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February 11, 2008
Surgical pioneer establishing limb transplant program

By Quinn Eastman

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

Linda Cendales helped organize the team that performed the first hand transplant in the United States in 1999 in Louisville, Ky.

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 10-hour operations as well as an understanding of the immune system after transplantation.
“We need to start training surgeons in CTA,” she told an Emory Transplant Center audience in January.

Cendales, an assistant professor of surgery, began work in November as director of the Emory Transplant Center’s Laboratory of Microsurgery and Composite Tissue Transplantation. She is also affiliated with the Atlanta Veterans Affairs Medical Center.

“We have an opportunity now to combine our continuing efforts to prevent graft rejection with Dr. Cendales’ unique training and skills,” said Christian Larsen, director of the Emory Transplant Center. “Together we could really propel the field.”

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

Cendales was involved in the Louisville team’s first two hand transplants in 1999 and 2001. Both men are still able to use their transplanted hands.

Surgeons have already tackled many of hand transplantation’s technical challenges, such as dealing with crushed bone or mangled connective tissue. Difficulty comes from the regimen of drugs patients must take to prevent their immune systems from attacking their new tissues. Their side effects can include diabetes, heart disease and an increased risk of cancer.

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, some critics say “quality-of-life”-driven procedures should be avoided.
“Recipients have to balance the benefits of having a transplanted hand against potential complications and side effects from the medications,” Cendales said.

Study of limb transplantation could also illuminate how the brain reorganizes after both injury and surgery and the phenomenon of “phantom limb pain,” she noted.

Originally from Colombia, Cendales attended medical school in Mexico City. She joined the Christine M. Kleinert Institute for Hand and Microsurgery in Louisville in 1997 and moved to the National Institutes of Health in 2001, completing two fellowships.