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Zuo KJ, Zaccardelli A, Talbot SG. Establishing an upper extremity transplantation program: lessons learnt over 12 years. Curr Opin Organ Transplant 2024:00075200-990000000-00142. [PMID: 39373265 DOI: 10.1097/mot.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024]
Abstract
PURPOSE OF REVIEW As one of the early hand transplant programs in the world, we are often asked to educate other programs on the lessons we have learned and on how to set up a successful hand transplantation program. RECENT FINDINGS Two decades of global experience with vascularized composite allotransplantation (VCA) of the upper limb have demonstrated improved functional outcomes and quality of life for carefully screened patients. Despite initial reticence about VCA, over 30 patients in the USA have benefited from hand transplantation, with around 80% long-term successes. We have experience with four bilateral upper extremity patients who have undergone bilateral upper extremity allotransplants. This review article highlights our personal experience and lessons with respect to VCA team assembly, logistics, patient selection, perioperative planning, the operative procedure, and postoperative management. SUMMARY Continual learning and critical evaluation are crucial to maintaining a successful upper extremity VCA program. This will ensure that patients who stand to benefit most from this life-enhancing procedure are identified and are others optimized to achieve the best possible outcomes.
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Affiliation(s)
- Kevin J Zuo
- Division of Hand & Upper Extremity Surgery, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | | | - Simon G Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Liu KF, Ramachandran S, Chang CW, Chen RF, Huang CH, Huang HT, Lee CC, Li YT, Kuo YR. The Synergistic Effect of Full-Spectrum Light Therapy and Transient Immunosuppressants Prolonged Allotransplant Survival. Plast Reconstr Surg 2024; 154:775-783. [PMID: 37815307 DOI: 10.1097/prs.0000000000011135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND The lifelong administration of immunosuppressants remains the largest drawback in vascularized composite allotransplantation (VCA). Therefore, developing alternative strategies to minimize the long-term use of immunosuppressive agents is crucial. This study investigated whether full-spectrum bright light therapy (FBLT) combined with short-term immunosuppressant therapy could prolong VCA survival in a rodent hindlimb model. METHODS Hindlimb allotransplantation was conducted from Brown-Norway to Lewis rats, and the rats were divided into 4 groups. Group 1 did not receive treatment as a rejection control. Group 2 received FBLT alone. Group 3 was treated with short-term antilymphocyte serum (ALS) and cyclosporine A (CsA). Group 4 was administered short-term ALS/CsA combined with FBLT for 8 weeks. Peripheral blood and transplanted tissues were collected for analysis. RESULTS The results revealed median survival time of FBLT alone (group 2) did not increase allograft survival compared with the control (group 1). However, in group 4, FBLT combined with short-term ALS/CsA, median composite tissue allograft survival time (266 days) was significantly prolonged compared with groups 1 (11 days), 2 (10 days), and 3 (41 days) ( P < 0.01). Group 4 also showed a significant increase in regulatory T cells ( P = 0.04) and transforming growth factor-β1 levels ( P = 0.02), and a trend toward a decrease in interleukin-1β levels ( P = 0.03) at 16 weeks after transplantation as compared with control (group 1). CONCLUSIONS FBLT combined with short-term immunosuppressants prolonged allotransplant survival by modulating T-cell regulatory functions and antiinflammatory cytokine expression. This approach could be a potential strategy to increase VCA survival. CLINICAL RELEVANCE STATEMENT Full-spectrum light therapy could be a potential strategy to increase vascularized composite allotransplant survival.
