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Gaetz W, Dockstader C, Furlong PL, Amaral S, Vossough A, Schwartz ES, Roberts TPL, Scott Levin L. Somatosensory and motor representations following bilateral transplants of the hands: A 6-year longitudinal case report on the first pediatric bilateral hand transplant patient. Brain Res 2023; 1804:148262. [PMID: 36706858 DOI: 10.1016/j.brainres.2023.148262] [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: 11/11/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023]
Abstract
A vascularized composite tissue allotransplantation (VCA) was performed at the Children's Hospital of Philadelphia (CHOP), on an 8-year-old patient in 2015, six years after bilateral hand and foot amputation. Hand VCA resulted in reafferentation of the medial, ulnar, and radial nerves serving hand somatosensation and motor function. We used magnetoencephalography (MEG) to assess somatosensory cortical plasticity following the post-transplantation recovery of the peripheral sensory nerves of the hands. Our 2-year postoperative MEG showed that somatosensory lip representations, initially observed at "hand areas", reverted to canonical, orthotopic lip locations with recovery of post-transplant hand function. Here, we continue the assessment of motor and somatosensory responses up to 6-years post-transplant. Magnetoencephalographic somatosensory responses were recorded eight times over a six-year period following hand transplantation, using a 275-channel MEG system. Somatosensory tactile stimuli were presented to the right lower lip (all 8 visits) as well as right and left index fingers (visits 3-8) and fifth digits (visits 4-8). In addition, left and right-hand motor responses were also recorded for left index finger and right thumb (visit 8 only).During the acute recovery phase (visits 3 and 4), somatosensory responses of the digits were observed to be significantly larger and more phasic (i.e., smoother) than controls. Subsequent measures showed that digit responses maintain this atypical response profile (evoked-response magnitudes typically exceed 1 picoTesla). Orthotopic somatosensory localization of the lip, D2, and D5 was preserved. Motor beta-band desynchrony was age-typical in localization and response magnitude; however, the motor gamma-band response was significantly larger than that observed in a reference population.These novel findings show that the restoration of somatosensory input of the hands resulted in persistent and atypically large cortical responses to digit stimulation, which remain atypically large at 6 years post-transplant; there is no known perceptual correlate, and no reports of phantom pain. Normal somatosensory organization of the lip, D2, and D5 representation remain stable following post-recovery reorganization of the lip's somatosensory response.
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Affiliation(s)
- W Gaetz
- Lurie Family Foundations' MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia PA, USA; Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - C Dockstader
- Human Biology Program, University of Toronto, Toronto ON, Canada
| | - P L Furlong
- Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
| | - S Amaral
- Department of Pediatrics, Division of Nephrology, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - A Vossough
- Lurie Family Foundations' MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia PA, USA; Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Neuroradiology, Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - E S Schwartz
- Lurie Family Foundations' MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia PA, USA; Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Neuroradiology, Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - T P L Roberts
- Lurie Family Foundations' MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia PA, USA; Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, PA 19104, USA
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Galvao FHF, Araki J, Fonseca ABS, Cruz RJ, Lanchotte C, Waisberg DR, Chaib E, Nacif LS, Traldi MCDC, de Mello EB, Andraus W, Carneiro-D'Albuquerque L. Multivisceral transplantation of pelvic organs in rats. Front Surg 2023; 10:1086651. [PMID: 37151860 PMCID: PMC10159176 DOI: 10.3389/fsurg.2023.1086651] [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: 11/01/2022] [Accepted: 03/15/2023] [Indexed: 05/09/2023] Open
Abstract
Background Multivisceral transplantation of pelvic organs would be a potential treatment for severe pelvic floor dysfunction with fecal and urinary incontinence, extensive perineal trauma, or congenital disorders. Here, we describe the microsurgical technique of multivisceral transplantation of pelvic organs, including the pelvic floor, in rats. Donor operation We performed a perineal (including the genitalia, anus, muscles, and ligaments) and abdominal incision. The dissection progressed near the pelvic ring, dividing ligaments, muscles, external iliac vessels, and pudendal nerves, allowing pelvic floor mobilization. The aorta and vena cava were isolated distally, preserving the internal iliac and gonadal vessels. The graft containing the skin, muscles, ligaments, bladder, ureter, rectum, anus and vagina, uterus and ovarian (female), or penile, testis and its ducts (male) was removed en bloc, flushed, and cold-stored. Recipient operation The infrarenal aorta and vena cava were isolated and donor/recipient aorta-aorta and cava-cava end-to-side microanastomoses were performed. After pelvic floor and viscera removal, we performed microanastomoses between the donor and the recipient ureter, and the rectum and pudenda nerves. The pelvic floor was repositioned in its original position (orthotopic model) or the abdominal wall (heterotopic model). We sacrificed the animals 2 h after surgery. Results We performed seven orthotopic and four heterotopic transplantations. One animal from the orthotopic model and one from the heterotopic model died because of technical failure. Six orthotopic and three heterotopic recipients survived up to 2 h after transplantation. Conclusion The microsurgical technique for pelvic floor transplantation in rats is feasible, achieving an early survival rate of 81.82%.
