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Candelo E, Belafsky PC, Corrales M, Farwell DG, Gonzales LF, Grajek M, Walczak DA, Strome M, Lorenz RR, Tintinago LF, Velez MA, Victoria W, Birchall M. The Global Experience of Laryngeal Transplantation: Series of Eleven Patients in Three Continents. Laryngoscope 2024. [PMID: 38970445 DOI: 10.1002/lary.31551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 04/06/2024] [Accepted: 05/14/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND The loss of laryngeal function affects breathing, swallowing, and voice, thus severely compromises quality of life. Laryngeal transplantation has long been suggested as a solution for selected highly affected patients with complete laryngeal function loss. OBJECTIVE To obtain insights regarding the advantages, weaknesses, and limitations of this procedure and facilitate future advances, we collected uniform data from all known laryngeal transplants reported internationally. METHODOLOGY A case series. Patients were enrolled retrospectively by each institutional hospital or clinic. Eleven patients with complete loss of laryngeal function undergoing total laryngeal transplantation between 1998 and 2018 were recruited. RESULTS After a minimum of 24 months follow-up, three patients had died (27%), and there were two graft explants in survivors, one total and one partial, due to chronic rejection. In the remaining cases, voice was functional in 62.5% and 50% achieved decannulation. Swallowing was initially restricted, but only one patient was gastrostomy-dependent by 6 months and all had normal or near-normal swallowing by the end of year two after transplantation. Median follow-up was 73 months. Functional (voice, swallowing, airway) recovery peaked between 12 and 24 months. CONCLUSIONS Laryngeal transplantation is a complex procedure with significant morbidity. Significant improvements in quality of life are possible for highly selected individuals with end-stage laryngeal disorders, including laryngeal neoplasia, but further technical and pharmacological developments are required if the technique is to be more widely applicable. An international registry should be created to provide better quality pooled data for analysis of outcomes of any future laryngeal transplants. LEVEL OF EVIDENCE IV Laryngoscope, 2024.
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Affiliation(s)
- Estephania Candelo
- University College London and Royal National Ear Nose and Throat and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, London, UK
- Head and Neck Department, Fundacion Valle del Lili, Cali, Colombia
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | | | - D Gregory Farwell
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luis F Gonzales
- Anesthesiology Department, Fundación Valle del Lili, Cali, Colombia
| | - Maciej Grajek
- Department of Oncological and Reconstructive Surgery, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, Poland
| | - Dominik A Walczak
- Department of Oncological and Reconstructive Surgery, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, Poland
| | - Marshall Strome
- Department of Otolaryngology Head & Neck Surgery, Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert R Lorenz
- Department of Otolaryngology Head & Neck Surgery, Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Luis F Tintinago
- Head and Neck Department, Fundacion Valle del Lili, Cali, Colombia
| | - Maria A Velez
- Head and Neck Department, Fundacion Valle del Lili, Cali, Colombia
| | - William Victoria
- Head and Neck Department, Fundacion Valle del Lili, Cali, Colombia
| | - Martin Birchall
- University College London and Royal National Ear Nose and Throat and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, London, UK
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Mackiewicz-Nartowicz H, Nawrocka L, Burduk P, Sinkiewicz A. Voice Rehabilitation After Laryngeal Transplantation: Own Experience. J Voice 2024:S0892-1997(24)00021-3. [PMID: 38443266 DOI: 10.1016/j.jvoice.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND AND PURPOSE Laryngeal transplantation (LT) remains an infrequently performed procedure due to well-defined and limited medical indications. The challenges include a very complicated surgery, continuous immunosuppressive treatment, as well as post-transplant rehabilitation of voice, speech, and swallowing. The aim of this paper is to describe a model of voice and speech rehabilitation after LT, based on our own experience. STUDY DESIGN Observational study. METHOD Presented here are the rehabilitation processes of two patients who had previously undergone LT as well as their pre- and postrehabilitation voice outcomes. Both patients underwent voice, speech, and swallowing rehabilitation in the fifth month after LT. RESULTS One of the patients had a significant improvement in voice quality. While, the other did not regain his natural, sonorous voice, but he scored very high on a voice self-assessment test. CONCLUSION Voice rehabilitation after LT is a complex and long-term process that requires the involvement of a team of specialists. The optimal anatomical conditions restored during surgery, the patient's motivation and the support of professionals make it possible to return to normal verbal communication.
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Affiliation(s)
- Hanna Mackiewicz-Nartowicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland.