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Affiliation(s)
- Keng-Fan Liu
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Orthopaedic Research Center, Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University
| | | | - Chao-Wei Chang
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Rong-Fu Chen
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Chao-Hsin Huang
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Han-Ting Huang
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Chia-Chun Lee
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Yun-Ting Li
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
| | - Yur-Ren Kuo
- From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Orthopaedic Research Center, Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital
- Department of Biological Sciences, National Sun Yat-sen University
- Academic Clinical Programme for Musculoskeletal Sciences, Duke-National University of Singapore Graduate Medical School
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Reed ER, Hendrycks R, Graham EM, Rosales M, Mendenhall SD. Wrist-Level Tendon Repairs Utilizing a Novel Tendon Stapler Device: An Efficiency and Biomechanical Study. Plast Reconstr Surg 2024; 154:582-591. [PMID: 37772910 DOI: 10.1097/prs.0000000000011102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND A novel tendon stapler device (TSD) to improve the strength and consistency of primary tendon repairs was recently approved by the U.S. Food and Drug Administration. The authors hypothesized that this TSD would demonstrate faster and superior biomechanical properties compared with a standard suture coaptation. The authors also hypothesized that the TSD biomechanical properties would be consistent across participants with differing tendon repair experiences. METHODS Participants included a novice, intermediate, and expert in tendon repairs. Timed comparisons were performed in flexor zones IV and V and extensor zones VI and VII on human cadaver arms. Suture repairs were performed with a modified Kessler technique with a horizontal mattress. TSD repairs were performed on the matched donor arms. Biomechanical testing included 2-mm gap force, ultimate failure load, and mode of failure. RESULTS In total, 228 tendon coaptations from 12 donor arms were performed and analyzed. TSD coaptations were 3 times faster and withstood nearly 50% higher forces on 2-mm gap testing and roughly 30% higher forces on ultimate failure testing. These findings did not change when the repair times were analyzed by participant. Suture coaptations failed owing to suture pull-through, suture breakage, or knot failure. TSD coaptation failures only occurred from device pull-through. CONCLUSIONS The TSD produces significantly faster and stronger primary tendon coaptations compared with a standard 4-strand core suture repair in human donor arms. The findings demonstrated minimal variability among participants with differing tendon repair experience. Although further investigation is needed, this device has potential to revolutionize tendon repairs.
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Affiliation(s)
- Evelyn R Reed
- From the Division of Plastic Surgery, Department of Surgery
| | | | - Emily M Graham
- Division of Plastic, Reconstructive, and Oral Surgery, Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Megan Rosales
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine
| | - Shaun D Mendenhall
- From the Division of Plastic Surgery, Department of Surgery
- Division of Plastic, Reconstructive, and Oral Surgery, Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
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Kodali NA, Janarthanan R, Sazoglu B, Demir Z, Dirican O, Zor F, Kulahci Y, Gorantla VS. A World Update of Progress in Lower Extremity Transplantation: What's Hot and What's Not. Ann Plast Surg 2024; 93:107-114. [PMID: 38885168 DOI: 10.1097/sap.0000000000004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
ABSTRACT The field of vascularized composite allotransplantation (VCA) is the new frontier of solid organ transplantation (SOT). VCA spans life-enhancing/life-changing procedures such as upper extremity, craniofacial (including eye), laryngeal, tracheal, abdominal wall, penis, and lower extremity transplants. VCAs such as uterus transplants are life giving unlike any other SOT. Of all VCAs that have shown successful intermediate- to long-term graft survival with functional and immunologic outcomes, lower extremity VCAs have remained largely underexplored. Lower extremity transplantation (LET) can offer patients with improved function compared to the use of conventional prostheses, reducing concerns of phantom limb pain and stump complications, and offer an option for eligible amputees that either fail prosthetic rehabilitation or do not adapt to prosthetics. Nevertheless, these benefits must be carefully weighed against the risks of VCA, which are not trivial, including the adverse effects of lifelong immunosuppression, extremely challenging perioperative care, and delayed nerve regeneration. There have been 5 lower extremity transplants to date, ranging from unilateral or bilateral to quadrimembral, progressively increasing in risk that resulted in fatalities in 3 of the 5 cases, emphasizing the inherent risks. The advantages of LET over prosthetics must be carefully weighed, demanding rigorous candidate selection for optimal outcomes.
