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

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.

The First Successful Combined Full Face and Bilateral Hand Transplant

BACKGROUND

Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant.

METHODS

A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure.

RESULTS

Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts.

CONCLUSIONS

Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Real-Time Assessment of Free Flap Capillary Circulation Using Videocapillaroscopy

BACKGROUND

Free tissue transfer is a common method of reconstruction for various surgical defects. Many clinical assessment methods, including flap color monitoring and capillary refill time measurements, are commonly used to assess the microcirculation of the flap, yet there is no objective tool available that can clear real-time visualization of the flap microcirculation. The purpose of this study was to use a novel videocapillaroscope to evaluate the circulation changes on free flap skin surfaces while purposely clamping pedicle vessels.

METHODS

Ten patients who underwent free flap transfer for head and neck cancer from November of 2019 to June of 2020 were included in the study. Videocapillaroscopic observation was performed after flap elevation, and changes in the flap skin capillary circulation with artery-controlled and vein-controlled clamping were recorded.

RESULTS

Average total surgery time was 517.91 minutes (SD, 73.3 minutes), average flap elevation time was 102.9 minutes (SD, 18.3 minutes). When the pedicle artery or vein was purposely clamped, the movement of red blood cells in blood vessels stopped; when clamps were removed after 60 seconds, the restoration of red blood cell movements was rapidly observed. When the pedicle artery was clamped, the number of visualizable blood vessels decreased and flap color became relatively white. When the pedicle vein was clamped, the number of visualizable blood vessels increased, and flap color tone had a tendency toward red.

CONCLUSION

Novel videocapillaroscopy can be utilized for objective real-time flap monitoring by directly visualizing flap skin capillary microcirculation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Long-term follow-up of three different nerve repair strategies (repair, autografting and allografting) in one-stage replantation to treat upper extremity amputation

OBJECTIVE

To examine the efficacy of three different nerve repair methods for one-stage replantation to treat complete upper extremity amputation and long-term postoperative functional recovery.

METHODS

Twenty-five patients underwent direct nerve anastomosis (Group A), for patients with nerve defects greater than 3 cm, nerve autograft transplantation be used (Group B), or patients with nerve defects less than 3 cm, nerve allograft transplantation be used (Group C) based on the severity of injury. The Disabilities of the Arm, Shoulder, and Hand (DASH) score (higher score means poorer function-less than 25 means good effect) and visual analogue scale (VAS) scores for pain at rest and under exertion were measured. Sensation recovery time and grip function were recorded.

RESULTS

The mean follow-up time was 78 ± 29 months. Group A had the lowest DASH score, while Group C had the highest DASH score. DASH score differed significantly between the three groups (P < 0.001). Sensation was not restored in two patients in Group B and two patients in Group C, and there were significant between-group differences in sensation recovery (P = 0.001). Group C had the lowest VAS score, while Group A had the highest, and there were significant differences between groups (P = 0.044). Only one patient in Group C recovered grip function.

CONCLUSION

Direct nerve anastomosis should be performed whenever possible in replantation surgery for complete upper extremity amputation, as the nerve function recovery after direct nerve anastomosis is better than that after nerve autograft transplantation or nerve allograft transplantation. Two-stage nerve autograft transplantation can be performed in patients who do not achieve functional recovery long after nerve allograft transplantation.

Process of Obtaining Social Consensus and 3-Year Functional Outcomes of the First Hand Allotransplantation in Korea

BACKGROUND

On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation's first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation.

METHODS

W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city's financial and legal support and the university's medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man.

RESULTS

With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed.

CONCLUSIONS

Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.

Analysis of factors involved in brain-death donor processing for face transplantation in Korea: How much time is available from brain death to transplantation?

Background

Face transplantation has naturally evolved from reconstructive procedures. However, few institutions perform face transplantations, because it is time-consuming and it is necessary to justify non-vital organ transplantation. We investigated the process of organ donation from brain-dead patients and the possibility of incorporating face transplantation into the donation process.

