The First (Double) Hand Transplantation in Turkey

Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports

INTRODUCTION

Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it.

METHODS

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included.

RESULTS

We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020).

CONCLUSIONS

In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.

Immunosuppressive strategies in face and hand transplantation: a comprehensive systematic review of current therapy regimens and outcomes

Background

Recipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections.

Methods

A systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA.

Results

The standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients.

Conclusions

Based on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.

Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb

Twenty years have surpassed since the first vascularised composite allotransplantation (VCA) of the upper limb. This is an opportunity to reflect on the position of VCA as the gold standard in limb reconstruction. The paucity of recipients, tentative clinical outcomes, and insufficient scientific progress question whether VCA will remain a viable treatment option for the growing numbers of amputees. Bionic technology is advancing at a rapid pace. The prospect of widely available, affordable, safely applied prostheses with long-standing functional benefit is appealing. Progress in the field stems from the contributions made by engineering, electronic, computing and material science research groups. This review will address the ongoing reservations surrounding VCA whilst acknowledging the future impact of bionic technology as a realistic alternative for limb reconstruction.

Two Decades of Hand Transplantation: A Systematic Review of Outcomes

ABSTRACT

Hand transplantation for upper extremity amputation provides a unique treatment that restores form and function, which may not be achieved by traditional reconstruction and prosthetics. However, despite enhancing quality of life, hand transplantation remains controversial, because of immunological complications, transplant rejection, and medication effects. This systematic literature review sought to collect information on current experiences and outcomes of hand transplants to determine the efficacy and utility of hand transplants. The databases PubMed, Scopus, and Embase were analyzed with combinations of "hand" or "upper extremity" or "arm" and "transplant" or "allograft," with information collected on recipient characteristics, details of transplant, immunological outcomes, functional outcomes, and complications. Functional outcomes, as measured by Disabilities of Arm, Shoulder and Hand score, were compared between patient groups using Wilcoxon signed-rank test or 1-way analysis of variance test and post hoc Tukey test. Within the 108 articles that fulfilled inclusion and exclusion criteria, there were 96 patients with 148 hand transplants. There were 57 patients who experienced acute rejection and 5 patients with chronic rejection. Disabilities of the Arm, Shoulder and Hand scores significantly decreased after hand transplantation and were significantly lower for distal transplants compared with proximal transplants. There were 3 patients with concurrent face transplantation and 2 patients with simultaneous leg transplants. Sixteen patients experienced amputation of the hand transplant, and there were 5 deaths. This study found that hand transplantation provides significant restoration of function and form, especially for proximal transplants. Reduction in complications, such as rejection and amputation, can be achieved by decreasing medication cost and patient education.

Complementary Phenomena: Phantom Hand and Phantom Face

After tissue or limb loss, the development of sensation and perception of the lost or deafferent tissue is defined as a phantom phenomenon. We investigated the presence of phantom phenomena in individuals who underwent a full face transplant as well as those who had a hand transplant. Specifically, we investigated sensory perception of the face on the fingers and sensory perception of the fingers on the face in three full face and four hand transplant patients. In all seven individuals, we used a brush to separately stimulate the right and left sides of the face or the palmar and dorsal faces of the hand. We then asked the individuals if they felt a sensation of touch on any other part of their body and, if so, to describe their perceptions. Changes in the regions of the primary sensory cortex representing the hand and face were defined using fMRI obtained via tactile sensory stimulation of the clinical examination areas. Two of the full face transplant patients reported sensory perceptions such as a prominent sensation of touch on their faces during sensory stimulation of their fingers. Three of the hand transplant patients reported sensory perceptions, which we referred to as finger patches, during sensory stimulation of the face area. In fMRI, overlaps were observed in the cortical hand and face representation areas. We consider the phantom hand and phantom face phenomena we observed to be complementary due to the neighborhood of the representations of the hand and face in the somatosensory cortex.

