Iraq vet undergoes successful double-arm transplant

Daily News Article — Posted on February 5, 2013

(by Saundra Young, CNN) — A U.S. Army infantryman who lost all four limbs in a 2009 roadside explosion in Iraq has undergone radical transplant surgery that [which doctors say will eventually allow him to regain almost the full use of his hands].

Last month, 26-year-old infantryman Brendan Marrocco had successful surgery — a rare double arm transplant — at Johns Hopkins Hospital in Baltimore.

“It feels amazing,” Marrocco told reporters Wednesday [Jan. 30]. “It is something that I was waiting for for a long time, and now that it happened, I don’t know what to say, because it is such a big thing for my life.”

The last thing Marrocco remembers before being hit by an explosion in 2009 was that he was driving an armored vehicle.

When he woke up at Walter Reed Medical Center in Washington, Marrocco was alive, but missing all four of his limbs. “When it happened, I didn’t remember too much,” Marrocco said. “I was still alive, so that’s really all that mattered to me at the time.”

Marrocco is one of only seven people in the country to successfully undergo the surgery, and the first quadruple-amputee soldier, according to Johns Hopkins.

The surgery, which took 13 hours and 16 orthopaedic and microvascular surgeons from five hospitals — was also the first bilateral arm transplant performed at Johns Hopkins. All of the surgeons volunteered their services; the surgery and rehabilitation costs were paid by the Department of Defense’s Armed Forces Institute of Regenerative Medicine and Hopkins.

The team of surgeons rehearsed the procedure on cadaver arms four times over the past 18 months, said lead surgeon Dr. W.P. Andrew Lee, director of the Department of Plastic and Reconstructive Surgery at Johns Hopkins.

[While Mr. Marrocco is not the first person to undergo a double arm transplant – he is the seventh – surgeons at Johns Hopkins hospital in Baltimore, where the operation took place, say his was “the most complicated one” so far.] “On his right side we did an above-elbow transplant by connecting the bone, muscles, blood vessels, nerves and skin between the donor and recipient,” Lee said. On Marrocco’s left side, “in order to preserve the elbow joint, we transplanted the entire donor forearm muscles over his remaining tissues, then rerouted the nerves to the new muscle.”

While Marrocco is doing well, his recovery will be long, the doctor said. “The nerves regenerate at the maximum speed of 1 inch per month. The therapy will continue for a few years, first at Johns Hopkins, then at Walter Reed. The progress will be slow, but the outcome rewarding.”

Marrocco is taking anti-rejection medication, which can lead to side effects like infection and organ damage. But he’s received an infusion of the donor’s bone marrow cells to further prevent rejection of his new arms. That infusion allows him to take only one anti-rejection drug instead of the usual three. [Dr. Lee pioneered the bone-marrow procedure, which has had favorable results in five other transplant patients.] He hopes the new anti-rejection regimen performed on Marrocco will become the new standard of care for limb and face transplants. Marrocco will participate in a anti-rejection regimen study that’s being funded by the Armed Forces Institute of Regenerative Medicine.

Doctors call his recovery so far remarkable.

“Now, I can move my left elbow,” Marrocco said. “This was my elbow, the one I had before. I can rotate a little bit. This (right) arm is pretty much not much movement at all — not yet at least. Hopefully, we are hopeful for the future to get some pretty good function out of it, out of both of them.”

Doctors said rehabilitation therapy is an integral part of the healing process. “The next two to three years, Brendan’s full-time job is doing hand therapy, six hours a day, every single day, once nerves grow in,” said Dr. Jaimie Shores, clinical director of hand transplantation at Johns Hopkins. “He’s going to be working very hard.”

Marrocco said he’s up to the task. The thing he’s looking forward to most? “Driving. Absolutely, driving. I used to love to drive and it was a lot of fun for me. So, I am really looking forward to getting back to that. And just becoming an athlete again. One of my goals is to hand-cycle a marathon.”

For his family, the surgery means moving forward with their lives.

“Our lives have been on hold for the last almost four years waiting for this surgery, getting him through Walter Reed and getting to the point where he was pretty independent,” said mother Michelle Marrocco. “And now he will be independent, and when he comes home, he’ll be the Brendan we’ve all been looking for.”

Marrocco’s message to other’s facing similar challenges? Don’t give up hope. “Life always gets better. You’re still alive … just be stubborn. Work your butt off.”

Lee agreed. “Advances in medicine are being made every day in different areas, whether it’s tissue transplantation or tissue regeneration,” he said.

“Research is being performed throughout the world with different ways of regenerating tissues and replacing arms, so they should be optimistic, as we are that there will be new treatments and modalities currently not available.”

Marrocco said he’s is very optimistic about his future.