| | - Lidia Nawrocka
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Paweł Burduk
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Anna Sinkiewicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
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Krishnan G, Du C, Fishman JM, Foreman A, Lott DG, Farwell G, Belafsky P, Krishnan S, Birchall MA. The current status of human laryngeal transplantation in 2017: A state of the field review. Laryngoscope 2017; 127:1861-1868. [PMID: 28224630 DOI: 10.1002/lary.26503] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Human laryngeal allotransplantation has long been contemplated as a surgical option following laryngectomy, but there is a paucity of information regarding the indications, surgical procedure, and patient outcomes. Our objectives were to identify all human laryngeal allotransplants that have been undertaken and reported in the English literature and to evaluate the success of the procedure. DATA SOURCES MEDLINE, Embase, Current Index to Nursing and Allied Health Literature, Web of Science and Scopus, and the Gray literature. REVIEW METHODS A comprehensive search strategy was undertaken across multiple databases. Inclusion criteria were case reports of patients who had undergone human laryngeal allotransplantation. Information regarding indications, operative techniques, complications, graft viability, and functional outcomes were extracted. RESULTS A total of 5,961 articles, following removal of duplicates, matched the search criteria and were screened, with five case reports relating to two patients, ultimately fulfilling the entry criteria. CONCLUSIONS Two laryngeal transplants have been reported in the medical literature. Although both patients report improved quality of life relating to their ability to communicate with voice, further research is necessary to shape our understanding of this complicated operation, its indications, and its functional outcomes. Laryngoscope, 127:1861-1868, 2017.
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Affiliation(s)
- Giri Krishnan
- Department of Otolaryngology-Head and Neck Surgery, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Charles Du
- Department of Otolaryngology-Head and Neck Surgery, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan M Fishman
- Department of Otolaryngology-Head and Neck Surgery, UCL Ear Institute, University College London, London, United Kingdom
| | - Andrew Foreman
- Department of Otolaryngology-Head and Neck Surgery, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David G Lott
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Gregory Farwell
- Department of Otolaryngology, Division of Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology, Division of Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Suren Krishnan
- Department of Otolaryngology-Head and Neck Surgery, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Martin A Birchall
- Department of Otolaryngology-Head and Neck Surgery, UCL Ear Institute, University College London, London, United Kingdom
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Welman T, Villani V, Shanmugarajah K, Hettiaratchy S. From Kidney Transplants to Vascularized Composite Allografts: The Role of the Plastic Surgeon in Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/23723505.2016.1197874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Morelon E, Petruzzo P. Vascularized composite allotransplantation still remains an emerging field after 17 years. Curr Opin Organ Transplant 2016; 20:593-5. [PMID: 26536418 DOI: 10.1097/mot.0000000000000254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Emmanuel Morelon
- aHospices Civils de Lyon, Hôpital Edouard Herriot, Service de Transplantation, Néphrologie et Immunologie Clinique bUniversité de Lyon cINSERM, U1111 dHospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Urologie et Transplantation, Lyon, France eDepartment of Surgery, University of Cagliari, Cagliari, Italy
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Sakallıoğlu Ö. Laryngeal Transplantation. Turk Arch Otorhinolaryngol 2015; 53:128-132. [PMID: 29391994 PMCID: PMC5782916 DOI: 10.5152/tao.2015.999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/03/2015] [Indexed: 11/22/2022] Open
Abstract
Patients who require laryngectomy usually do not want to completely or partially lose their larynx. Laryngeal transplantation (LT) is a composite tissue transplantation from a cadaver to an alive recipient and requires lifelong immunosuppression in postoperative term. The aims of LT are breathing without tracheostoma, normal swallowing, and voice production. To date, only two successful complete LT have been performed in human despite many researches. The requirement of post-transplant immunosuppressive treatment has ethical concern for the larynx, which is a non-vital organ. However, LT may be an option for improving the quality of life of patients undergoing laryngectomy. In this study, we discussed the LT procedure and researches with the literature.
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Affiliation(s)
- Öner Sakallıoğlu
- Clinic of Otorhinolaryngology, Elazığ Training and Research Hospital, Elazığ, Turkey
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Immunology of Transplant Protocols. CURRENT OTORHINOLARYNGOLOGY REPORTS 2014. [DOI: 10.1007/s40136-014-0057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lorenz RR, Strome M. Total laryngeal transplant explanted: 14 years of lessons learned. Otolaryngol Head Neck Surg 2014; 150:509-11. [PMID: 24436467 DOI: 10.1177/0194599813519748] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 1998, the first successful total laryngeal transplant was performed. Outstanding voice quality and swallowing function were achieved, and over the subsequent 14 years, much was learned about tolerance of a transplanted larynx. After approximately a decade, a slowly progressive, chronic rejection process gradually rendered the organ nonfunctional, and the patient and his providers deemed him appropriate for explantation. This is a report of the clinical indications and outcome surrounding the explantation of the first successful total laryngeal transplant.
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Affiliation(s)
- Robert R Lorenz
- Department of Otolaryngology Head & Neck Surgery, Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Plastic surgery is presently typified by the existence of discrete clinical identities, namely that of the cosmetic plastic surgeon and the reconstructive plastic surgeon. The emergence of vascularized composite allotransplantation has been accompanied by the development of a third distinct clinical identity, that of the restorative plastic surgeon. The authors describe the core competencies that characterize this new identity, and discuss the implications of the advent of this new professional paradigm.
