Ground­break­ing Surgery

The Per­fect Hand Trans­plant

Reader's Digest Asia Pacific - - Front Page - BY AMY WAL­LACE FROM LOS ANGELES

ON MON­DAY, JAN­UARY 26, 2015, JONATHAN KOCH AWOKE feel­ing aw­ful. God, I’m sweaty, he thought. Even my knees are aching. And what’s up with my freez­ing-cold feet?

Jonathan was sup­posed to fly from Los Angeles to Wash­ing­ton; as the co-run­ner of a re­al­ity TV pro­duc­tion com­pany, he was ex­pected at a con­fer­ence that af­ter­noon. In­stead, he headed not to the air­port but to a med­i­cal cen­tre, where doc­tors – find­ing no cause for his dis­com­fort – gave him a shot of mor­phine and sent him on his way. He made it to Wash­ing­ton, checked in to his ho­tel, and fell into bed by mid­night.

The next morn­ing, he could barely get up. Why does my body feel like con­crete? he won­dered. His eyes were be­yond blood­shot. He stopped by a phar­macy to buy an over-the-counter pain re­liever, eye drops and an en­ergy drink, then dragged him­self to his first meet­ing. Mid­way through the sec­ond meet­ing, Jonathan looked at a col­league and saw three of her. When he stum­bled in the hall­way a minute later, she in­sisted on tak­ing him to the emer­gency depart­ment. “You’ve got work to do,” Jonathan told her. “I can get there on my own.”

A taxi dropped him off at Ge­orge Wash­ing­ton Univer­sity Hospi­tal around 11am. His tem­per­a­ture was 38.8°C.

Other than a knee surgery and a his­tory of kid­ney stones, Jonathan Koch’s body had never failed him, and he’d al­ways re­turned the favour. At 1.85 me­tres tall and 102 kilo­grams, the 49 year old was an ex­er­cise ad­dict who led a daily predawn work­out for friends. He didn’t drink or smoke, ate a high-pro­tein diet and loved his sleep. He and his girl­friend, Jen­nifer Gunkel, were typ­i­cally in bed by 9pm.

Now doc­tors won­dered if he had pneu­mo­nia. De­spite a bat­tery of ex­am­i­na­tions and pain surg­ing through his limbs, he man­aged to text Jen­nifer: “They are killing me in here, baby.”

Tues­day night fell, and the hospi­tal ad­mit­ted Jonathan to the ICU. His con­di­tion re­mained a mys­tery, and the pain was be­yond de­bil­i­tat­ing. His cir­cu­la­tion slowed; his hands and feet were turn­ing blue as his body pulled blood from his limbs to pro­tect his vital or­gans. Around 2am, Dr Lynn Abell lev­elled with Jonathan. “Text ev­ery­one you love,” she said. “You’re prob­a­bly go­ing to die tonight.”

By the time Jen­nifer ar­rived in Wash­ing­ton on Wed­nes­day night, doc­tors had put her part­ner into a propo­fol- in­duced coma. The next day, he was in full-blown sep­tic shock. With his outer ex­trem­i­ties de­prived of oxy­genated blood, gan­grene set in. De­spite huge doses of an­tibi­otics, Jonathan’s body “was get­ting ready to die”. Chance of sur­vival: ten per cent.

MOST OF US THINK THAT

pa­tients who are put into a med­i­cally in­duced coma fall into a peace­ful sleep. In fact, many peo­ple who’ve been ‘put un­der’ have ter­ri­fy­ing hal­lu­ci­na­tions or night­mares. As Jonathan lay un­con­scious over the fol­low­ing weeks, he had both. He be­lieved he was be­ing held hostage by a fam­ily of ghouls with ­gi­ant faces and jagged teeth. Lashed to a wooden bench, he was bit­ten re­peat­edly by snakes. He sensed the pres­ence of his 15-yearold daugh­ter, Ari­ana, de­spite her be­ing more than 4800 km away. (With Jonathan’s con­di­tion so un­cer­tain, Ari­ana, who had bron­chi­tis, stayed at home with her mother.) Jonathan and his daugh­ter had a tight bond. Each Fe­bru­ary since pre- kin­der­garten,

they’d at­tended her school’s fa­ther– daugh­ter dance. Now he was miss­ing it for the first time.

