title: Lessons learned from the first quadruple extremity transplantation in the world.
abstract: BACKGROUND
  Limb transplantation is emerging as a promising area of surgery and is an indispensable alternative for prosthetic rehabilitation of amputees, the severity of which is increasing because of combat-related injuries. Successful unilateral and bilateral limb transplantations have already been performed before this operation.
  
  
  METHODS
  We performed the first ever quadruple limb transplantation in February 2012. The limbs procured from a 40-year-old man heart-beating donor were transplanted to a 27-year-old male patient who was a quadruple amputee for the last 14 years because of an electrical injury.
  
  
  RESULTS
  To shorten the ischemic period to a minimum, 3 separate microsurgery teams worked simultaneously. All extremities were reperfused within 8 hours of procurement, and the operation lasted for 12 hours. Metabolic load was managed by hemodialysis. One hour after the completion of the operation, cardiac arrest developed, resuscitation of which necessitated median sternotomy and temporary partial cardiopulmonary support. Despite the removal of the transplanted limbs and all efforts including continuous hemodialysis, plasmapheresis, and extracorporeal membrane oxygenation, the patient died on the fourth day after transplantation in a clinical condition of severe systemic inflammation.
  
  
  CONCLUSIONS
  The problems we faced were difficulty of vascular access for invasive monitoring and fluid replacement, and the severe systemic inflammation effects of which could not be dealt with, despite aggressive supportive treatment. We hope that our experience will enlighten the surgeons who are willing to extend the limits of limb transplantation and serve the success of future operations.
authors.affiliation: *From the Department of Plastic, Reconstructive and Aesthetic Surgery, Hacettepe University, Ankara, Turkey; †Department of General Surgery, Hacettepe University, Ankara, Turkey; ‡Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem University, Istanbul; and §Department of Nefrology, Hacettepe University, Ankara, Turkey.
authors.forename: Serdar
authors.initials: S
authors.lastname: Nasir
authors.forename: Yusuf Alper
authors.initials: YA
authors.lastname: Kilic
authors.forename: Mehmet Veli
authors.initials: MV
authors.lastname: Karaaltin
authors.forename: Yunus
authors.initials: Y
authors.lastname: Erdem
mesh_terms: D000328:Adult; D000673:Amputation, Traumatic / Q000601:surgery*; D005121:Extremities / Q000293:injuries* / Q000637:transplantation*; D006801:Humans; D008297:Male; D016377:Organ Transplantation / Q000379:methods