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Affiliation(s)
- Naga Anvesh Kodali
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Ramu Janarthanan
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Bedreddin Sazoglu
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Zeynep Demir
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Omer Dirican
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Fatih Zor
- Department of Plastic Surgery, Indiana University, Indianapolis, IN
| | - Yalcin Kulahci
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Vijay S Gorantla
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
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Kumnig M, Kobler C, Zaccardelli A, Brandacher G, Talbot SG. Advancing vascularized composite allotransplantation: essential factors for upper extremity transplant program development. FRONTIERS IN TRANSPLANTATION 2024; 3:1406626. [PMID: 38993746 PMCID: PMC11235377 DOI: 10.3389/frtra.2024.1406626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/27/2024] [Indexed: 07/13/2024]
Abstract
Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Kobler
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Gerald Brandacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Simon G. Talbot
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
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Xu G, Zou X, Dong Y, Alhaskawi A, Zhou H, Ezzi SHA, Kota VG, Abdulla MHAH, Alenikova O, Abdalbary SA, Lu H. Advancements in autologous peripheral nerve transplantation care: a review of strategies and practices to facilitate recovery. Front Neurol 2024; 15:1330224. [PMID: 38523615 PMCID: PMC10959128 DOI: 10.3389/fneur.2024.1330224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
Autologous peripheral nerve transplantation, a pioneering technique in nerve injury treatment, has demonstrated remarkable progress. We examine recent nursing strategies and methodologies tailored to various anatomical sites, highlighting their role in postoperative recovery enhancement. Encompassing brachial plexus, upper limb, and lower limb nerve transplantation care, this discussion underscores the importance of personalized rehabilitation plans, interdisciplinary collaboration, and innovative approaches like nerve electrical stimulation and nerve growth factor therapy. Moreover, the exploration extends to effective complication management and prevention strategies, encompassing infection control and pain management. Ultimately, the review concludes by emphasizing the advances achieved in autologous peripheral nerve transplantation care, showcasing the potential to optimize postoperative recovery through tailored and advanced practices.
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Affiliation(s)
- Guoying Xu
- Operating Theater, Shaoxing City Keqiao District Hospital of Traditional Chinese Medicine, Shaoxing, Zhejiang, China
| | - Xiaodi Zou
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yanzhao Dong
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- Faculty of Medicine, School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | | | | | - Olga Alenikova
- Department of Neurology, Republican Research and Clinical Center of Neurology and Neurosurgery, Minsk, Belarus
| | - Sahar Ahmed Abdalbary
- Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt
| | - Hui Lu
- Operating Theater, Shaoxing City Keqiao District Hospital of Traditional Chinese Medicine, Shaoxing, Zhejiang, China
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Kim YH, Choi YR, Joo DJ, Baek WY, Suh YC, Oh WT, Cho JY, Lee SC, Kim SK, Ryu HJ, Jeon KO, Lee WJ, Hong JW. Reaching New Heights: A Comprehensive Study of Hand Transplantations in Korea after Institutionalization of Hand Transplantation Law. Yonsei Med J 2024; 65:108-119. [PMID: 38288651 PMCID: PMC10827641 DOI: 10.3349/ymj.2023.0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE With the revision of the Organ and Transplantation Act in 2018, the hand has become legal as an area of transplantable organs in Korea. In January 2021, the first hand allotransplantation since legalization was successfully performed, and we have performed a total of three successful hand transplantation since then. By comparing and incorporating our experiences, this study aimed to provide a comprehensive reconstructive solution for hand amputation in Korea. MATERIALS AND METHODS Recipients were selected through a structured preoperative evaluation, and hand transplantations were performed at the distal forearm level. Postoperatively, patients were treated with three-drug immunosuppressive regimen, and functional outcomes were monitored. RESULTS The hand transplantations were performed without intraoperative complications. All patients had partial skin necrosis and underwent additional surgical procedures in 2 months after transplantation. After additional operations, no further severe complications were observed. Also, patients developed acute rejection within 3 months of surgery, but all resolved within 2 weeks after steroid pulse therapy. Motor and sensory function improved dramatically, and patients were very satisfied with the appearance and function of their transplanted hands. CONCLUSION Hand transplantation is a viable reconstructive option, and patients have shown positive functional and psychological outcomes. Although this study has limitations, such as the small number of patients and short follow-up period, we should focus on continued recovery of hand function, and be careful not to develop side effects from immunosuppressive drugs. Through the present study, we will continue to strive for a bright future regarding hand transplantation in Korea.