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Affiliation(s)
- Flavio Henrique Ferreira Galvao
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Correspondence: Flavio Henrique Ferreira Galvao Av. Dr. Arnaldo 433, sala 3210. Sao Paulo-SP, Brazil. 01246-903
| | - Jun Araki
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Ana Bruna Salles Fonseca
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ruy Jorge Cruz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Cinthia Lanchotte
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniel Reis Waisberg
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eleazar Chaib
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Souto Nacif
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Clara de Camargo Traldi
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Estrella Bianco de Mello
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Carneiro-D'Albuquerque
- Laboratory of Medical Investigation 37, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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A Systematic Review of the Reported Complications Related to Facial and Upper Extremity Vascularized Composite Allotransplantation. J Surg Res 2023; 281:164-175. [PMID: 36162189 DOI: 10.1016/j.jss.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Twenty three years after the first successful upper extremity transplantation, the role of vascularized composite allotransplantation (VCA) in the world of transplantation remains controversial. Face and upper extremity reconstruction via transplantation have become successful options for highly selected patients with severe tissue and functional deficit when conventional reconstructive options are no longer available. Despite clear benefit in these situations, VCA has a significant potential for complications that are more frequent when compared to visceral organ transplantation. This study intended to perform an updated systematic review on such complications. MATERIALS AND METHODS MEDLINE database via PubMed, Embase and Cochrane Library were searched. Face and upper extremity VCA performed between 1998 and 2021 were included in the study. Relevant media and press conferences reports were also included. Complications related to face and upper extremity VCA were recorded and reviewed including their clinical characteristics and complications. RESULTS One hundred fifteen patients underwent facial (43%) or upper extremity (57%) transplantation. Overall, the surgical complication rate was 23%. Acute and chronic rejection was identified in 89% and 11% of patients, respectively. Fifty eight percent of patients experienced opportunistic infection. Impaired glucose metabolism was the most common immunosuppression-related complication other than infection. Nineteen percent of patients ultimately experienced partial or complete allograft loss. CONCLUSIONS Complications related to VCA are a significant source of morbidity and potential mortality. Incidence of such complications is higher than previously reported and should be strongly emphasized in patient consent process. Strict patient selection criteria, complex preoperative evaluation, consideration of alternatives, and thorough disclosure to patients should be routinely performed prior to VCA indication.
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Amin KR, Fildes JE. Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb. Front Surg 2022; 9:873507. [PMID: 35599802 PMCID: PMC9122218 DOI: 10.3389/fsurg.2022.873507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
Twenty years have surpassed since the first vascularised composite allotransplantation (VCA) of the upper limb. This is an opportunity to reflect on the position of VCA as the gold standard in limb reconstruction. The paucity of recipients, tentative clinical outcomes, and insufficient scientific progress question whether VCA will remain a viable treatment option for the growing numbers of amputees. Bionic technology is advancing at a rapid pace. The prospect of widely available, affordable, safely applied prostheses with long-standing functional benefit is appealing. Progress in the field stems from the contributions made by engineering, electronic, computing and material science research groups. This review will address the ongoing reservations surrounding VCA whilst acknowledging the future impact of bionic technology as a realistic alternative for limb reconstruction.
