Mayo Clinic Performs First Successful Laryngeal Transplant in Patient with Active Cancer

The Mayo Clinic Larynx and Trachea Transplant Program was established in 2016 and is located on the clinic’s campus in Arizona. The program helps people who have damaged or lost their larynx or trachea due to cancer, disease, or trauma (asamonitor.pub/3z2GJZq).

The transplant program eventually received approval from the United Network for Organ Sharing (UNOS) and was interviewing potential patients before pausing during the initial COVID outbreak.

Molly Kraus, MD, FASA, Vice Chair of the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, helped develop a protocol for the anesthesia team on recommendations from the department’s Clinical Practice Committee. They delineated expected steps of the surgery with Dr. Lott and how that might impact anesthesia delivery. Protocols were published online for all anesthesia practitioners so they could access them any time a transplant occurred.

The laryngeal transplant (LT) was performed on a 59-year-old Massachusetts man who had previous subtotal resections of a low-grade chondrosarcoma with various attempts at complex reconstruction (asamonitor.pub/3TDPfVZ). For 10 years, the patient underwent dozens of surgeries, which eventually robbed him of his voice and ability to swallow and breathe normally. Several years ago, he had a tracheostomy to allow him to breathe through a hole in his neck. However, after years of surgeries, his only remaining option was to receive a laryngectomy in which his larynx would be completely removed (asamonitor.pub/3MuzZGX/). He declined that option and found the program at Mayo Clinic.

“He was an ideal transplant candidate because, although he had cancer, he was already on immunosuppression drugs due to a previous kidney transplant,” explains Dr. Lott. “Typically, we don’t do a transplant on a patient with active cancer because we’re concerned about increasing recurrence or metastasis risk. This significantly limits the number of potential LT candidates since most patients who would benefit have laryngeal cancer.”

“He was also a good choice because he had the right reasons for wanting the transplant, the right outlook as to how to recover and what the overall outcome may be, and has great family support,” continues Dr. Lott. “The patient checked all those boxes, and, in addition, he understands what a gift larynx transplantation is and wants to partner with us to get the word out about this procedure and how it can change your life.”

The patient was also an ideal candidate from the anesthesiologist’s viewpoint, according to Dr. Kraus, who was part of the selection committee that reviewed potential patients. “From our perspective, his functional status was very good. He was active and his cardiac function was good. We ran a lot of baseline tests – echocardiogram, EKG, blood tests – and a six-minute walk.”

Laryngeal transplant is an example of vascularized composite allograft (VCA) transplantation, in which multiple tissue components are transplanted. During this surgery, the larynx, pharynx, proximal esophagus, proximal trachea, thyroid gland, and parathyroid glands were transplanted (Mayo Clinic Proceedings 2024;99:1445-8). The procedure started at 2:30 p.m., February 29, 2024, and stretched until 11:30 a.m., the next day. During the long operation, three different sets of anesthesia professionals tended to the patient.

“There were three anesthesiologists, one resident, and two CRNAs involved in this case from start to finish,” says Tony Yen MD, MBA, FASA, Senior Associate Consultant, who served on the last of the three anesthesiology teams. “We were stationed away from the patient’s head to give the surgeons more room to work. Communication with the surgical team was key during periods of time when we shared management of the airway. We also used special airway instruments like wire-reinforced endotracheal tubes to prevent them from kinking during the long procedure.”

In addition, there were other concerns, Dr. Yen explains. “In any long case, you need to closely monitor overall fluid status, stay on top of lab values, and maintain hemodynamics within a safe zone. In the last several hours of this case, the patient started showing some physiologic derangements. We had to make choices as to what type of product to resuscitate the patient with, and decide between colloids or crystalloids and other intervention strategies without risking compromise to the transplanted tissue. The key is maintaining vigilance and constantly checking monitors and labs to make sure we weren’t falling behind.”

Although none of the anesthesiology team members had provided anesthesia for a laryngeal transplant before, they had participated in Dr. Lott’s ENT surgeries and knew some of the issues that could crop up. “It was important to have anesthesiologists who were familiar with head and neck surgeries where we remove a cancer, do a free-flap surgery and microvascular anastomoses,” says Dr. Lott. “There are special considerations with these surgeries of which anesthesiologists need to be aware, such as we can’t have a patient on pressers because it causes the vessels to constrict which prevents blood flow from going through the new anastomosis. A patient must be on certain levels of blood thinners to make sure the anastomosis doesn’t clot.”

The success of this surgery bodes well for doing more in the future, says Dr. Lott. “Laryngeal transplantation is a promising option to restore quality-of-life in patients with severe laryngeal dysfunction or a laryngectomy. Because the surgery was conducted as part of a clinical trial, it is a pivotal step in making this rare procedure available to a wider population. This clinical trial allowed us to conduct a true scientific investigation aimed at thoroughly researching the safety and efficacy of laryngeal transplantation as a trusted option for patients.” The program is approved to perform additional larynx transplants in the coming years (asamonitor.pub/3TDPfVZ).