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Affiliation(s)
- Yo Han Kim
- Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Rak Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
- Organ Transplantation Center, Severance Hospital, Seoul, Korea
| | - Dong Jin Joo
- Organ Transplantation Center, Severance Hospital, Seoul, Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Yeol Baek
- Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chul Suh
- Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Won Taek Oh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Yong Cho
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Chul Lee
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kyum Kim
- Department of Diagnostic Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyang Joo Ryu
- Department of Diagnostic Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Ock Jeon
- Organ Transplantation Center, Severance Hospital, Seoul, Korea
| | - Won Jai Lee
- Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Won Hong
- Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
- Organ Transplantation Center, Severance Hospital, Seoul, Korea.
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Goutard M, de Vries RJ, Tawa P, Pendexter CA, Rosales IA, Tessier SN, Burlage LC, Lantieri L, Randolph MA, Lellouch AG, Cetrulo CL, Uygun K. Exceeding the Limits of Static Cold Storage in Limb Transplantation Using Subnormothermic Machine Perfusion. J Reconstr Microsurg 2023; 39:350-360. [PMID: 35764315 PMCID: PMC10848168 DOI: 10.1055/a-1886-5697] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND For 50 years, static cold storage (SCS) has been the gold standard for solid organ preservation in transplantation. Although logistically convenient, this preservation method presents important constraints in terms of duration and cold ischemia-induced lesions. We aimed to develop a machine perfusion (MP) protocol for recovery of vascularized composite allografts (VCA) after static cold preservation and determine its effects in a rat limb transplantation model. METHODS Partial hindlimbs were procured from Lewis rats and subjected to SCS in Histidine-Tryptophan-Ketoglutarate solution for 0, 12, 18, 24, and 48 hours. They were then either transplanted (Txp), subjected to subnormothermic machine perfusion (SNMP) for 3 hours with a modified Steen solution, or to SNMP + Txp. Perfusion parameters were assessed for blood gas and electrolytes measurement, and flow rate and arterial pressures were monitored continuously. Histology was assessed at the end of perfusion. For select SCS durations, graft survival and clinical outcomes after transplantation were compared between groups at 21 days. RESULTS Transplantation of limbs preserved for 0, 12, 18, and 24-hour SCS resulted in similar survival rates at postoperative day 21. Grafts cold-stored for 48 hours presented delayed graft failure (p = 0.0032). SNMP of limbs after 12-hour SCS recovered the vascular resistance, potassium, and lactate levels to values similar to limbs that were not subjected to SCS. However, 18-hour SCS grafts developed significant edema during SNMP recovery. Transplantation of grafts that had undergone a mixed preservation method (12-hour SCS + SNMP + Txp) resulted in better clinical outcomes based on skin clinical scores at day 21 post-transplantation when compared to the SCS + Txp group (p = 0.01613). CONCLUSION To date, VCA MP is still limited to animal models and no protocols are yet developed for graft recovery. Our study suggests that ex vivo SNMP could help increase the preservation duration and limit cold ischemia-induced injury in VCA transplantation.