On the fi­nal day of his two-and-ahalf-week coma, Jonathan saw him­self in an empty, misty room with two doors. He un­der­stood that one door was the way back to ex­is­tence; the other, the way out. Then he heard a deep voice. “If you choose to live, there will be a price that is so heavy that at times you’ll re­gret it,” the voice said. “If you de­cide to go back, it will be the fight of your life.” Jonathan knew his an­swer. A fight? Bring it.

In an in­stant, he was pro­pelled up­wards like a tor­pedo through dark wa­ter that grew lighter and lighter. Fi­nally he burst through. His first words were “How did I get here?” Then he looked down at his feet, which were strangely black and be­gin­ning to shrivel. “Wow,” he said. “Im­pres­sive.”

Dur­ing Jonathan’s 39 days at Ge­orge Wash­ing­ton, his hands and feet be­came necrotic, or as he put it, down­right ‘Egyp­tian’ – leath­ery, mum­mi­fied, char­coal black. Doc­tors sought to dis­cover what had thrown his sys­tem into chaos, rul­ing out can­di­dates one by one. He didn’t have measles or Lyme dis­ease. There was ev­i­dence that he had an­ti­bod­ies to the Ep­stein-Barr virus, which can re­sult in chronic fa­tigue syn­drome, but 95 per cent of adults have the virus and do not de­velop com­pli­ca­tions. For a while, doc­tors thought he might have a rare bone mar­row cancer and started him on chemo­ther­apy. Their strat­egy: treat ev­ery pos­si­bil­ity at the same time. And it worked; he sur­vived.

That March, hop­ing to dis­cover what had caused his ill­ness, Jonathan made the dif­fi­cult de­ci­sion to leave the hospi­tal to travel to the Mayo Clinic in Rochester, Min­nesota. “The one thing I don’t un­der­stand,” he ad­mit­ted to Abell on his last day, “is, why did this hap­pen?” The doc­tor’s re­sponse: “Jonathan, the rea­son you took such great care of your­self was not to avoid this. It was to sur­vive this.”

Still, Jonathan’s time at Mayo was rough; his limbs were in con­stant, un­speak­able pain. He lost 18 kilo­grams. His hands and feet, wrapped in gauze, looked like paws. Doc­tors at Mayo ­be­gan to dis­cuss the pos­si­bil­ity of am­pu­ta­tions and, per­haps even­tu­ally, a trans­plant for his ru­ined left hand.

On April 20, 2015, 85 days af­ter Jonathan had been ad­mit­ted to Ge­orge Wash­ing­ton, he and Jen­nifer told Mayo they wanted to re­turn to Los Angeles for Ari­ana’s 16th birth­day. That was when some­one men­tioned a doc­tor whose name they’d never heard be­fore: Kodi Azari.

AZAR I ,

48, is the sur­gi­cal d i rec tor of the Hand Trans­plant Pro­gram at the Univer­sity of Cal­i­for­nia at Los Angeles (UCLA). The field is still rel­a­tively new. The first hand trans­plant to achieve pro­longed suc­cess was per­formed in 1991 in Ken­tucky; by 2015, fewer than 85 pro­ce­dures had been un­der­taken world­wide. But Kodi Azari is at the fore­front. He has per­formed as a lead sur­geon in five hand trans­plants, in­clud­ing the first dou­ble-hand trans­plant and the first arm trans­plant in the US.

The doc­tor had some hy­pothe­ses he wanted to test, pro­vided he could find a pa­tient with the ideal re­quire­ments: ex­cel­lent health, enor­mous self-dis­ci­pline, and – rarest of all – a limb that needed to be re­placed but had not yet been am­pu­tated. Most hand trans­plant can­di­dates have been in­jured in ac­ci­dents or in bat­tle, when a cat­a­strophic event forces an emer­gency am­pu­ta­tion to min­imise suf­fer­ing.

Gen­er­ally that means the arm is sev­ered closer to the el­bow than to the wrist, and the nerves and ten­dons are trimmed and tucked in­ward to lessen dis­com­fort. All those tucked- in nerves and ten­dons tend to merge over time into a jum­ble that is dif­fi­cult to ­con­nect to a new hand with pre­ci­sion.

