers as possible. With Jonathan, I cut his tendons very distally, close to the fingers, and we took all the tendons and attached them to the bone so they wouldn't retract. He could flex each individual tendon in his mind and maintain his hand's shape and function. Also, the tendons would actually have some resistance, and they would already be the length they were supposed to be. That is part of the reason that Jonathan is doing so well.
Dr. Azari: He woke up after 18 hours of surgery, and the first thing he said was, “Doc, did you do it?” I said, “Yes.” Then he started singing the Rocky theme song. What did I do to deserve this guy? He's perfect! The patient is an absolutely critical part of this procedure. Without the patient's input, dedication to therapy and getting better and being compliant with medications they have to take, this would be a failure. I think this story summarizes it all. He doesn't drink or smoke. He's never used a drug in his life. His drug of choice is exercise. Having had the hand transplant allows him to do that now, whereas before he couldn't. Now he pushes through that pain and does extra reps — for the donor, because that person gave him this gift, and he wants to treat it with respect. That shows you what an incredible person Jonathan is.
Dr. Azari: Yes. I don't think that's a new discovery, but it may be a paradigm shift. Maybe before doing an amputation, surgeons might consult with teams that do hand transplantations to see whether or not the patient may be a candidate for transplantation. Many patients come to us after their amputation, but they are excluded as transplant candidates because their kidneys or lungs might not be functioning properly. Maybe they are not sufficiently motivated psychologically, or they are not prepared for the rigors of hand transplantation and post-surgical therapy. With Jonathan, we began the process from the opposite direction. We looked first at the things that could exclude him — his kidneys and lungs and other elements, and then we determined before his amputation that he would be a good candidate for transplant. That's when we proceeded.
Dr. Azari: Every one of them varies. If you do the amputation at one point on the arm, you would have three nerves to reattach. At another point, there would be four or five nerves to reattach. Nerves are like coaxial cables, except there's no red-to-red, green-to-green or yellow-to-yellow color codes to properly orient the connections. You have to figure out the orientation of the nerve so that you know that the parts of the nerve that are involved with motor function match up to the ones in the donor hand. You don't want to take a part that's involved with movement and connect it to a part that's involved with sensation. It just won't work. You have to figure out those connections precisely.
Dr. Azari: Patients aren't used to taking medications at first, so there's an adjustment period. We often say that your life during the first year after surgery is going to take a quality hit, but thereafter, everything falls into place. Jonathan has gotten used to the medication, and he's not having any side effects.
Immunosuppression and controlling rejection is the holy grail of all transplantations, and we always are working to make improvements. UCLA just received a donation to start the Connie Frank and Evan Thompson Restorative Transplantation Research Program. This is a basic science research program designed to help minimize the effects of anti-rejection medications. If there are ways to mitigate the immune response to the transplanted organ, operations can be done more safely, and we can increase or expand the indications for the procedures.
Dr. Azari: It is not unusual for recipients to initially refer to the hand transplant as the hand. Then something happens, usually about three-to-six months after transplantation, and they subconsciously switch to saying my hand. I think that happens when the nerve regeneration and sensation really start to come back. What I love about Jonathan is that he keeps telling me, “Doc, my transplanted hand is the best part of my body. It's the part I don't have to think about. Every other part hurts. This is the best limb that I have.” That's really encouraging.
Dr. Azari: The program is the vision of Dr. Ronald W. Busutill (RES '77, executive chair of the Department of Surgery) to help people who have suffered severe trauma or other disfigurement to the upper extremities, face or abdomen. Its growth has been slow, but that's by design. At the outset, when you have a new program, you don't want to make mistakes. You want to have home runs. We purposely have moved slowly in finding the appropriate candidates for procedures such as hand, face and abdominal-wall transplants. When the program was established six years ago, reconstructive transplantation was where we were with solid-organ transplantation in the mid-1980s, and it is clear that for certain patients — like Jonathan — the outcomes can be life-changing.