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ASRM#2: Trachea allotransplantation: the learning curve
Jan Jeroen Vranckx, MD, PhD1, P. Delaere, MD, PhD2, K. Segers, MD1 and V. Van der Poorten, MD, PhD2
1Dept Plastic & Reconstructive Surgery, KUL Leuven University Hospitals, Leuven, Belgium, 2ORL, KUL Leuven University Hospitals, Leuven, Belgium

There are few therapeutic options for repairing trachea defects longer than 5 cm since no autologous donor fibrocartilagenous framework is available for reconstruction and trachea lacks an identifiable vascular pedicle that would enable direct vascular anastomosis to vessels of the recipient.

Material and methods
Based on our experimental and clinical experience with tracheal auto-and allotransplantation, we reconstructed 6 long-segment tracheal defects using an allograft that was revascularized by heterotopic wrapping in vascularized forearm fascia. The patients received immunosuppressive therapy before the operation. After revascularization, the mucosal lining was replaced progressively using recipient buccal mucosa. A fully remucosalized tracheal chimera was obtained 4 months after implantation in the first patient; the mucosal lining consisted of donor respiratory epithelium and of recipient buccal mucosa. The chimera allowed for gradual withdrawal of immunosuppressive therapy. Ten months after implantation, the tracheal allograft was dissected with its new vascular pedicle from the forearm. The time points in this protocol were modified based on the internal mucosal healing of the allo trachea.

Results
In all patients immunosuppressive therapy was withdrawn. However, in one patient longterm vascularization problems occurred in the transplant. Shortening the time span for the orthotopic transplantation in 2nd stage, limits the quality of outcome. There is a precious balance between the immunologic parameters and the vascularisation of the internal lining of the trachea.

Conclusion
We report the first 6 trachea allotransplantations following initial indirect revascularization of the graft in a heterotopic position. Tracheal allotransplantation after initial revascularization can be used to treat long, non-malignant tracheal stenoses. Importantly, tracheal allotransplantation can occur without lifelong immunosuppression. The vascularization process of the mucosal lining of the trachea determines the quality of outcome and time of treatment.


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