Replantation of forequarter amputation: Report of two cases with successful structural, motor and sensorial results

Although there have been numerous reports of major replantation of upper extremity amputations, limited numbers of above-elbow amputation replantation have been reported. We present the technical details of two successful replantations of forequarter amputations in a nine-year-old girl and a three-year-old boy. In both cases, the forequarter was amputated due to avulsion traction injuries resulting in amputation including the entire upper limb, while the integrity of the scapula and parascapular muscles was maintained, with no injury to the glenohumeral joint. Replantation was performed, involving a shorter ischemia time with proper fixation, and vascular and neural repairs. Postoperative recovery was uneventful, and motor and sensorial acquisition were quite satisfactory during follow-up periods of 9 and 6 years, respectively. Proper fixation of the amputated part mimicking the original anatomy, radical debridement of avulsed vessels, and reconstruction of the defect using long vein grafts and neural repair while maintaining proper integrity are the most important factors in success. When the requirements are met, replantation of the forequarter in a child yields a superior outcome, from both the functional and esthetic perspectives. To the best of our knowledge, this is the first report in the English literature involving two sequential cases of such high-level replantation resulting in successful reacquisition of both viability and function.

An Individualized Physiotherapy and Rehabilitation Program for Bilateral Hand Transplantations

METHODS

This article describes a rehabilitation program and the long-term results after its application in 2 double-hand transplantation patients after 9- and 4-year follow-up periods. A personal rehabilitation program was planned to commence as early as possible after postoperative patient stabilization. Splinting, edema, positioning, passive and active joint movements, daily life activity modification and education, and occupational therapy were also emphasized.

RESULTS

Positioning, edema, and passive joint movements were started in the acute phase. Strengthening and exercises were continued for 8 weeks and later for functional gains and adaptation to daily living activities. Subjective and overall results were quite satisfactory. The Hand Transplantation Score System, Disabilities of the Arm Shoulder and Hand, Semmes Weinstein Monofilaments, sensory tests, and modified Kapandji index improvements were all within good acceptable ranges. Although rapid recovery and functional development were observed in the first 4 years, these are still continuing at the time of writing.

DISCUSSION

The most important determining factors in the success of rehabilitation are to return to daily life and the ability to acquire functional skills. Long-term follow-up of the patients in this study showed that they were able to return to their independent daily lives and that external assistance decreased to a minimum.

Bilateral Proximal Forearm Transplantation: Case Report at 7 Years

BACKGROUND

Although return of function has been reported in patients undergoing proximal forearm transplantations (PFTs), reports of long-term function are limited. In this study, we evaluated the clinical progress and function 7 years postoperatively in a patient who underwent bilateral PFT.

CASE PRESENTATION

A 58-year-old man underwent bilateral PFT in May 2012. Transplantation involved all of the flexor and extensor muscles of the forearm. Neurorrhaphies of the median, ulnar, and radial nerves were epineural and 7 cm proximal to the elbow. Immunosuppressive maintenance medications during the first 3 years postoperatively were tacrolimus, mycophenolate, and steroids, and later, tacrolimus, sirolimus, and steroids. Forearm function was evaluated annually using the Disabilities of the Arm, Shoulder, and Hand; Carroll; Hand Transplantation Score System; Short Form-36; and Kapandji scales. We also evaluated his grip and pinch force.

RESULTS

Postoperatively, the patient developed hypertriglyceridemia and systemic hypertension. He experienced 6 acute rejections, and none were resistant to steroids. Motor function findings in his right/left hand were: grip strength: 10/13 kg; key pinch: 3/3 kg; Kapandji score: 6/9 of 10; Carroll score: 66/80; Hand Transplantation Score System score: 90/94. His preoperative Disabilities of the Arm, Shoulder, and Hand score was 50 versus 18, postoperatively; his Short Form-36 score was 90. This function improved in relation with the function reported in the second year.

CONCLUSIONS

Seven years following PFT, the patient gained limb strength with a functional elbow and wrist, although with diminished digital dexterity and sensation. Based on data presented by other programs and our own experience, PFT is indicated for select patients.