“I just want to get the most out of these arms and just as goals come up, knock them down, and take it as absolutely far as I can. So really, I just want to get to the point that I can be completely on my own and just get back to enjoying life.”

Reprinted here for educational purposes only. May not be reproduced on other websites without permission from CNN. Bracketed text is from a Wall Street Journal article on the scanners.

Questions

1. How many people in the U.S. have successfully undergone double arm transplant surgery?

2. How many surgeons operated on Brendan Marrocco?
b) How did they prepare for the surgery?
c) Why was Brendan's particular surgery so complicated?

3. What new method did lead surgeon Dr. Lee use on Brendan to help his body accept the new arms?

4. What will Brendan's recovery involve? Be specific.

5. a) What encouragement does Brendan give to others facing similar challenges?
b) What encouragement does Dr. Lee give?

6. Russell Giambrone, a Staten Island neighbor of Marrocco’s grandparents, said that the soldier never lost his rambunctious spirit, even after losing his limbs. “For a while, he had these big mechanical arms. He wasn’t shy about it. He’d show them to you with a big smile on his face,” Giambrone said. “Whenever I feel like crying about my life, I just look at him and his life and what he’s been able to overcome.”
How does Brendan's attitude and optimism encourage you?

Background

Watch a news report:

More on Brendan Marrocco from London's Daily Telegraph:

Brendan Marrocco, 26, who was hit by a roadside bomb on Easter Sunday 2009, was the first soldier to survive quadruple limb loss from the wars in Iraq in Afghanistan. He has now received two donor arms following a 13-hour operation, which doctors described as the most complex arm transplant ever performed in the US.
Mr. Marrocco spoke for the first time about the procedure, saying that he felt like himself again. He said that he was looking forward to driving a car for the first time since his injuries and taking up hand cycling, adding: "I hated not having arms," he said. "Not having arms takes so much away from you. You talk with your hands, you do so much with your hands. When you don't have that, you're kind of lost for a while."
The former GI lost both legs above the knee, his left arm below the elbow and his right arm above the elbow when a military vehicle he was driving was hit by a makeshift bomb in northern Iraq.
While Mr. Marrocco is not the first person to undergo a double arm transplant - he is the seventh - surgeons at Johns Hopkins hospital in Baltimore, where the operation took place, say his was "the most complicated one" so far.
His transplants, which took place on December 18, involved the connection of bones, blood vessels, muscles, tendons, nerves and skin on both arms.
And while the early signs are positive - he wrote on Twitter after the surgery that his new limbs "already move a little" - doctors say it could be two to three years before the full functionality of his arms will be known.
It is, however, hoped that his new arms will allow him to support himself on prosthetic legs and walk unaided for the first time since he was wounded.
Other patients who have undergone similar transplants have ultimately been able to tie their shoelaces and use chopsticks, doctors said.
Jaimie Shores, the clinical director of hand transplants at Johns Hopkins, said: "I think he will be able to throw a football," before adding: "Although I don't think he will be able to hit 60 yard runs like Joe Flacco," in reference to the current Baltimore quarterback.
While Mr. Marrocco's surgery carried inevitable risks, he said that he had never wavered in his desire to go through with the operation. "I have overcome so much in the past four years and really the worst case scenario was…I go back to the way I was."
Inevitably Mr. Marrocco's story will give hope to other war veterans who lose limbs in battle.
Asked if he had a message for those in a similar position, he said: "Not to give up hope," before adding: "I still thought of myself as being normal. I hated the word handicapped. I never really looked at it like that and now I'm just looking forward to doing everything I was doing four years ago."

And from a Washington Post article - Dr. Lee:

In an interview, Dr. Lee said there have been about 80 arms transplanted in about 60 patients so far around the world.

His team, which until two years ago was based at the University of Pittsburgh, has transplanted 10 arms in six patients, which is about half the U.S. cases, he said.

There are hundreds of military amputees around the country - including four others who have lost four limbs and others who have lost three or two.

Many, like Marrocco, have been treated at the old Walter Reed Army Medical Center in Washington, now the Walter Reed National Military Medical Center in Bethesda. Marrocco was at the old Walter Reed for several years, and two other quadruple amputees are recovering at the new site.

Most such patients have been fitted with - and mastered - sophisticated mechanical prostheses. But Lee said in a recent interview that research has suggested younger amputees don’t always use them.

“The nonacceptance rate of prosthetics is highest among young people in their 20s and 30s,” he said.

So the possibility of limb transplantation, despite its enormous medical, psychological and logistical complexity, holds great promise, he said.

Aside from the physical outcome, “I think it also has additional advantage for the patient to be restored whole,” the doctor said. “Once they’re transplanted, they regard the arm as theirs. And I think they’re more comfortable going out on social occasions, as opposed to wearing a prosthetic.”