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Affiliation(s)
- Kavit R. Amin
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Correspondence: Kavit R. Amin ;
| | - James E. Fildes
- The Ex-Vivo Research Centre CIC, Alderley Park, Macclesfield, United Kingdom
- The Healthcare Technologies Institute, School of Chemical Engineering, University of Birmingham, Birmingham, United Kingdom
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Abstract
BACKGROUND Recent progress in biomechatronics and vascularized composite allotransplantation have occurred in the absence of congruent advancements in the surgical approaches generally utilized for limb amputation. Consideration of these advances, as well as of both novel and time-honored reconstructive surgical techniques, argues for a fundamental reframing of the way in which amputation procedures should be performed. METHODS We review sentinel developments in external prosthetic limb technology and limb transplantation, in addition to standard and emerging reconstructive surgical techniques relevant to limb modification, and then propose a new paradigm for limb amputation. RESULTS An approach to limb amputation based on the availability of native tissues is proposed, with the intent of maximizing limb function, limiting neuropathic pain, restoring limb perception/proprioception and mitigating limb atrophy. CONCLUSIONS We propose a reinvention of the manner in which limb amputations are performed, framed in the context of time-tested reconstructive techniques, as well as novel, state-of-the-art surgical procedures. Implementation of the proposed techniques in the acute setting has the potential to elevate advanced limb replacement strategies to a clinical solution that perhaps exceeds what is possible through traditional surgical approaches to limb salvage. We therefore argue that amputation, performed with the intent of optimizing the residuum for interaction with either a bionic or a transplanted limb, should be viewed not as a surgical failure, but as an alternative form of limb reconstruction.
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Zuo KJ, Gold A, Zlotnik Shaul R, Ho ES, Borschel GH, Zuker RM. Pediatric Upper Extremity Vascularized Composite Allotransplantation—Progress and Future. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00297-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The current outcomes and future challenges in pediatric vascularized composite allotransplantation. Curr Opin Organ Transplant 2020; 25:576-583. [PMID: 33044345 DOI: 10.1097/mot.0000000000000809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation. RECENT FINDINGS In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression. SUMMARY Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.
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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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Rifkin WJ, David JA, Plana NM, Kantar RS, Diaz-Siso JR, Gelb BE, Ceradini DJ, Rodriguez ED. Achievements and Challenges in Facial Transplantation. Ann Surg 2019; 268:260-270. [PMID: 29489486 DOI: 10.1097/sla.0000000000002723] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
: The first facial transplantation in 2005 ushered in a new era in reconstructive surgery, offering new possibilities for the repair of severe disfigurements previously limited by conventional techniques. Advances in allograft design, computerized preoperative planning, surgical technique, and postoperative revisions have helped push the boundaries in this new frontier of vascularized composite allotransplantation. Over the past 12 years, 40 of these procedures have been performed across the world, offering the field the opportunity to reflect on current outcomes. Successes achieved in the brief history of facial transplantation have resulted in a new set of obstacles the field must now overcome. In this review, we aim to highlight the achievements, major challenges, and future directions of this rapidly evolving field.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Joshua A David
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Natalie M Plana
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Bruce E Gelb
- Division of Transplant Surgery, NYU Langone Health, New York, NY
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
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Honeyman C, Fries CA. Vascularised Composite Allotransplantation – Basic Science and Clinical Applications. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Is Lower Extremity Transplantation a Superior Alternative to Prostheses? No—At Least Not Yet. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0217-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kulahci Y, Karagoz H, Zor F. Experimental Models of Penile and Lower Limb Transplantation: Are They Really Translational? CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0216-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Vascularized composite allotransplantation in children: what we can learn from solid organ transplantation. Curr Opin Organ Transplant 2018; 23:605-614. [DOI: 10.1097/mot.0000000000000576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Stem cell-based approaches to enhance nerve regeneration and improve functional outcomes in vascularized composite allotransplantation. Curr Opin Organ Transplant 2018; 23:577-581. [PMID: 30138147 DOI: 10.1097/mot.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The current review will discuss the current understanding of nerve regeneration in vascularized composite allotransplantation (VCA). The success of proximal arm and leg transplants has been hampered by the limitations of nerve regrowth across long distances resulting in poor regeneration and functional recovery. Relevant research in stem-cell therapies to overcome these issues will be reviewed. RECENT FINDINGS The effect of rejection on nerve regeneration in the VCA may be unpredictable and may be quite different for the nerve allograft. The issues that limit functional outcome are likely common to both VCA and proximal nerve injuries or replantation. Stem-cell therapies have focused on augmenting Schwann cell function and appear promising. SUMMARY A better understanding of the effects of transplant rejection on nerve regeneration and function, as well as the factors that affect regeneration over long distances may inform further therapeutic approaches for improvement.