Wouldn’t it be great, Azari pos­tu­lated, if a trans­plant re­cip­i­ent’s arm could be am­pu­tated in a way that prepped it specif­i­cally to re­ceive a new limb? How much more quickly would a ­pa­tient re­cover if each ten­don, nerve, artery and vein were left in place and marked like so many coloured speaker wires to be hooked up to a match­ing ap­pa­ra­tus? Azari be­lieved this fan­tasy pa­tient would awaken post- op, look at the new hand, and be able to move the fin­gers right away. Now all he needed was the right pa­tient.

And then he met Jonathan. ­Azari set about ex­am­in­ing his pa­tient a week af­ter his re­turn from the Mayo Clinic.

He started with Jonathan’s ru­ined left hand, with its charred-look­ing ex­te­rior ex­cept for a tiny patch of palm. The right hand was bet­ter off; while the fin­gers and thumb were black­ened, the rest could be saved. Dam­age to the left foot was mostly con­fined to the toes, but the right looked as if it had been fash­ioned wholly out of char­coal bri­quettes. “Get rid of it,” Azari said. “It’s a no- brainer.” Some­thing about his man­ner – di­rect, gen­tle, kind around the eyes – calmed Jonathan and Jen­nifer. “I will make you this prom­ise,” the sur­geon said. “I will not do any­thing to make you worse.”

ON JUNE 23, 2015, DE

TERMINED TO save as much healthy tis­sue as pos­si­ble, Azari am­pu­tated Jonathan’s left hand and about half of each fin­ger on his right. Sev­er­ing the left hand closer to the wrist than to the el­bow, Azari kept all the nerves and ten­dons long and ex­tended, which would give him plenty to work with later.

There was much to pre­pare. UCLA, where Azari hoped to per­form the surgery, re­quired Jonathan to un­dergo myr­iad phys­i­cal and psy­cho­log­i­cal tests. Then came the chal­lenge of match­ing a donor’s left hand with Jonathan’s in terms of size, skin tone and hair pat­tern. While he waited, Jonathan tried to re­learn tasks that he’d once taken for granted. He taught him­self to hold a fork us­ing the stubs of the fin­gers that re­mained on his right hand and learned to use a sty­lus to type on his phone.

On Au­gust 17, 2015, Jonathan and Jen­nifer were mar­ried in a tiny cer­e­mony in their back­yard. The next day, doc­tors am­pu­tated Jonathan’s right leg mid­way be­tween his knee and his an­kle and snipped off the necrotic toes on his left foot. Jonathan tried to joke about the hor­ror of watch­ing parts of him­self dis­ap­pear, call­ing him­self Mr Po­tato Head ­af­ter the chil­dren’s toy. But the loss of his foot hit hard. “The hard­est part for me has been in the pe­riod of sub­trac­tion,” he said. “This is the be­gin­ning of the pe­riod of ad­di­tion.”

Eight weeks af­ter his foot surgery, Jonathan was fit­ted for his first pros­the­sis; he walked right away. Soon he would up­grade to a Tri­ton smart ­an­kle, a bionic con­trap­tion he could ad­just for what­ever type of move­ment he needed to do. He’d also have a pros­the­sis for run­ning called a Rush Foot. “Even­tu­ally I’ll have a spe­cial tuxedo leg for the Em­mys,” he joked.

Azari was less at ease. “Hand

“THE HARD PART HAS BEEN THE PE­RIOD OF SUB­TRAC­TION,” JONATHAN SAID. “THIS IS THE BE­GIN­NING OF THE AD­DI­TION”

trans­plants throw you curve­balls,” he said. “And there is no cook­book on how to do it.” So like a chef try­ing out a dish be­fore serv­ing it, Azari and his team prac­tised Jonathan’s surgery sev­eral times in the anatomy lab.

On Oc­to­ber 24, 2016, a donor can­di­date was found who shared Jonathan’s blood type and had a hand that matched his. The next morn­ing, Jonathan walked into the med­i­cal cen­tre at 9.45. Azari met him with a prom­ise: “We’re go­ing to do this.” As Jonathan was pre­pared for surgery, the sur­geon headed to an­other hospi­tal. It was time to pick up Jonathan’s new hand.

