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Iyer S, Subramaniam N, Vidhyadharan S, Thankappan K, Balasubramanian D, R BK, Nair A, Purushottaman K, Ramu J, Paul Z. Tracheal Allotransplantation-Lessons Learned. Indian J Plast Surg 2020; 53:306-308. [PMID: 32884201 PMCID: PMC7458829 DOI: 10.1055/s-0040-1716420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reconstruction of long tracheal defects still proves to be a challenge. Free fasciocutaneous flaps with cartilaginous struts or an allotransplant trachea have been reported but not been widely performed. This article reports with the experience of using a tracheal allotransplant in such a defect. A 43-year-old lady presented with adenoid cystic carcinoma involving the entire trachea from subglottic area up to the carina, leading to a life-threatening airway occlusion. After preliminary stenting, allotransplant trachea obtained from a brain-dead individual was revascularized in the forearm of the patient after mechanical decellularization to reduce the immune load and fulfil the need for immunosuppression in the background of active cancer. Subsequently, the trachea and larynx were resected. The vascularized neotrachea was transferred successfully into the neck. The patient did well initially but succumbed to a fatal hemorrhage due to innominate vein aneurysmal rupture on the 22nd day after the transplant. The technical details of resection, fabrication of the neotrachea, its transfer, and the lessons learnt in this tracheal allotransplant are described.
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Affiliation(s)
- Subramania Iyer
- Department of Head and Neck Oncology and Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.,Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Narayana Subramaniam
- Department of Head and Neck Oncology and Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sivakumar Vidhyadharan
- Department of Head and Neck Oncology and Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Krishnakumar Thankappan
- Department of Head and Neck Oncology and Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Deepak Balasubramanian
- Department of Head and Neck Oncology and Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Balasubramanian K R
- Department of Cardiothoracic and Vascular Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Arun Nair
- Department of Pulmonology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Kishore Purushottaman
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Janarthanan Ramu
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Zachariah Paul
- Department of Nephrology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Sharma M, Iyer S, Purushottaman K, Vijayaraghavan S, Matthew J, Dudipala RR, Ramu J, Paul J, Rajan S, Verma V, Chaudary A, Dhake S, Omkumar A, Kapahtia R, Sharma D, Maharaja N. Indian Subcontinent's First Proximal Forearm Level Double Upper Extremity Transplantation. Indian J Plast Surg 2020; 52:277-284. [PMID: 31908365 PMCID: PMC6938444 DOI: 10.1055/s-0039-3401474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction
Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols.
Materials and Methods
A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime.
Discussion
Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant “reestablishes” the “donor extremity length,” maintains the normal functional length of the donor muscles, and the functional return happens only after the newly transplanted donor muscles are reinnervated over a period of time.
Conclusion
As the sequence of surgical repair and associated decision making could be quite confusing for this level of transplantation, it is highly advisable to do mock cadaver surgical dissections in order to standardize the procedure and make the team familiar with it.
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Affiliation(s)
- Mohit Sharma
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Subramania Iyer
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Kishore Purushottaman
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sundeep Vijayaraghavan
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jimmy Matthew
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Raghuveer Reddy Dudipala
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Janarthanan Ramu
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jerry Paul
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sunil Rajan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | | | | | | | | | | | - Vishak Verma
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Ashish Chaudary
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Swapnil Dhake
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Akshay Omkumar
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Radhika Kapahtia
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Dimpy Sharma
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Nirav Maharaja
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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