Hand in Hand
Dr. W.P. Andrew Lee and his team at UPMC are forging a new frontier in medicine by improving the lives of amputees with hand transplants.
When U.S. Marine Cpl. Joshua Maloney’s right hand was blown off during a training exercise in early 2007, the young solider from Pittsburgh felt just one emotion: annoyance.
At the Marine base in Quantico, Va., Maloney, now 26, was a combat engineer, skilled in the art of “how to blow things up.”
“I had to be good at my job, and I was,” he says. But that day, a stick of dynamite with a faulty detonator would rob him of his right hand and prematurely end his military career. “I wanted to make sergeant so bad, but it wasn’t meant to be.”
Maloney returned home to Pittsburgh and began to adjust to the twin challenges of life as a civilian and as an amputee. He was outfitted with a prosthetic arm, an ungainly thing made of cables and hooks that was painful to remove and offered all the functionality of a paperweight. Later, he was outfitted with a more elaborate prosthesis called a myoelectric arm, which was dependent upon a battery that, just like the one in your laptop, never ran as long as advertised. Eventually, “it wound up in my truck somewhere,” Maloney says of the device he jokingly calls a “$25,000 paperweight.”
The engineer faced an engineering problem. Enter Dr. W. P. Andrew Lee with a solution.
Lee, the chief of plastic surgery at the University of Pittsburgh Medical Center (UPMC) and a professor at University of Pittsburgh School of Medicine, had been working on the problem of composite tissue allo-transplantation, or human-to-human limb transplantation since 1986. Fresh from college at Harvard University and medical school at Johns Hopkins University, he began working in the research labs at Johns Hopkins and Massachusetts General Hospital in Boston. Knowing the limitations of prosthetic devices, Lee imagined a better alternative.
The scientific framework for accomplishing hand transplant surgeries was already there—or, rather, here. Pittsburgh’s own Dr. Thomas E. Starzl had already proved that an internal organ could be safely transplanted from a same-species donor to a host, and his innovative work had turned Pittsburgh into one of the largest transplant centers in the world and at one time, the largest. Still, challenges remained. How, Lee wondered, could he and his colleagues give amputees real, new limbs without subjecting them to the side effects—infections, diabetes—that have plagued transplant recipients for years, the result of potent anti-rejection drugs that can ravage internal organs? The lack of an answer to that question had “held the field up” for years, Lee explains during an interview at his office in Pitt’s Scaife Hall. “We didn’t have enough advances in transplant immunology.”
As a result, only some 30 hand transplants had ever been done in the world, and the first such transplant in the United States had only been performed 10 years ago, in Louisville, Ky.
The big advancement finally came in 2007, says Lee, when, with the help of “brilliant scientists” from Pittsburgh’s Thomas E. Starzl Institute, his team developed the Pittsburgh Protocol, a three-pronged approach to hand transplantation that would offer patients lower risk of rejection, less potentially harmful drug therapy and, best of all, real feeling and function.
Lee and his fellow researchers had discovered after years of working in the lab with pigs as subjects that if they took bone marrow from a donor’s bones and placed it into a host’s body prior to the transplant procedure, the host’s immune system already would be trained to accept the new limb—a process Lee calls “immune modulation.” Antibody treatments and the administration of one, proven anti-rejection drug as opposed to the usual and sometimes-toxic three-drug cocktail used for organ transplantation complete the process.
After receiving the approval of Pitt’s institutional review board in 2008, Lee assembled a team of micro, orthopedic, plastic and reconstructive surgeons, anesthesiologists, hematologists, therapists and other specialists to begin operating on people. He found much of the talent he needed right here in Pittsburgh, but knowing that some of the best minds in transplant science were working abroad, he brought in two doctors from Europe—Stefan Schneeberger and Gerald Brandacher. As of press time, three patients have been given a total of five new hands from Lee’s team.
To accommodate 21 physicians and 19 nurses and aides working at one time, Lee’s group had to find the largest area operating room they could: UPMC Montefiore’s O.R. No. 40. Joshua Maloney was the first of Lee’s patients to receive a new hand on March 14, 2009, in a surgery that lasted 11 hours.