When Azari ar­rived, the donor was on life sup­port, and the doc­tor had the rare op­por­tu­nity to meet the donor’s brother and pas­tor.

AT 3.32PM, the first cut was made to pre­pare Jonathan’s arm. Azari ar­rived within the hour and joined his team. The first curve­ball came right away. The doc­tors had planned to sever the ra­dius and ulna bones at about 11 cm above the wrist. But af­ter open­ing up Jonathan’s arm, pre­serv­ing more bone seemed pos­si­ble. This ap­proach might en­able the arm to heal bet­ter and have more range of mo­tion, but there were no guar­an­tees. The sur­geons came to a unan­i­mous de­ci­sion: pre­serve an­other 7 cm of each bone, af­fix­ing the hand just 4 cm above the wrist.

Tick, tick, tick. They were only a few hours in, with at least a dozen more to go. The team su­tured a few key ten­dons to­gether. Then the doc­tors moved on to the ar­ter­ies and veins. Here came the sec­ond curve­ball. Be­cause of the gan­grene and the lack of use, Jonathan’s veins and ar­ter­ies were very small – “like chives”, Azari says. They were also tough with scar tis­sue, which made su­tur­ing them more dif­fi­cult.

As the team con­tin­ued re­pair­ing the mus­cu­la­ture of the arm, pulling it more tightly to­gether, the ar­ter­ies and veins they’d at­tached early on be­gan to pro­trude, like a loop of ex­tra yarn. The sur­geons had ex­pected this. Those ves­sels were short­ened and re­su­tured.

Var­i­ous ten­dons were sim­i­larly tight­ened, par­tic­u­larly in Jonathan’s pointer, mid­dle and ring fin­gers. “We went back and did these three ten­dons many times un­til we got them right,” Azari says. The ten­dons of the

fore­arm, mean­while, were wo­ven into one an­other over a 7.6-cm span to max­imise strength and re­sist tear­ing.

At 11.01pm, af­ter the doc­tors had re­moved the tourni­quets and clamps, Jonathan’s new hand went from white to pink to red. The full­ness re­turned to the tis­sue, and the pulse be­gan to pound. It was ex­hil­a­rat­ing.

The sur­geons worked to com­plete re­pairs on the re­main­ing ten­dons. At 7.07am, the hospi­tal called Jen­nifer to tell her that the team was clos­ing and su­tur­ing. They’d been at it for 17 hours and 37 min­utes.

Jonathan’s first words af­ter emerg­ing from the anaes­the­sia were “Did you do it?” When Azari an­swered, “Yes”, Jonathan looked down at his new hand and started singing the theme song from Rocky. Jen­nifer ar­rived at the hospi­tal about an hour later. It was her birth­day, and she was ready for her gift. “Move your thumb,” she told Jonathan. And he did.

THE TO­TAL COST OF JONATHAN’S

trans­plant and care is im­pos­si­ble to mea­sure, but some past pro­ce­dures have cost more than US$1 mil­lion.

So what made him sick? He will never know for sure. Jonathan says the con­sen­sus is that ex­po­sure to the Ep­stein-­Barr virus, com­bined with stress, may have trig­gered “a one-in20-mil­lion event”.

Now he is fo­cused on what’s ahead. He is back to lead­ing intense work­outs for friends, and he’s learn­ing to use a set of pros­thetic fin­gers fit­ted to his right hand.

Re­cently, Jonathan put on a suit and tie, his Tri­ton smart an­kle, and a pair of black leather high-tops and took Ari­ana, a se­nior in sec­ondary school, to their fi­nal fa­ther–daugh­ter dance. Dec­o­rat­ing his lapel were 14 red hearts – one for each dance they’d at­tended to­gether. Few peo­ple other than Ari­ana knew that his at­ten­dance it­self was a mir­a­cle.

Jonathan Koch be­fore his 17-hour hand-trans­plant surgery

The day af­ter Jonathan and Jen­nifer’s wed­ding, doc­tors am­pu­tated his right leg

Jonathan Koch wasn’t a lefty be­fore his hand trans­plant surgery, but he is now

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