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Kollar B, Tasigiorgos S, Dorante MI, Carty MJ, Talbot SG, Pomahac B. Innovations in reconstructive microsurgery: Reconstructive transplantation. J Surg Oncol 2018; 118:800-806. [PMID: 30098294 DOI: 10.1002/jso.25147] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 12/17/2022]
Abstract
In the past 20 years, reconstructive transplantation (RT) has emerged as a viable reconstructive option for carefully selected patients. More than 100 upper extremity and 40 face transplants have been performed worldwide to date. Concomitantly, the portfolio of reconstructive transplantation has been extended by additional procedures such as lower extremities, abdominal wall, neck, uterus, genitourinary, and pediatric transplants. In the present review article, we aim to summarize the current state of knowledge about this exciting field.
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Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Miguel I Dorante
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Carty
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon G Talbot
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Bramstedt KA. A Lifesaving View of Vascularized Composite Allotransplantation: Patient Experience of Social Death Before and After Face, Hand, and Larynx Transplant. J Patient Exp 2017; 5:92-100. [PMID: 29978024 PMCID: PMC6022947 DOI: 10.1177/2374373517730556] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Introduction: Most solid organ transplantation is viewed as lifesaving, whereas vascularized composite allotransplantation (VCA) has been viewed as life enhancing. This article challenges the latter and argues that “social death” evident in severe face, hand, and larynx disfigurement can be potentially treated via VCA. Social death (from a social science perspective) consists of a combination of 7 components: social isolation, loneliness, ostracism, loss of personhood, change of role and identity, harm, and disfigurement. Methods: In February 2016, PubMed and Google were searched for case reports of human face, hand, and larynx transplantation. Patient and team narratives were then coded for components of social death using social science and medical model criteria. Results: Eleven narratives were identified among 9 articles. The social science model (but not the medical model) described pretransplant social death and the resolution of social death by receiving VCA. Notably, the medical model of social death was deemed unsuitable for application to VCA. This is because case narratives consistently contradict elements of the medical model. Conclusions: By including social death as a patient inclusion criterion for face, hand, and larynx VCA, these transplants can be considered lifesaving. Additionally, because VCA requires lifelong immunosuppressant medication, considering VCA as a lifesaving intervention improves the technology’s risk–benefit analysis. Guidance for assessing social death is provided.
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Affiliation(s)
- Katrina A Bramstedt
- Bond University School of Medicine, University Drive, Gold Coast, Queensland, Australia
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Hand transplantation in children: is it too early or too late? THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:4-6. [DOI: 10.1016/s2352-4642(17)30035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/10/2017] [Indexed: 11/20/2022]
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Mukesh N, Bramstedt KA. Perspectives of US and Australian Hand Therapists About Pediatric Hand Transplantation. Prog Transplant 2016; 27:73-78. [PMID: 27881813 DOI: 10.1177/1526924816679837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pediatric hand transplantation (PHT), an investigational therapy, was recently performed in the United States. RESEARCH QUESTIONS Perspectives of hand therapists about PHT patient selection (inclusion and exclusion criteria), team configuration, patient assent, and patient compliance were explored. DESIGN Quantitative survey. We used a research ethics committee-approved 18-question e-link anonymous questionnaire to survey members of the American Society of Hand Therapists and the Australian (AU) Hand Therapy Association for their perspectives on PHT. RESULTS All surveyed hand therapists work with children (n = 18 Australia [AU], n = 85 United States) and some had been involved in adult hand transplant rehabilitation (28% AU, 21% United States; P = .543, not significant (NS)). The US and AU therapists differ regarding their opinions on multidisciplinary team membership, smoking as an exclusion criterion, and risk of posttransplant rehabilitation noncompliance. DISCUSSION This research opens a dialogue on the clinical and ethical complexity of PHT, including team configuration, inclusion/exclusion criteria, the assent process, and rehabilitation access/compliance. Furthermore, international perspectives are informative as they highlight funding and access issues and can potentially guide global professional society policy.