Hand Transplantation: Current Status and Immunologic Obstacles

Hand transplantation is the most common form of modern composite tissue allotransplantation, with 89 cases reported worldwide since 1998. The procedure is a treatment option for complex injuries that leave patients with structural, functional, and aesthetic deficits that cannot be addressed by other means. Successful application of this technology requires a multidisciplinary approach, incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and so on. Its long-term results depend on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection. Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation. Despite the enormous antigen load associated with composite tissue allografts, hand transplant has become a clinical reality, with immunosuppression comparable to that of solid-organ transplants. Our understanding of hand transplantation is still evolving, and ongoing research is needed to improve functional outcomes and to decrease the morbidity associated with long-term immunosuppression. This review discusses the current protocols for upper extremity donation, transplant receipt, surgical techniques, postoperative rehabilitation and immunosuppression, nerve regeneration, functional outcomes, ethical issues, and financial considerations.

Technical, Immunological, and Ethical Similarities and Differences Between Vascularized Composite Allotransplantation and Solid Organ Transplantation in Current Practice

Solid organ transplantation (SOT) is a surgical method used as the gold standard in end-term organ failure. Following SOT, successful results have also been achieved in vascularized composite tissue transplantation, which improves the quality of life with the success of solid organ transplants and the development of modern immunosuppressive regimens. This review discusses the preoperative, operative, postoperative, and immunological differences between vascularized tissue transplantation and SOT.

Immunosuppression maintenance in vascularized composite allotransplantation: what is just right?

PURPOSE OF REVIEW

Over the last two decades advances in vascularized composite allotransplantation have achieved clinically significant milestones. This review provides a synopsis for immunosuppressive maintenance therapy for VCA and discusses the nuances surrounding the determination of the right amount of immunosuppression in vascularized composite allotransplantation.

RECENT FINDINGS

Functional results after vascularized composite allotransplantation remain highly encouraging as are the immunologic outcomes, however, challenges persist. Currently, although conventional immunosuppressive protocols have been successful at preventing allograft loss; they have not totally prevented episodes of acute rejection in the skin. Furthermore, vascularized composite allotransplantation carries a significant risk profile attributed to the complications of life-long, high-dose immunosuppression regimens.

SUMMARY

Examining conventional treatment protocols can lead to the development of novel immunosuppression concepts that will ultimately assist in favorably tilting the risk-benefit scale for these life-changing transplants.

Ex-vivo flush of the limb allograft reduces inflammatory burden prior to transplantation

BACKGROUND

Passenger leucocytes and inflammatory debris transferred from the donor limb to the recipient can induce allorecognition, which activates the host immune response. This is the first study to evaluate whether the transfer of this inflammatory burden can be reduced via post-preservation flush prior to revascularisation, and whether this is influenced by ischaemia.

METHODS

Bilateral forelimbs from the same pig were procured and infused with preservation flush and stored on ice. Each limb from the same pig underwent a post-preservation intravascular flush with isotonic solution at either 2 or 6 h. Venous effluent underwent flow cytometry to phenotype leucocyte populations, with additional quantification of cytokines and cell-free DNA.

RESULTS

We identified large populations of viable leucocytes in the flush effluent (8.65 × 10⁸ ± 3.10 × 10⁸ cells at 2 h and 1.02 × 10⁹ ± 2.63 × 10⁸ at 6 h). This comprised T cells, B cells, NK cells and monocytes. Post-preservation flush yielded significant concentrations of pro-inflammatory cytokines including IL-6, IL-18, GM-CSF, IL-1β, IL1α and CXCL-8 and mitochondrial DNA. The regulatory cytokine, IL-10 was undetectable.

CONCLUSIONS

This study supports the finding that a post-preservation flush removes leucocytes and inflammatory components that are responsible for direct presentation. This study also gives an indication of how ischaemia impacts on the inflammatory burden transferred to the recipient upon reperfusion.

The First Hand Allotransplantation in Taiwan: A Report at 9 Months

PURPOSE

Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan.

