Total Laryngeal Transplant Explanted in 2012: 14 Years of Lessons Learned

Abstract

Objectives: In 1998, the first successful total laryngeal transplant was performed at the Cleveland Clinic. The patient was a 40 year-old-man who had suffered an MVA, which left him aphonic. Not only was his larynx completely replaced with a vascularized graft, but also his pharynx, thyroid, parathyroids, and a portion of his trachea. Over the subsequent 14 years, much was learned about tolerance of a transplanted laryngeal complex, marking this surgery as the longest surviving maiden transplanted organ system when immunosuppression was applied. Methods: Outstanding voice quality and swallowing function were achieved, although volitional vocal cord movement was not attempted, and therefore the patient remained stoma dependent for breathing. The scientific advancement of understanding around laryngeal transplantation was concurrently conducted in the laboratory via animal models, which translated into gradual reduction in the level of immunosuppression for the patient without acute rejection. Results: After approximately a decade, a slowly progressive, chronic rejection process gradually rendered the organ non-functional, and the patient and his providers deemed him appropriate for explantation with free-flap reconstruction and tracheoesophageal puncture voice restoration. Pre-operative functional studies showed a reversion back to his original thyroidal tissue as the source of his circulating thyroid hormone. Post-explantation histologic studies demonstrated loss of tissue cellularity and organ architecture. Conclusions: On routine explantation follow-up, the patient was found to have an asymptomatic early stage, human papillomavirus-related oropharyngeal neoplasm that was successfully treated with surgical resection alone. Voice results will be demonstrated over the patient’s 14 year experience, as well as his own perspective on this landmark experience.