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Affiliation(s)
- Nitin Mukesh
- 1 Bond University Medical Program, Gold Coast, Queensland, Australia
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Galvão FHF, Waisberg DR, Seid VE, Costa ACL, Chaib E, Baptista RR, Capelozzi VL, Lanchotte C, Cruz RJ, Araki J, D'Albuquerque LC. Allogeneic anorectal transplantation in rats: technical considerations and preliminary results. Sci Rep 2016; 6:30894. [PMID: 27488366 PMCID: PMC4973224 DOI: 10.1038/srep30894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/11/2016] [Indexed: 01/24/2023] Open
Abstract
Fecal incontinence is a challenging condition with numerous available treatment modalities. Success rates vary across these modalities, and permanent colostomy is often indicated when they fail. For these cases, a novel potential therapeutic strategy is anorectal transplantation (ATx). We performed four isogeneic (Lewis-to-Lewis) and seven allogeneic (Wistar-to-Lewis) ATx procedures. The anorectum was retrieved with a vascular pedicle containing the aorta in continuity with the inferior mesenteric artery and portal vein in continuity with the inferior mesenteric vein. In the recipient, the native anorectal segment was removed and the graft was transplanted by end-to-side aorta-aorta and porto-cava anastomoses and end-to-end colorectal anastomosis. Recipients were sacrificed at the experimental endpoint on postoperative day 30. Surviving animals resumed normal body weight gain and clinical performance within 5 days of surgery. Isografts and 42.9% of allografts achieved normal clinical evolution up to the experimental endpoint. In 57.1% of allografts, signs of immunological rejection (abdominal distention, diarrhea, and anal mucosa inflammation) were observed three weeks after transplantation. Histology revealed moderate to severe rejection in allografts and no signs of rejection in isografts. We describe a feasible model of ATx in rats, which may allow further physiological and immunologic studies.
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Affiliation(s)
- Flavio H F Galvão
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Daniel R Waisberg
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Victor E Seid
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Eleazar Chaib
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Rachel Rossini Baptista
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Cinthia Lanchotte
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Ruy J Cruz
- Intestinal Rehabilitation and Transplant Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jun Araki
- Department of Plastic Surgery, University of Tokyo, Tokyo, Japan
| | - Luiz Carneiro D'Albuquerque
- Laboratory of Experimental Transplant Surgery, LIM-37, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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Anorectal autotransplantation in a canine model: the first successful report in the short term with the non-laparotomy approach. Sci Rep 2014; 4:6312. [PMID: 25204282 PMCID: PMC4159625 DOI: 10.1038/srep06312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/10/2014] [Indexed: 11/08/2022] Open
Abstract
Colostomy is conventional treatment for anal dysfunction. Recently, a few trials of anorectal transplantation in animals have been published as a potential alternative to colostomies; however, further development of this technique is required. In this study, we utilized a canine model of anorectal transplantation, evaluated the patency of our microsurgical anastomoses, and assessed the perfusion of the transplanted anus. We designed a canine anorectal transplantation model, wherein anorectal autotransplantation was performed in four healthy beagle dogs by anastomoses of the lower rectum, the bilateral pudendal arteries (PAs) and veins (PVs), and pudendal nerves (PNs). Postoperative graft perfusion was measured by indocyanine green (ICG) angiography and histological examination. The length of the anorectal graft including perianal skin, anal sphincter muscle, bilateral PAs, PVs, and PNs was 4.9 ± 0.3 cm. All diameters of the PAs, PVs, and PNs were large enough to be microscopically anastomosed. Both ICG angiography and histological examination demonstrated good graft perfusion, except for one case that lead to venous congestion. These results show that anastomosis of the bilateral PAs, PVs, and PNs is required for anorectal transplantation. This is the first successful report of canine anorectal autotransplantation.
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Chim H, Amer H, Mardini S, Moran SL. Vascularized composite allotransplant in the realm of regenerative plastic surgery. Mayo Clin Proc 2014; 89:1009-20. [PMID: 24996237 DOI: 10.1016/j.mayocp.2014.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/27/2014] [Accepted: 05/27/2014] [Indexed: 12/13/2022]
Abstract
Vascularized composite allotransplant (VCA) has led to new treatment options for patients with severe upper extremity and facial injuries. Although VCA can restore form and function, it exposes the patient to the risks associated with lifelong immunosuppression. Hopefully, ongoing advances in regenerative medicine will someday obviate the need for VCA, but until that time, VCA remains an immediate means of reconstructing otherwise unreconstructable defects. We review the outcomes of hand and face transplants, as well as the recent developments in immunosuppression as it relates to the field of VCA.