MATERIALS AND METHODS

On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support.

RESULTS

The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient.

CONCLUSIONS

Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

Psychosocial Evaluation for First Hand Allotransplantation in Taiwan

Hand transplantation has raised ethical and psychological concerns. Few studies have focused on reasons for not selecting candidates on waiting lists. To describe the psychosocial evaluation of referred prospective hand transplant candidates, we investigated candidate suitability by using 22-month follow-up data regarding the first hand transplant recipient in Taiwan. Pretransplant psychosocial assessments comprised an interview with 2 psychiatrists, a social worker, and a psychologist, followed by intelligence quotient scoring with the Wechsler Adult Intelligence Scale and Taiwanese Depression Questionnaire. After team member consensus, of the 20 patients referred to our team to confirm their hand transplantation suitability during April 26, 2013, to March 19, 2015, 7 potential recipients were placed on the waiting list after completing all prehand transplant evaluations. On September 3, 2014, the left distal forearm and hand of a brain-dead man was transplanted to a 45-year-old man who had undergone traumatic amputation of the distal third of his right forearm 30 years previously. During a 22-month follow-up, he complied with scheduled visits, including routine posttransplant laboratory tests, skin biopsies, and intensive physical therapy. Moreover, he overcame repeated graft rejections, bacterial and viral infections, immunosuppressant side effects, considerable economic stress, and the difficulties associated with the adhesion of hand tendons. Finally, he regained some satisfactory function of the transplanted hand. Considering posttransplantation difficulties, suitable candidates for hand transplantation should have persistent motivation, appropriate expectations, patience, immediate availability, fair intelligence, fair social functioning, and adequate economic and familial support.

Might uterus transplantation be an option for uterine factor infertility?

Current data on uterus allotransplantation research has been reviewed and summarized. Over the past 15 years, progress in uterus transplantation research has increased dramatically. As a consequence, the first pregnancy and delivery following uterus allotransplantation in rats have been reported. The technique has been better defined. Although clinical pregnancy and delivery following uterus allotransplantation has been reported in humans, there are still many questions to be answered before clinical application. Gestational surrogacy still remains an important option for being a genetic parent in selected cases with uterine factor infertility.

Two-stage face transplantation: a new concept in vascularized composite allotransplantation

BACKGROUND

Animal models and clinical cases of facial allotransplantation have been performed as a single stage procedure. A staged surgery might offer some advantages in selected cases. In this study, a two-stage face transplantation approach was performed on rat and the feasibility and safety were evaluated.

METHODS

Brown Norway rats were used as donors and Lewis rats as recipients in the allotransplantation groups. A total of 33 hemiface-scalp transplantations were performed. Syngeneic orthotopic transplantations were performed either in one-stage (one single stage surgery; N = 3), local two-stage [heterothopic transplantation to the neck during the first stage and graft rotation as a pedicled flap to cover the facial defect on postoperative day (POD) 2; N = 3], or distant two-stage approaches (heterothopic transplantation to the groin during the first stage and free graft transfer to the face on postoperative day 2; N = 3). In the allotransplantation groups using the same approaches, 12 received no treatment (N = 4 each subgroup) and 12 received the same tapering dose of cyclosporine (10 to 2 mg/Kg/day; N = 4 each subgroup). Graft survival and the rejection grades were assessed clinically and pathologically.

RESULTS

All syngeneic transplants survived for the follow-up period of 180 days. The mean rejection-free survival and total survival of the allograft in the no treatment group was 6 ± 0.3 and 14.3 ± 4.5 days in the one-stage group, 6 ± 0.4 and 18.5 ± 1 days in the local two-stage group and 6 ± 0.2 and 14.3 ± 5.7 (P > 0.05). All allografts in the treatment groups did not develop rejection during the 42 days follow-up period.

CONCLUSIONS

It is feasible, reliable, reproducible, and safe to perform a two-stage face transplantation in rats. This novel approach has the potential to be applied in research and eventually in selected clinical cases of facial allotransplantation.