Risk Acceptance in Laryngeal Transplantation

Voice Rehabilitation After Laryngeal Transplantation: Own Experience

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.

Laryngeal graft after total laryngectomy in humans: A SWiM analysis

Evaluation of the results of laryngeal transplantation (LT) in humans. Analysis of 3 bibliographic databases with the keywords "larynx, transplantation, autograft". In total, 626 abstracts were read and 25 articles selected. The main objective was to analyze the characteristics of laryngeal transplant patients. The accessory objectives comprised analysis of operative technique, immunosuppressive treatment and results. Four articles were selected for analysis. Two patients were transplanted after total laryngectomy for laryngeal carcinoma and 2 after laryngeal trauma. Three of the 4 patients had true transplantation with arterial, venous and neural microanastomosis. Two patients were decannulated and the tracheostomy tube was maintained in the other 2. Three of the 4 patients had good-quality phonation and could feed without a gastric tube. One patient died of carcinoma progression and 1 patient had to be explanted 14 years after transplantation. The number of LTs reported is too small for scientific determination of the place of this intervention in laryngology. The published results could, at first sight, suggest that the future of LT is uncertain. However, several elements, also suggest that otolaryngologists should continue to take an interest in this technique.

Decellularized tracheal scaffolds in tracheal reconstruction: An evaluation of different techniques

In humans, the trachea is a conduit for ventilation connecting the throat and lungs. However, certain congenital or acquired diseases may cause long-term tracheal defects that require replacement. Tissue engineering is considered a promising method to reconstruct long-segment tracheal lesions and restore the structure and function of the trachea. Decellularization technology retains the natural structure of the trachea, has good biocompatibility and mechanical properties, and is currently a hotspot in tissue engineering studies. This article lists various recent representative protocols for the generation of decellularized tracheal scaffolds (DTSs), as well as their validity and limitations. Based on the advancements in decellularization methods, we discussed the impact and importance of mechanical properties, revascularization, recellularization, and biocompatibility in the production and implantation of DTS. This review provides a basis for future research on DTS and its application in clinical therapy.

Body Image in Liver Transplantation Recipients

Body image (BI) concerns have been reported to play a significant role in the psychological adaptation after organ transplantation. There is a paucity of data about BI beliefs in liver transplant recipients. We report the results of a cross-sectional study of 177 liver transplant recipients for whom we assessed BI, anxiety, depression, and quality of life (QOL) using validated instruments. Our results indicate that higher BI concerns correlated with higher levels of anxiety and depression. BI concerns were more elevated in females, younger patients, and patients with a lower income. Patients with chronic liver disease had more BI concerns than patients who received liver transplantation for acute liver failure. Specific BI concerns also correlated independently with QOL scores. We conclude that BI concerns are significant in liver transplant recipients and should be evaluated by clinicians involved in the mental health care of this population.

The current status of human laryngeal transplantation in 2017: A state of the field review

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.

Body image in transplant recipients and living organ donors

PURPOSE OF REVIEW

The purpose of this article is to describe the current evidence regarding the prevalence and significance of concerns about body image in transplant recipients and organ donors.

RECENT FINDINGS

Body image and organ integration concerns have been reported as main themes in the psychological adaptation to transplantation. Their prevalence, severity, description and impact vary wildly. There is a lack of validated instruments to measure body image or organ integration in transplant patients. For organ recipients, satisfaction with body image depends on the organ, genre, pretransplant medical illness, time since transplantation and post-transplant medication regimen. Complete or partial denial of the graft is frequently reported. For organ donors, body image is influenced by the type of surgical incision. There is little evidence that body image or organ integration impact medical or psychological outcomes after transplantation or organ donation.

SUMMARY

Body image is becoming a significant component of measuring the quality of life in transplant patients. Body image may become a factor in decisions about if and when to pursue transplant for nonlife-threatening conditions (e.g. face transplantation), about the type of incision or about the immunosuppressant regimen. For mental health professionals, understanding the complexities of body image and organ integration will help enhance the assistance provided before and after transplant or donation.

Risk acceptance and expectations of laryngeal allotransplantation

BACKGROUND

Laryngeal allotransplantation (LA) is a technique involving transplantation of a deceased donor's larynx into a recipient, and it may be substituted for conventional laryngeal reconstruction. There are widely different views on LA, as the recipient is administered continuous, potentially life-threatening, immunosuppressive therapy for a functional or aesthetic result, which is not directly related to life extension. The purpose of this study was to analyze the difference in risk acceptance and expectations of LA between four population groups.

METHODS

A survey was performed to examine patients' risk acceptance and expectations of LA. The survey included 287 subjects in total (general public, n=100; kidney transplant recipients, n=53; post-laryngectomy patients, n=34; doctors, n=100), using a Korean translated version of the louisville instrument for transplantation (LIFT) questionnaire.

RESULTS

All four groups responded differently at various levels of their perception in risk acceptance and expectations. The kidney transplant recipients reported the highest risk acceptance and expectations, and the doctor group the lowest.

CONCLUSIONS

This study examined the disparate perception between specific population groups of the risks and benefits of using LA for the promotion of the quality of life. By addressing the information gaps about LA in the different populations that have been highlighted from this survey, we suggest that LA can become a more viable alternative to classical surgery with resultant improved quality of life for patients.

Stem cell-based organ replacements-airway and lung tissue engineering

Tissue engineering requires the use of cells seeded onto scaffolds, often in conjunction with bioactive molecules, to regenerate or replace tissues. Significant advances have been made in recent years within the fields of stem cell biology and biomaterials, leading to some exciting developments in airway tissue engineering, including the first use of stem cell-based tissue-engineered tracheal replacements in humans. In addition, recent advances within the fields of scaffold biology and decellularization offer the potential to transplant patients without the use of immunosuppression.