Methods

A retrospective review was performed of 1,074 brain-dead patients from January 2015 to December 2016 in Korea. We analyzed the time intervals from admission to brain death decisions (first, second, and final), the causes of brain death, and the state of the transplanted organs.

Results

The patient base (n=1,074) was composed of 747 males and 327 females. The average period between admission to the first brain death decision was 8.5 days (±15.3). The average time intervals between the first brain death decision and medical confirmation using electroencephalography and between the first brain death decision and the final determination of brain death were 16 hours 58 minutes (±14 hours 50 minutes) and 22 hours 57 minutes (±16 hours 16 minutes), respectively. The most common cause of brain death was cerebral hemorrhage/stroke (42.3%), followed by hypoxia (30.1%), and head trauma (25.2%).

Conclusions

When face transplantation is performed, the transplantation team has 22 hours 57 minutes on average to prepare after the first brain death decision. The cause of brain death was head trauma in approximately one-fourth of cases. Although head trauma does not always imply facial trauma, surgeons should be aware that the facial tissue may be compromised in such cases.

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.

Infections after upper extremity allotransplantation: a worldwide population cohort study, 1998-2017

Risk-to-benefit analysis of upper extremity allotransplantation (UEA) warrants a careful assessment of immunosuppression-related complications. This first systematic report of infectious complications after UEA aimed to compare incidence and pattern of infections to that observed after kidney transplantation (KT). We conducted a matched cohort study among UEA and KT recipients from the International Registry on Hand and Composite Tissue Transplantation and the French transplant database DIVAT. All UEA recipients between 1998 and 2016 were matched with KT recipients (1:5) regarding age, sex, cytomegalovirus (CMV) serostatus and induction treatment. Infections were analyzed at three posttransplant periods (early: 0-6 months, intermediate: 7-12 months, late: >12 months). Sixty-one UEA recipients and 305 KT recipients were included. Incidence of infection was higher after UEA than after KT during the early period (3.27 vs. 1.95 per 1000 transplant-days, P = 0.01), but not statistically different during the intermediate (0.61 vs. 0.45/1000, P = 0.5) nor the late period (0.15 vs. 0.21/1000, P = 0.11). The distribution of infectious syndromes was significantly different, with mucocutaneous infections predominating after UEA, urinary tract infections and pneumonia predominating after KT. Incidence of infection is high during the first 6 months after UEA. After 1 year, the burden of infections is low, with favorable patterns.

Bone infarction of the hip after hand allotransplantation: A case report

Vascularized composite allotransplantation represents as an emerging field in reconstructive surgery. However, some complications can be associated with the procedure. The authors describe a case of bone infarctions of the bilateral hip joints following the first hand allotransplantation in Taiwan. A 45-year-old man who experienced a traumatic amputation of the distal third of his forearm received a hand transplantation from a brain-dead donor. Immunosuppression included antithymocyte globulins, and bolus methylprednisolone (Solu-Medrol) was used for the induction. The maintenance therapy protocol included systemic tacrolimus, mycophenolate mofetil, and prednisone. The patient discontinued the systemic steroid 15 months after surgery. Two episodes of acute rejections were observed at 105 and 810 days after surgery. These signs disappeared after pulse therapy with Solu-Medrol, titration with tacrolimus, and topical immunosuppressive creams (tacrolimus and clobetasol). However, the patient felt pain in both hips after long periods of standing 30 months after the transplantation. A pelvic radiograph and magnetic resonance imaging revealed avascular necrosis (AVN) in both hip joints. Because of the progressive worsening of the pain, the patient underwent a decompression surgery on the left hip involving a fibula bone graft. The patient underwent a right hip hemi-arthroplasty with a bipolar prosthesis 3 months later. The patient remained in good health without major complications. These findings indicate that systemic steroids and tacrolimus might be the major predisposing factors for the induction of AVN after hand allotransplantation.

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.