Extremitätentransplantation

Zusammenfassung

Die Entwicklung der letzten 20 Jahre hat die technischen wie immunologischen Voraussetzungen geschaffen, komplexe Rekonstruktionen amputierter Extremitäten mittels allogener Transplantation möglich zu machen. Dabei sind diese Eingriffe inzwischen aus dem Stadium eines experimentellen therapeutischen Eingriffs zu einer klinisch etablierten Rekonstruktionsmöglichkeit erwachsen. Aufgrund der lebensqualitätsspendenden, aber nicht lebensrettenden Natur dieser Eingriffe müssen die möglichen Risiken und Komplikationen, die aus einem solchen Eingriff erwachsen, sowie der lebenslang notwendigen Immunsuppression, kritisch und individuell evaluiert werden. Aus diesem Grund ist die Indikation auch nur bei Patienten mit bilateraler Verletzung zu stellen. Eine erfolgreiche Transplantation kann den Patienten jedoch dann eine deutliche Verbesserung der sensorischen und motorischen Fähigkeiten mit relevanter Verbesserung der Lebensqualität ermöglichen und sollte daher als Therapieoption bei selektiven Patienten mitbedacht werden.

Abstract

The development over the last 20 years has created the technical and immunological prerequisites for making complex reconstructions of amputated limbs possible by means of allogenic transplantation. These interventions have grown from the stage of an experimental therapeutic intervention to a clinically established possibility of reconstruction. Due to the life-giving but not life-saving nature of these interventions, the potential risks and complications arising from such surgery as well as the required lifelong immunosuppression must be evaluated critically and individually. For this reason, the indication should only be available in patients with bilateral injury. However, successful transplantation can then provide patients with significant improvement in sensory and motor skills with relevant quality of life improvements and should therefore be considered as a treatment option for selective patients.

Schlüsselwörter

Transplantation komplexer Gewebe - VCA - CTA - vaskularisierte Composite-Transplantation - Extremitätenamputation - plastische Allotransplantation - plastische Transplantation - rekonstruktive Transplantation

Key words

vascularized composite allotransplantation - VCA - composite tissue allotransplantation - CTA - extremity transplantation - plastic allotransplantation - reconstructive transplantation