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Affiliation(s)
- Marion Goutard
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Reinier J. de Vries
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Amsterdam University Medical Centers – location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pierre Tawa
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
| | - Casie A. Pendexter
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ivy A. Rosales
- Immunopathology Research Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon N. Tessier
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura C. Burlage
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
- Division of Plastic and Reconstructive Surgery within the Department of Surgery, Radboudumc, Radboud University, Nijmegen, the Netherlands
| | - Laurent Lantieri
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Mark A. Randolph
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
| | - Alexandre G. Lellouch
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Curtis L. Cetrulo
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
| | - Korkut Uygun
- Department of Surgery, Harvard Medical School, Harvard Medical School, Boston, Massachusetts
- Department of Research, Shriners Children’s, Boston, Massachusetts
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
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9
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Boczar D, Seu M, O’Connell A, Gersh E, Chaya BF, Berman Z, Ruiz N, Welsh L, Rodriguez ED. Hand Therapy Regimen for Functional Recovery Following Combined Face and Bilateral Hand Transplantation. Hand (N Y) 2023; 18:NP7-NP15. [PMID: 36214276 PMCID: PMC10152528 DOI: 10.1177/15589447221124250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Intensive postoperative rehabilitation therapy is associated with positive functional recovery in hand transplants (HTs). Our goal is to share the hand therapy protocol developed for our patient who underwent a combined face and bilateral HT. The patient is a 23-year-old right-hand-dominant male with a history of third-degree burns to 80% of his body following a motor vehicle accident. A multidisciplinary evaluation established his candidacy for a combined face and bilateral HT, and surgery took place in August 2020. Our individualized hand therapy protocol consisted of 4 phases. The pre-surgery phase focused on planning the orthotics and patient/caregivers' education on the rehabilitation process. The intensive care unit (ICU)/acute care phase involved hand allograft protection and positioning via orthotic fabrication, safe limb handling, and edema/wound management. The inpatient rehabilitation phase aimed to prepare the patient for independent living via neuromuscular and sensory re-education, improvement of upper extremities strength/flexibility, training basic activities of daily living, and providing a home exercise program (HEP). Finally, the outpatient phase aimed to maximize our patient's range of motion and independency in performing his routine activities and HEP. The patient's post-transplant functional outcomes showed a significant improvement compared to the pre-operative baseline. We hope this report sheds light on a comprehensive hand therapy program in HT.
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Affiliation(s)
- Daniel Boczar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Monica Seu
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - April O’Connell
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Eugene Gersh
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Bachar F. Chaya
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Zoe Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Natalia Ruiz
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Laura Welsh
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Eduardo D. Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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Aravind P, Frost C, Javia V, Cooney DS, Brandacher G, Shores JT, Cooney CM. Special Considerations for Secondary Surgery After Upper Extremity Transplantation. Hand (N Y) 2022; 17:969-974. [PMID: 33190550 PMCID: PMC9465781 DOI: 10.1177/1558944720966723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Upper extremity (UE) transplantation is a complex undertaking that may require emergent or elective secondary surgery (SS) days to years following transplant. Various patient and transplantation may help determine what SS is needed. In this study, we characterize the SS needed by our UE transplant patients. METHODS We retrospectively reviewed 6 patients who underwent hand and UE transplantation by one of the authors. Transplantation and SS details were obtained from medical records. Hand and arm function was quantified both subjectively (patient-reports) and objectively (Disabilities of the Arm, Shoulder, and Hand Score; Carroll test; Action Research Arm Tests; Box and Block test). RESULTS Six patients underwent transplantation for a total of 10 transplanted limbs. Five transplants were performed below and 5 above the elbow. Mean time post-transplantation at last follow-up was 5 years (range: 1-9 