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Affiliation(s)
- Harvey Chim
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Samir Mardini
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN.
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Leonard DA, Kurtz JM, Mallard C, Albritton A, Duran-Struuck R, Farkash EA, Crepeau R, Matar A, Horner BM, Randolph MA, Sachs DH, Huang CA, Cetrulo CL. Vascularized composite allograft tolerance across MHC barriers in a large animal model. Am J Transplant 2014; 14:343-55. [PMID: 24405666 PMCID: PMC3971524 DOI: 10.1111/ajt.12560] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/25/2013] [Accepted: 10/25/2013] [Indexed: 01/25/2023]
Abstract
Vascularized composite allograft (VCA) transplantation can restore form and function following severe craniofacial injuries, extremity amputations or massive tissue loss. The induction of transplant tolerance would eliminate the need for long-term immunosuppression, realigning the risk-benefit ratio for these life-enhancing procedures. Skin, a critical component of VCA, has consistently presented the most stringent challenge to transplant tolerance. Here, we demonstrate, in a clinically relevant miniature swine model, induction of immunologic tolerance of VCAs across MHC barriers by induction of stable hematopoietic mixed chimerism. Recipient conditioning consisted of T cell depletion with CD3-immunotoxin, and 100 cGy total body irradiation prior to hematopoietic cell transplantation (HCT) and a 45-day course of cyclosporine A. VCA transplantation was performed either simultaneously to induction of mixed chimerism or into established mixed chimeras 85-150 days later. Following withdrawal of immunosuppression both VCAs transplanted into stable chimeras (n=4), and those transplanted at the time of HCT (n=2) accepted all components, including skin, without evidence of rejection to the experimental end point 115-504 days posttransplant. These data demonstrate that tolerance across MHC mismatches can be induced in a clinically relevant VCA model, providing proof of concept for long-term immunosuppression-free survival.
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Affiliation(s)
- D. A. Leonard
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Department of Plastic and Reconstructive Surgery Research, University of Manchester, Manchester, UK
| | - J. M. Kurtz
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Department of Biology, Emmanuel College, Boston, MA
| | - C. Mallard
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Albritton
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R. Duran-Struuck
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - E. A. Farkash
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R. Crepeau
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Matar
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B. M. Horner
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M. A. Randolph
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D. H. Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - C. A. Huang
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Corresponding authors: Curtis L. Cetrulo Jr, , and Christene A. Huang,
| | - C. L. Cetrulo
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Corresponding authors: Curtis L. Cetrulo Jr, , and Christene A. Huang,
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Araki J, Nishizawa Y, Nakamura T, Sato T, Naito M, Fujii S, Mihara M, Koshima I. The development of a canine anorectal autotransplantation model based on blood supply: a preliminary case report. PLoS One 2012; 7:e44310. [PMID: 22970198 PMCID: PMC3435401 DOI: 10.1371/journal.pone.0044310] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/01/2012] [Indexed: 12/16/2022] Open
Abstract
Colostomy is conventionally the only treatment for anal dysfunction. Recently, a few trials of anorectal transplantation in animals have been published; however, further development of this technique is required. Moreover, it is crucial to perform this research in dogs, which resemble humans in anorectal anatomy and biology. We designed a canine anorectal transplantation model, wherein anorectal autotransplantation was performed by anastomoses of the rectum, inferior mesenteric artery (IMA) and vein, and pudendal nerves. Resting pressure in the anal canal and anal canal pressure fluctuation were measured before and after surgery. Graft pathology was examined three days after surgery. The anal blood supply was compared with that in three beagles using indocyanine green (ICG) fluorescence angiography. The anorectal graft had sufficient arterial blood supply from the IMA; however, the graft's distal end was congested and necrotized. Functional examination demonstrated reduced resting pressure and the appearance of an irregular anal canal pressure wave after surgery. ICG angiography showed that the pudendal arteries provided more blood flow than the IMA to the anal segment. This is the first canine model of preliminary anorectal autotransplantation, and it demonstrates the possibility of establishing a transplantation model in dogs using appropriate vascular anastomoses, thus contributing to the progress of anorectal transplantation.
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Affiliation(s)
- Jun Araki
- Department of Plastic Surgery, University of Tokyo, Tokyo, Japan.
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