• Literatur

• 1 Medawar PB. Biological problems of skin surgery. J Int Chir 1953; 13: 385-391 includes translations
• 2 Starzl TE. Back to the future. Transplantation 2005; 79: 1009-1014
• 3 Unadkat J, Sacks JM, Schneeberger S, Lee WPA. Relative Antigenicity of Allograft Components and differential Rejection. In: Hewitt CW, Lee WPA, Gordon CR. Transplantation of Composite Tissue Allografts. Boston, MA: Springer US; 2008: 55-69
• 4 Gilbert Fernandez JJ, Febres-Cordero RG, Simpson RL. The Untold Story of the First Hand Transplant: Dedicated to the Memory of one of the Great Minds of the Ecuadorian Medical Community and the World. J Reconstr Microsurg 2019; 35: 163-167
• 5 Errico M, Metcalfe NH, Platt A. History and ethics of hand transplants. JRSM Short Rep 2012; 3: 74
• 6 Dubernard JM, Owen E, Herzberg G. et al. Human hand allograft: report on first 6 months. Lancet 1999; 353: 1315-1320
• 7 Siegmund-Schultze N. Transplantationsmedizin: Erstmals komplette Arme verpflanzt. Dtsch Arztebl 2008; 105: A-1728/B-1490/C-1458
• 8 Swanson EW, Cheng H-T, Lough DM. et al. Lower extremity allotransplantation: are we ready for prime time?. Vascularized Composite Allotransplantation 2015; 2: 37-46
• 9 Alolabi N, Chuback J, Grad S. et al. The utility of hand transplantation in hand amputee patients. J Hand Surg Am 2015; 40: 8-14
• 10 Chung KC, Oda T, Saddawi-Konefka D. et al. An economic analysis of hand transplantation in the United States. Plast Reconstr Surg 2010; 125: 589-598
• 11 Majzoub RK, Cunningham M, Grossi F. et al. Investigation of risk acceptance in hand transplantation. J Hand Surg Am 2006; 31: 295-302
• 12 Piza-Katzer H, Wechselberger G, Estermann D. et al. [Ten years of hand transplantation experiment or routine?]. Handchir Mikrochir Plast Chir 2009; 41: 210-216
• 13 Bueno E, Benjamin MJ, Sisk G. et al. Rehabilitation following hand transplantation. Hand (N Y) 2014; 9: 9-15
• 14 Amaral S, Levin LS. Pediatric and congenital hand transplantation. Curr Opin Organ Transplant 2017; 22: 477-483
• 15 Clark RA, Chong B, Mirchandani N. et al. The vast majority of CLA+ T cells are resident in normal skin. J Immunol 2006; 176: 4431-4439
• 16 Pomahac B, Pribaz J, Eriksson E. et al. Three patients with full facial transplantation. N Engl J Med 2012; 366: 715-722
• 17 Kanitakis J, Jullien D, Petruzzo P. et al. Clinicopathologic features of graft rejection of the first human hand allograft. Transplantation 2003; 76: 688-693
• 18 Petruzzo P, Lanzetta M, Dubernard JM. et al. The international registry on hand and composite tissue transplantation. Transplantation 2008; 86: 487-492
• 19 Petruzzo P, Sardu C, Lanzetta M. et al. Report (2017) of the International Registry on Hand and Composite Tissue Allotransplantation (IRHCTT). Current Transplantation Reports 2017; 4: 294-303
• 20 Kanitakis J, Petruzzo P, Badet L. et al. Chronic Rejection in Human Vascularized Composite Allotransplantation (Hand and Face Recipients): An Update. Transplantation 2016; 100: 2053-2061
• 21 Shores JT, Malek V, Lee WPA. et al. Outcomes after hand and upper extremity transplantation. J Mater Sci Mater Med 2017; 28: 72
• 22 Petruzzo P, Dubernard JM. The International Registry on Hand and Composite Tissue allotransplantation. Clin Transpl 2011; 247-253
• 23 Lanzetta M, Petruzzo P, Dubernard JM. et al. Second report (1998–2006) of the International Registry of Hand and Composite Tissue Transplantation. Transpl Immunol 2007; 18: 1-6
• 24 Bernardon L, Gazarian A, Petruzzo P. et al. Bilateral hand transplantation: Functional benefits assessment in five patients with a mean follow-up of 7.6 years (range 4–13 years). J Plast Reconstr Aesthet Surg 2015; 68: 1171-1183
• 25 Weissenbacher A, Hautz T, Zelger B. et al. Antibody-mediated rejection in hand transplantation. Transpl Int 2014; 27: e13-e17
• 26 Schneeberger S, Ninkovic M, Piza-Katzer H. et al. Status 5 years after bilateral hand transplantation. Am J Transplant 2006; 6: 834-841
• 27 Pei G, Xiang D, Gu L. et al. A report of 15 hand allotransplantations in 12 patients and their outcomes in China. Transplantation 2012; 94: 1052-1059
• 28 He H, Stone JR, Perkins DL. Analysis of differential immune responses induced by innate and adaptive immunity following transplantation. Immunology 2003; 109: 185-196
• 29 He H, Stone JR, Perkins DL. Analysis of robust innate immune response after transplantation in the absence of adaptive immunity. Transplantation 2002; 73: 853-861
• 30 Cendales LC, Kanitakis J, Schneeberger S. et al. The Banff 2007 working classification of skin-containing composite tissue allograft pathology. Am J Transplant 2008; 8: 1396-1400
• 31 Kueckelhaus M, Fischer S, Seyda M. et al. Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration. Transpl Int 2016; 29: 655-662
• 32 Herzberg G, Weppe F, Masson N. et al. Clinical evaluation of two bilateral hand allotransplantations at six and three years follow-up. Chir Main 2008; 27: 109-117
• 33 Kanitakis J, Petruzzo P, Gazarian A. et al. Capillary Thrombosis in the Skin: A Pathologic Hallmark of Severe/Chronic Rejection of Human Vascularized Composite Tissue Allografts?. Transplantation 2016; 100: 954-957
• 34 Heemann U, Lutz J. Pathophysiology and treatment options of chronic renal allograft damage. Nephrol Dial Transplant 2013; 28: 2438-2446
• 35 Morelon E, Petruzzo P, Kanitakis J. Chronic rejection in vascularized composite allotransplantation. Curr Opin Organ Transplant 2018; 23: 582-591
• 36 Krezdorn N, Tasigiorgos S, Wo L. et al. Kidney Dysfunction After Vascularized Composite Allotransplantation. Transplant Direct 2018; 4: e362