years). In all, 66.7% of the patients required SS: total 7 surgeries comprising 13 procedures. The most common procedures were to improve hand function-nerve decompressions and tendon transfer, both in above-elbow transplant. Both patients showed a mean improvement of 15 points on Carroll scores. One above-elbow transplant had a brachioplasty for excess skin and another had a hematoma evacuation immediately after transplantation. Procedures in the below-elbow transplants included multiple incision and drainages for a septic wrist and an open reduction and internal fixation for a forearm fracture. CONCLUSION Patients receiving UE transplantation often require one or more secondary procedures which may vary with level of transplantation. Secondary surgery should be an important aspect of pretransplant planning and cost-effectiveness determinations. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Pathik Aravind
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Vidhi Javia
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Damon S. Cooney
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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11
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Levy TJ, Tyner CE, Amaral S, Lefkowitz DS, Kessler SK, Levin LS. 5-Year Activity and Participation Outcomes of the First Successful Pediatric Bilateral Hand Transplantation: A Case Report. Phys Occup Ther Pediatr 2022; 42:663-679. [PMID: 35379065 DOI: 10.1080/01942638.2022.2057210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Describe the 5-year outcomes of the first successful pediatric bilateral hand transplantation. METHODS The child underwent quadrimembral amputation at age two and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes, patient-reported measures, and parent-reported measures were repeated over a 5-year period. RESULTS Observation assessments revealed functional dexterity skills and modified independence to full independence with self-care activities. The parent reported the child had moderate difficulty with upper extremity functioning 25-, 41-, and 48-months post-transplantation, and mild difficulty at 60-months; the child reported no difficulties in this domain at 41 months. Five years post-transplantation the child reported enjoying many age-appropriate activities, and high-quality peer relations were endorsed by both parent and child. CONCLUSION The child developed hand movements for daily activities and was completing daily activities with improved efficiency. Health-related quality of life outcomes were favorable.
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Affiliation(s)
- Todd J Levy
- Center for Rehabilitation, Occupational Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Callie E Tyner
- Center for Health Assessment Research and Translation, University of Delaware, Newark, Delaware, USA
| | - Sandra Amaral
- Departments of Pediatrics and Epidemiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Debra S Lefkowitz
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sudha K Kessler
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - L Scott Levin
- Paul B Magnusson Professor and Chairman of Orthopedic Surgery, Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA.,Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Mangled upper extremity: Our strategy of reconstruction and clinical results. Injury 2021; 52:3588-3604. [PMID: 33867148 DOI: 10.1016/j.injury.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 04/04/2021] [Indexed: 02/02/2023]
Abstract
The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.
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13
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Ruiz-Moya A, Infante-Cossio P, Gomez-Ciriza G, Gomez-Ciriza M, Gomez-Cia T. Donor-recipient matching in hand transplantation: a comparison of anthropometric measurements, 3-dimensional virtual models and printed epitheses. J Hand Surg Eur Vol 2021; 46:995-1002. [PMID: 34107785 DOI: 10.1177/17531934211021548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Donor-recipient matching in hand transplantation remains challenging. The usefulness of three-dimensional (3-D) virtual models and printed epitheses were compared with measurements on cadaveric extremities to evaluate the most accurate method of donor-recipient matching for allograft procurement. Ten anthropometric measurements were recorded from 12 human cadaveric upper extremities and matched to printed epitheses and 3-D virtual models. Five circumferential and two longitudinal measurements obtained an intra-class correlation of >0.75 with all three methods, with the Kaplan (0.973) and wrist circumferences (0.942) achieving the highest concordance. Measurement on cadaveric specimens was the most reliable method. Using different combinations of donor hand and recipient forearms, a series of 72 virtual transplantations were then created, and their compatibility rated by ten transplant surgeons. The results confirmed that anthropometric measurements, obtained directly from potential human donor limbs and based on wrist circumference as the primary parameter, provide the best and most clinically relevant donor-recipient match.