Two months later, Lee’s next patient, Jeff Kepner, of Augusta, Ga., would receive the first-ever bilateral (two hands) transplant done in the United States. His third and most recent patient, Christopher J. Pollock, of Portage, Pa., received a bilateral transplant as well, and as of press time was still in UPMC Montefiore recovering from surgery and beginning rigorous occupational therapy. When we met Pollock in his hospital room last February, he had a fork in his new, left hand and had just finished feeding himself dinner for the first time since he lost both of his hands 14 months earlier in a farming accident.
Surely hospital food never tasted so good. But to get to this point required major surgery and much preparation before the first scalpel was raised. Here’s how the process works:
First, an amputee between the ages of roughly 18 and 60 approaches Lee and his team. That potential patient is screened by Dr. Andrea DiMartini, a UPMC psychiatrist who specializes in the field of transplant psychiatry.
A good candidate, she says, is just not physically strong but mentally disciplined. The physical therapy involved in a successful hand transplant is rigorous—hours of work every day in the beginning—and a patient also has to be diligent about taking anti-rejection medicine daily. Finally, the patient has to be ready for the emotional transition involved, the change in body image after the addition of a new hand or hands and the resulting change in personal independence.
“The way Dr. Lee thought comprehensively about the needs of his patients when building this team is genius, to borrow his patients’ term,” DiMartini stresses. “It takes a lot of forethought to look at the total picture of what a patient needs.”
That’s evident when you consider the next step in Lee’s hand-transplant process. After a donor hand is located through the regional Center for Organ Recovery and Education, Lee makes certain that the hand is of the same gender and color of his patient and a good match for size. After he obtains permission from the donor’s family to transplant that hand to a patient in need, the hand is procured by his team members and flown into Pittsburgh literally in a picnic cooler, and the team mobilizes.
For a recent surgery, Dr. Kodi Azari, a former UPMC hand surgeon who now works at the University of California at Los Angeles, flew here on a red eye flight to assist.
Inside the operating room, every person on the 40-member team “has our assigned roles,” Lee explains. First, the bones of the donor hand are connected to the patient’s forearm. Next come the muscles and all 23 tendons—“the tedious part,” says Lee. Then the blood vessels are connected under a microscope—the riskiest part of the surgery. “If circulation is not reestablished, the transplant will have failed,” says Lee. But when it does work, the next step is the “most dramatic moment” in the surgery, Lee continues, when “a pale hand becomes pink.” At that moment, “everyone literally holds his breath.” After that, the nerves are connected and then finally, some 11 hours later, the skin is pieced together to minimize scar tissue.
Currently, as an emerging science, hand transplantation is not yet covered by insurance, although Lee predicts that “with time, as its efficacy is demonstrated, that will change.” Picking up the tab for each of Lee’s surgeries has been UPMC itself, with the help of a grant from the U.S. Department of Defense. Although Lee concedes that hand transplants are not saving lives, he stresses how much they’re “improving patients’ quality of life.” That improvement is easy to see. During a visit to Maloney’s new apartment in the South Hills, he hosted a poker game with four friends, a tradition he recently revived. His handshake is firm, befitting a Marine. His new hand looks so natural you could forget it once belonged to a young West Virginia man who died from brain injury.
With the use of that hand, Maloney is winning at a game of Texas Hold ’Em, a pile of green, blue and red chips stacked before him. Soon he’ll raise the blinds (bets), and the sky’s the limit. Life appears that way for him now.
After the surgery, he and girlfriend, Erin, would sit in a movie theater. “I could feel her fingers going across my hand. On an emotional level, it’s one of the coolest things I’ve ever felt.” Other new experiences await. He plans to join the International Brotherhood of Electrical Workers, a once unimaginable goal.
For Pollock, 41, receiving not one—but two—hands from Lee’s team of surgeons has changed his life, but it’s getting to do more mundane tasks that is the thrill.
Maloney and Pollock, also a former soldier, are men of few words, but when asked about Lee, they gush praise and gratitude, calling him and his team of doctors geniuses.
All of this begs the question: Who is Dr. W. P. Andrew Lee? What’s more: What made him the right person to have led this discovery, to charter what others are calling a new frontier in medicine? The answers might surprise you.
