In a first for France, a Lyon-based team of surgeons performed a larynx transplant in early September. The patient is doing well and starting to regain the use of her voice. Philippe Ceruse, MD, PhD, one of the coordinators of the procedure, explains how the team prepared for it and carried it out.
Laryngeal Stenosis
"The larynx is a complex organ that enables us to talk, breathe, and eat. It's here where the vocal cords are found; if your larynx isn't functioning, then you won't be able to talk," explained Ceruse, head of the ear, nose, and throat and oral and maxillofacial surgery department at the Croix-Rousse Hospital in Lyon, France.
Karine, a 49-year-old female patient, had a heart attack in 1996. Being intubated in the intensive care unit caused her to develop laryngeal stenosis. Over time, her condition gradually worsened, and for the past 20 years or so, she has only been able to breathe via a tracheostomy and has been unable to speak.
"I met her 15 years ago, and from the moment I mentioned the possibility of a larynx transplant, she was interested," said Ceruse.
Fourteen surgeons from Lyon, Paris, Rennes, Nantes, Toulouse, and Rouen studied and trained for 10 years to perform this delicate procedure. "Our group, known as Clinical Assessment of Larynx Transplantation (ECLAT), has practiced regularly since 2012, initially on animal models and then on cadavers," said Ceruse. "Each surgeon had their own 'section,' their own surgical protocol. We decided that we were ready when we were able to carry out the procedure on cadavers smoothly.”
27-Hour Surgery
In 2014, the team was granted a hospital clinical research program that allowed them to start enrolling patients eligible for larynx transplantation. In 2019, it received approval from the Lyon biomedical and transplant coordination agency.
Once ready, the surgeons had to find a compatible donor. This was not an easy task, as any donor had to have anatomical characteristics that were completely compatible with the recipient in terms of sex, weight, height, and blood group. They also needed to have not been intubated for more than 7 days and be in the same region as the hospital where the procedure was to be performed. "A larynx graft cannot survive for more than six hours in a state of ischemia," said Ceruse.
On September 1, a donor was found. It was a case of all systems go, and 12 of the 14 surgeons managed to free themselves to get to the operating room at Lyon's Edouard Herriot Hospital at 9 AM the next morning. "It took 10 hours to remove the organ from the donor and 17 hours to perform the transplant. It's extremely precise, because you have to remove the larynx, the thyroid, the vessels, and the nerves. The vessels measure between three and five millimeters, which is minuscule. We had to perform eight vascular anastomoses and six nerve anastomoses," said Ceruse.
Regaining Speech
Two coordinators supervised the procedure: Lionel Badet, MD, PhD, head of the department of urology and transplant surgery at the Edouard Herriot Hospital, and Ceruse. "My task was mainly to manage the team's food and rest breaks, because everything went well," Ceruse joked.
The procedure began on September 2 at 9 AM with the organ being removed from the donor. It finished the following day at around 8 AM at the Croix-Rousse Hospital with transplantation into the recipient. The donor recipient then spent 2 months in the hospital and returned home 3 weeks ago. "It all went perfectly. She is doing well and is starting to speak again, although she is finding that the quality of her voice is not that good yet. But she hasn't spoken for 20 years; she needs to regain coordination, and to do that, she will need to put a lot of work into vocal rehabilitation," said Ceruse.
“Revascularization was successful, and we now need to re-innervate her larynx. For the time being, the patient still can't eat, because food will go down the wrong way. She is still being tube-fed. We estimate that after around 6 months, she will regain some sensitivity, and after 12 to 18 months her motor function will have been restored. Within 6 months, she should be able to eat again at least as well as before.”
The team was handed a budget of €450,000 for three transplant operations, but it is waiting to see how their patient recovers before planning further procedures. "The indications for future procedures will be laryngeal trauma. It isn't indicated for cancer patients, except in rare cases when patients are already on immunosuppressants," said Ceruse.
This article was translated from the Medscape French edition.
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