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Affiliation(s)
- Alejandro Ruiz-Moya
- Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Seville, Spain
| | | | - Gorka Gomez-Ciriza
- FABLAB, Biomedical Institute of Seville (IBiS)/Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
| | - Mikel Gomez-Ciriza
- FABLAB, Biomedical Institute of Seville (IBiS)/Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
| | - Tomas Gomez-Cia
- Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Seville, Spain
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14
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Chen PN, Ramachandran S, Kuo YR. Application of stroke volume variation for optimized hemodynamic monitoring in hand allotransplantation. Microsurgery 2021; 42:97-98. [PMID: 34713916 DOI: 10.1002/micr.30833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/15/2021] [Accepted: 09/13/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Po-Nien Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore, Singapore.,Department of Plastic and Reconstructive Surgery, KK Women's and Children's Hospital, Kaohsiung, Taiwan
| | - Yur-Ren Kuo
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.,Academic Clinical Programme for Musculoskeletal Sciences, Duke-NUS Graduate Medical School, Singapore
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15
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Lupon E, Cetrulo CL, Lantieri LA, Lellouch AG. Vascularized Composite Allotransplantation in a Post-COVID-19 Pandemic World. Plast Reconstr Surg 2021; 148:315e-317e. [PMID: 34228010 PMCID: PMC8312337 DOI: 10.1097/prs.0000000000008134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elise Lupon
- Department of Plastic Surgery, University Toulouse III Paul Sabatier, Toulouse, France, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Department of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laurent A Lantieri
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France
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16
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Mendenhall SD, Lutfy J, Graham E, Overschmidt B, Levin LS, Neumeister MW. Technique for Rapid Hand Transplant Donor Procurement Through the Elbow. Hand (N Y) 2021; 16:391-396. [PMID: 31331207 PMCID: PMC8120581 DOI: 10.1177/1558944719863127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.
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Affiliation(s)
- Shaun D. Mendenhall
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA,Shaun D. Mendenhall, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 E, 3B400, Salt Lake City, UT 84132, USA.
| | - Justyn Lutfy
- Kootenay Surgery Clinic, Trail, British Columbia, Canada
| | - Emily Graham
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Bo Overschmidt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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17
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Grajek M, Bula D, Zeman M, Maciejewski A. Limitations and limits and of vascularized composite allotransplantations: can we reach the holy grail? Curr Opin Organ Transplant 2020; 25:609-614. [PMID: 33105202 DOI: 10.1097/mot.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In recent times, vascularized composite allotransplantation (VCA) have been gaining more attention and applications. Currently, VCA are at the highest level of the reconstruction pyramid, and thus the effects expected after them are intended to outweigh what the 'classical' reconstructive surgery can offer us, including even the most advanced microsurgical techniques. RECENT FINDINGS Over 40 patients have received a partial or full-face transplant. Others have received penis, uterus, larynx, abdominal wall, and lower extremity transplants. Each type of VCA has its own problems and limitations. However, resolving the limits defined by immunosuppression and improved donor selection would revolutionize all of them. SUMMARY Defining the limits and limitations of given procedures will not only allow for better preparation of transplant teams but will also help in determining the direction of future research.
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Affiliation(s)
- Maciej Grajek
- Oncological and Reconstructive Surgery Department, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
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18
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Upper extremity and craniofacial vascularized composite allotransplantation: ethics and immunosuppression. Emerg Top Life Sci 2019; 3:681-686. [PMID: 32915212 DOI: 10.1042/etls20190060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/02/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022]
Abstract
Vascularized composite allotransplantation (VCA) is the name most often used to refer to the transplantation of anatomical units composed of multiple tissue types (skin, bone, muscle, tendon, nerves, vessels, etc.) when such transplants do not have the primary purpose of extending life, as is the case in the more familiar field of solid organ transplantation (SOT). A serious interest in VCA developed in the late twentieth century following advances in immunosuppression which had led to significant improvements in short and medium-term survival among SOT recipients. Several ethical concerns have been raised about VCA, with many being connected in one way or another to the limitations, burdens, and risks associated with immunosuppression. This article will focus on upper extremity and craniofacial VCA, beginning with a brief review of the history of VCA including reported outcomes, followed by a discussion of the range of ethical concerns, before exploring in greater detail how immunological issues inform and shape several of the ethical concerns.
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