Quantifying benefit-risk preferences for medical interventions: an overview of a growing empirical literature

Decisions regarding the development, regulation, sale, and utilization of pharmaceutical and medical interventions require an evaluation of the balance between benefits and risks. Such evaluations are subject to two fundamental challenges-measuring the clinical effectiveness and harms associated with the treatment, and determining the relative importance of these different types of outcomes. In some ways, determining the willingness to accept treatment-related risks in exchange for treatment benefits is the greater challenge because it involves the individual subjective judgments of many decision makers, and these decision makers may draw different conclusions about the optimal balance between benefits and risks. In response to increasing demand for benefit-risk evaluations, researchers have applied a variety of existing welfare-theoretic preference methods for quantifying the tradeoffs decision makers are willing to accept among expected clinical benefits and risks. The methods used to elicit benefit-risk preferences have evolved from different theoretical backgrounds. To provide some structure to the literature that accommodates the range of approaches, we begin by describing a welfare-theoretic conceptual framework underlying the measurement of benefit-risk preferences in pharmaceutical and medical treatment decisions. We then review the major benefit-risk preference-elicitation methods in the empirical literature and provide a brief overview of the studies using each of these methods. The benefit-risk preference methods described in this overview fall into two broad categories: direct-elicitation methods and conjoint analysis. Rating scales (6 studies), threshold techniques (9 studies), and standard gamble (2 studies) are examples of direct elicitation methods. Conjoint analysis studies are categorized by the question format used in the study, including ranking (1 study), graded pairs (1 study), and discrete choice (21 studies). The number of studies reviewed here demonstrates that this body of research already is substantial, and it appears that the number of benefit-risk preference studies in the literature will continue to increase. In addition, benefit-risk preference-elicitation methods have been applied to a variety of healthcare decisions and medical interventions, including pharmaceuticals, medical devices, surgical and medical procedures, and diagnostics, as well as resource-allocation decisions such as facility placement. While preference-elicitation approaches may differ across studies, all of the studies described in this review can be used to provide quantitative measures of the tradeoffs patients and other decision makers are willing to make between benefits and risks of medical interventions. Eliciting and quantifying the preferences of decision makers allows for a formal, evidence-based consideration of decision-makers' values that currently is lacking in regulatory decision making. Future research in this area should focus on two primary issues-developing best-practice standards for preference-elicitation studies and developing methods for combining stated preferences and clinical data in a manner that is both understandable and useful to regulatory agencies.

Laryngeal transplantation in minipigs: vascular, myologic and functional outcomes

There is no effective way of replacing all the functions of the larynx in those requiring laryngectomy. Regenerative medicine offers promise, but cannot presently deliver implants with functioning neuromuscular units. A single well-documented laryngeal transplant in man was a qualified success, but more information is required before clinical trials may be proposed. We studied the early response of the larynx to laryngeal transplantation between 17 pairs of NIH minipigs full matched at the MHC2 locus. Following iterative technical improvements, pigs had good swallowing and a patent airway at 1 week. No significant changes in mucosal blood flux were observed compared with pre-operative measurements. Changes in muscle morphology and fibre phenotype were observed in transplant muscles retrieved after 7 days: the levels of fast and slow myosin heavy chain (MyHC) protein were reduced and embryonic MyHC was up regulated consistent with denervation induced atrophy. At 1 week laryngeal transplantation can result in good swallowing, and is not associated with clinical evidence of ischemia-reperfusion injury in MHC-matched pigs.

[Facial graft, archetype of microsurgical innovation?]

Is innovation breaking of the way of thinking, breaker of taboos, concretisation of chimeras or simple benefit of an ineluctable evolution? The surgical act should be considered as innovation itself? From the first facial allotransplantation, innovation is declined in various ways, which could constitute the different answers regarding the planning and management to prepare such surgery, the realisation of the transplantation and also the multiple developments in terms of science and medicine. It is exactly in that meaning that could be really mentioned the term archetypal.

Reconstruction of the esophagus and voice

BACKGROUND

Esophageal defects are reconstructed using a variety of methods and tissue types. The choice depends on the location of the defect, the condition of the patient, and the flaps that are available for reconstruction. Often, patients with esophageal defects also lack a mechanism for voice production following a total laryngectomy procedure.

METHODS

A review of the literature was performed for esophagus reconstruction and voice rehabilitation following laryngectomy. Methods of voice restoration using intestinal transfers are presented based on the authors' experience.

RESULTS

Several methods of esophagus and voice restoration can achieve excellent functional outcomes.

CONCLUSION

Esophagus reconstruction and voice rehabilitation following esophageal resection and total laryngectomy are possible using a variety of flaps with good functional outcomes.

Réalités et perspectives des allotransplantations laryngées

Laryngeal stenosis or amputation for tumor definitely impairs laryngeal functions with negative impact on quality of life. Experimental laryngeal transplantation has been carried out for nearly 40 years hoping that human transplantation would become feasible in the near future. Nearly 10 years ago, a 40 years old man with a long-standing history of recalcitrant laryngeal stenosis, benefited from a vascularized laryngeal allotransplantation. Speech and deglutition resumed quickly making of this first attempt a success. Although a tracheostomy canula and immunosuppressive regimen are still necessary, this man enjoyed a tremendous improvement in this quality of life. Cumulated experiences tend to demonstrate that laryngeal transplantation in human is not only feasible, but may represents the only chance for rehabilitation of number of laryngeal cripple. Induction of a functional tolerance may allow the necessary evaluation of laryngeal allotransplantation in humans.

Research and Events Leading to Facial Transplantation

Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.