Humble and self-effacing, the 52-year-old who came to UPMC from Harvard Medical School in 2002 goes simply by “Andy.” His office is decorated with photographs of his former students, and the walls brim with plaques and certificates honoring their scholastic achievements, not his. When asked about the Pittsburgh Protocol and what his work will mean to science, he either downplays the magnitude of his success or deflects attention away from himself and toward the rest of his medical team. When asked about the impact of his surgeries on his patients’ lives, he won’t presume to speak for them.
That humility “isn’t phony,” says Columbia University orthopedic surgeon Dr. Steven Glickel, a colleague of Lee’s through the American Society of Surgery of the Hand, of which Glickel is a past president and Lee now the vice president. “When I compliment him in a board meeting, he asks if we can move along. You don’t get the feeling he needs the limelight. He doesn’t need to be patted on the back. He just does the work.”
What’s so remarkable about that work, Glickel continues, is its diversity. “He’s a superb surgeon, very good administrator and has done excellent research,” he says of Lee. “It is more and more difficult to be this model of clinician and scientist. Not that many people can be a good surgeon and spend enough time in the lab to be productive.” How does Lee do it? “He’s incredibly organized, and he has vision. I have a lot of admiration for [him],” Glickel responds.
When asked how he can wear so many hats—treating patients, running UPMC’s plastic surgery department and conducting laboratory research—Lee explains that the secret to his success is balancing his priorities. As he breaks it down, that mix works out to: “80 percent clinical work, 80 percent research and 40 percent administrative.” Yes, that adds up to 200 percent.
Lee laughs, and soon he’s waxing rhapsodic about his two other passions: family and music. The pace of his words changes. When he’s talking about transplant science, his speech is andante, slow and full of meditative pauses. His tempo becomes allegro, quick and bouncy, when the topic turns to his lifelong love of ‘70s disco music, his wife, Teresa, and the couple’s three children: Jacqueline, 21, a sophomore at Harvard; Joshua, 18, a graduate of Shady Side Academy and incoming freshman at Harvard; and Jonathan, 24, a special-needs person who works in Pittsburgh.
“My interaction with my three children is the most rewarding part of my personal life,” he says. “I consider myself truly friends with my children.” Lee’s been known to spend up to two hours a night on the phone with his daughter, Jacqueline. Lately, he’s converted son Jonathan into a fan of disco and reveals that there’s a mirrored disco ball and mixing equipment set up in the basement of his Fox Chapel home, a throwback to his college days when he and his two roommates made extra money on the weekends as deejays playing the sounds of the Village People and the Bee Gees.
That job was harder than it looks, Lee explains. “I spent a lot of time learning how to transition from one piece of music to another without ever missing a beat,” he says. If you think about it, says colleague Dr. Andrea DiMartini, Lee puts that skill to use as head of the hand transplant team. He’s still spinning music, still conducting the show in the O.R.
Lee can command more than 30 people in one operating room because he “knows the expertise of his team and how to delegate. He’s in charge, but he’s not heavy-handed,” DiMartini explains. “He leads with calm, allowing everyone on his team to play an active role.”
Lee concedes that surgeons can have egos and that working with so many smart people could have been difficult. He says he is proud to have “no malignant personalities” on this team and that he strongly believes that different specialists should work together.
Lee learned all about making friends and adapting to new environments when he moved to this country as a 15-year-old boy from Taiwan. He met his wife at Princeton High School in New Jersey, one of several schools he attended as he bounced from one state to another, living with an older brother and sister who had immigrated to America earlier. As a teenager, he carried an English dictionary with him wherever he went. When he moved his family here from Boston in 2002, Lee thought it would build character for his children to move to a new place. All had expressed hesitation about coming here but later became Pittsburgh fans.
What’s next for Andy Lee? He doesn’t hesitate with the answer: He and his team want to build on their success with hand transplants and begin performing face transplants. For people with serious disfigurement, such procedures could “greatly enhance their quality of life.” It’s clear that for Dr. Lee, just as with his patients, the sky’s the limit.
Geoffrey W. Melada, a trial lawyer and former Philadelphia news reporter, is a regular contributor to Pittsburgh Magazine.
|Scenes from the operating room|
(Operating room photos courtesy UPMC)