Unique transplantation
The first transplantation of a whole trachea
Maxim Rousseau, Polit.roo
A team of surgeons from New York's Mount Sinai Hospital performed the world's first complete tracheal transplant to a human. If successful, such an operation can save the lives of thousands of patients with congenital tracheal defects, incurable respiratory diseases, burns, tumors or severe tracheal injuries.
Transplantation of the donor trachea was a difficult task for surgeons, since this organ does not have a blood supply through a sufficiently large vessel that could be used to restore blood supply to the donor organ. The arteries feeding the trachea have a very small diameter, are located in unstable places, so the imposition of anastomoses between them and the recipient's vessels becomes an extremely difficult task. And even when surgeons learned how to transplant donor lungs, tracheal transplantation remained unattainable for them because of the seemingly impossibility of revasculating the transplant, that is, restoring the blood vessels that feed it.
Artificial organs could become an alternative to donor tracheas, but even here it has not yet been possible to achieve complete success. A few years ago, a lot of attention was attracted by the operations of Paolo Macchiarini, who implanted tracheas created from the patient's stem cells on a donor or artificial matrix. But then it turned out that Macchiarini's publications deliberately distorted data on the condition of patients after surgery and the functionality of the new trachea. Seven of the nine patients to whom Macchiarini transplanted a trachea in 2011-2014 died. In 2018, it was found that Macchiarini had resorted to forgery in six of his articles.
Therefore, so far only transplants of tracheal fragments have been carried out. This was first done in 1979, when a 21-year-old man with scarred tracheal stenosis was transplanted with a short fragment of the cervical trachea of a donor. The fragment was first implanted into the sternocleidomastoid muscle of the patient, and after three weeks, when a network of small blood vessels formed around it, it was transplanted to a permanent place together with these vessels. In the USSR, the first transplantation of the thoracic trachea was performed in 1990 by Yu. N. Levashev at the Leningrad Institute of Pulmonology. Four months later, the patient showed signs of tracheal stenosis, so surgeons inserted a stent into the trachea to prevent its development, and the patient lived after the operation for more than eight years.
In 2001, Marshall Strom and his colleagues performed a successful transplant of the larynx, five rings of the trachea and thyroid gland to a forty-year-old woman injured in an accident. They managed to connect not only blood vessels, but also nerves, which allowed the patient to regain the ability to swallow and speak. In 2006, a team of surgeons from the Russian Scientific Center of Surgery of the Russian Academy of Medical Sciences, headed by N. O. Milanov and V. D. Parshin, successfully transplanted a tracheal and thyroid gland section to a patient with cicatricial tracheal stenosis.
The current operation at the Mount Sinai Clinic was, according to a press release, the result of thirty years of research into the biology of the trachea and especially the problem of restoring its vascular network and ensuring blood flow. The operation carried out on January 13 lasted 18 hours. The team was led by surgeon Eric M. Genden, Head of the Department of Otolaryngology and Head and Neck Surgery at the Mount Sinai Clinic. The team consisted of more than fifty specialists, including surgeons, nurses, anesthesiologists, respiratory specialists and residents.
"For the first time, we can offer a viable treatment option to patients with life-threatening defects of long tracheal segments. And this achievement will change the standards of treatment. It is especially timely, given the growing number of patients with extensive tracheal defects that occur during intubation of patients with COVID-19. Due to mechanical ventilation and the nature of the respiratory tract disease caused by COVID-19, the number of tracheal diseases is growing rapidly, and now we can offer their treatment. Our tracheal transplantation and revascularization protocol is reliable, reproducible and technically simple. For many years, the medical and scientific consensus was that tracheal transplantation could not be performed because the complexity of the organ made revascularization impossible, and all previous attempts to perform tracheal transplantation from a donor ended in failure. Our achievement was the culmination of thirty years of research that began when I was a medical student at Mount Sinai, and was made possible thanks to the spirit of cooperation that exists in the clinic," says Professor Genden. – Despite extensive studies of the vascular supply of the organ in humans and animals, there is no real way to fully prepare for the first-ever human trachea transplantation. We didn't have a guide on how well the graft endures the transplant, so we worked very quickly. Eighteen hours later, it became clear that we had accomplished what many thought was impossible. In the end, everything went smoothly because we assembled a strong team with extensive surgical experience in the field of organ transplantation and tracheal reconstruction. Seeing a transplant come to life and knowing that the organ is well vascularized was an amazing experience."
The recipient of the donor trachea was 56-year-old social worker Sonya Sayn from New York. She had serious damage to her trachea due to repeated intubation after an asthma attack. Several unsuccessful surgical attempts to repair the trachea led to even more damage. The woman breathed through a tracheostomy – a surgically created hole in her neck – and was at high risk of suffocation and death due to the progression of respiratory tract disease and the likelihood of tracheal collapse. The fear of falling asleep and never waking up became the main motivator for her to agree to an experimental operation.
Surgeons took the donor trachea and associated blood vessels, then they implanted it to the patient from the larynx to the bronchi, performing a series of microvascular anastomoses, that is, connecting the small blood vessels feeding the donor trachea with the recipient's blood vessels. For successful revasculation, they also transplanted fragments of the esophagus and thyroid gland. In the end, the operation allowed the patient to remove the tracheostomy, which gave her the opportunity to breathe through her mouth for the first time in six years. The operation was carried out without complications, the patient is breathing independently. Sonya Sayn is currently undergoing immunosuppressive therapy to prevent rejection of the transplanted organ.
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