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Lessons Learned from Simultaneous Face and Bilateral Hand Allotransplantation. Plast Reconstr Surg 2013; 132:423-432. [DOI: 10.1097/prs.0b013e318295883d] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siemionow M. Impact of reconstructive transplantation on the future of plastic and reconstructive surgery. Clin Plast Surg 2013; 39:425-34. [PMID: 23036293 DOI: 10.1016/j.cps.2012.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article summarizes the current knowledge on the new developing field of reconstructive transplantation. A brief outline of vascularized composite allografts (VCA) such as human hand, face, larynx, and abdominal wall transplants is provided. The clinical applications and indications for these new reconstructive transplantation procedures are outlined. The advantages, disadvantages, and complications and concerns surrounding clinical VCA are discussed. Finally, the impact of reconstructive transplantation on the future of plastic and reconstructive surgery is presented.
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Affiliation(s)
- Maria Siemionow
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, 9500 Euclid Avenue, Desk NA-21, Cleveland, OH 44195, USA.
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Farwell DG, Birchall MA, Macchiarini P, Luu QC, de Mattos AM, Gallay BJ, Perez RV, Grow MP, Ramsamooj R, Salgado MD, Brodie HA, Belafsky PC. Laryngotracheal transplantation: technical modifications and functional outcomes. Laryngoscope 2013; 123:2502-8. [PMID: 23483551 DOI: 10.1002/lary.24053] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/19/2012] [Accepted: 01/22/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal transplantation offers the potential for patients without a larynx to recover their voice, which is critical in our communication age. We report clinical and functional outcomes from a laryngotracheal transplant. Widespread adoption of this technique has been slowed due to the ethical concerns of life-long immunosuppression after a nonvital organ transplant. Our patient was already on immunosuppressive medication from prior kidney-pancreas transplantation, and therefore was not exposed to added long-term risk. We describe the unique technical advances, clinical course, and rehabilitation of this patient and the implications for future laryngeal transplantation. STUDY DESIGN Case report. METHODS A laryngotracheal transplantation was performed in a 51-year-old prior kidney-pancreas transplant recipient presenting with complete laryngotracheal stenosis. Surgical modifications were made in the previously described technique related to retrieval, vascular supply, and reinnervation. This resulted in a robustly vascularized organ with well-perfused long-segment tracheal transplant and early return of motor reinnervation. RESULTS A multidisciplinary approach resulted in a successful transplant without evidence of rejection to date. Postoperatively, the patient continues to rely on a tracheotomy but has had the return of an oral and nasal airway, vocalization, smell, and taste, all experienced for the first time in 11 years. CONCLUSIONS We have demonstrated that our methods may result in a successful laryngotracheal transplant. We describe the preparation, surgical technique, rehabilitation, and interventions employed in achieving optimal outcomes. This report contributes valuable information on this rarely performed composite transplant.
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Affiliation(s)
- D Gregory Farwell
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
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Ma R, Li M, Luo J, Yu H, Sun Y, Cheng S, Cui P. Structural integrity, ECM components and immunogenicity of decellularized laryngeal scaffold with preserved cartilage. Biomaterials 2013; 34:1790-8. [DOI: 10.1016/j.biomaterials.2012.11.026] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
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Is open surgery for head and neck cancers truly declining? Eur Arch Otorhinolaryngol 2013; 270:2793-802. [DOI: 10.1007/s00405-012-2322-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 12/12/2012] [Indexed: 11/25/2022]
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Mitchell O, Durrani A, Price R. Rehabilitation of patients following major head and neck cancer surgery. ACTA ACUST UNITED AC 2012; 21:S31-7. [DOI: 10.12968/bjon.2012.21.sup10.s31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Amer Durrani
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge
| | - Richard Price
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge
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Fishman JM, Ansari T, Sibbons P, De Coppi P, Birchall MA. Decellularized rabbit cricoarytenoid dorsalis muscle for laryngeal regeneration. Ann Otol Rhinol Laryngol 2012; 121:129-38. [PMID: 22397223 DOI: 10.1177/000348941212100210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although considerable progress has been made in regenerative medicine, a quantum step would be the replacement and/or regeneration of functional muscle tissue. For example, although patients' airways can now be successfully replaced with stem cell-based techniques, a much greater patient need would be addressed by regeneration of the muscles required for engineering a functional larynx, in which active movement is critical. The rabbit cricoarytenoid dorsalis muscle was chosen for the present study because it is equivalent to the posterior cricoarytenoid muscle, the only significant abductor muscle in human larynges. METHODS Rabbit cricoarytenoid dorsalis muscles were harvested, and different decellularization methods were compared by use of a combination of histologic, immunohistochemical, and molecular techniques. Decellularized scaffolds were implanted into Sprague-Dawley rats as part of a 2-week biocompatibility study to assess immunogenicity. RESULTS Decellularization with a combination of latrunculin B, potassium iodide, potassium chloride, and deoxyribonuclease resulted in total DNA clearance and reduced levels of major histocompatibility complex class II expression, with relative preservation of the scaffold's structural integrity (collagen, elastin, and glycosaminoglycan content). The scaffolds showed minimal signs of rejection at 2 weeks in a cross-species (xenotransplantation) study. CONCLUSIONS Decellularized laryngeal muscles, which are nonimmunogenic, may provide the optimal scaffold source for the generation of a fully functional tissue-engineered larynx.
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Affiliation(s)
- Jonathan M Fishman
- University College London Institute of Child Health, 30 Guilford St, London WC1N 1EH, United Kingdom
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