27 February 2009
The complex clinical and ethical issues surrounding the possible introduction of tracheal (windpipe) and laryngeal (voice-box) transplantation are to be debated by a new taskforce set up by the Royal College of Surgeons.
Despite years of research, there is no current definitive treatment for the 1,000 people every year in the UK whose larynx is destroyed by trauma or tumour. At present these patients undergo laryngectomy - a procedure which means they have a permanent breathing hole (or stoma) in their neck.
As a result, these patients experience a range of problems which include difficulties speaking, swallowing, lifting, straining, coughing, smelling, tasting and even kissing. Some also struggle with a deformed appearance. The only previously documented laryngeal transplant occurred over a decade ago in the US and was only a partial success. Although the patient was able to speak after the operation, he still needed a stoma to breathe.
The larynx creates and controls sound through muscle and cartilage interaction of the vocal cords and this is controlled by sensory nerves. The difficulty of restoring the complicated nerve and muscle functions has, to date, been beyond surgery. But it is now believed that, with improved technology, there is the prospect that these technical challenges might be overcome and clinical trials may soon be possible.
This possibility raises a wide range of ethical dilemmas. Since this is not a life-saving procedure, do the benefits of the procedure outweigh the significant risks of harm? Which patients would be best suited for surgery and how should they be selected? How can we obtain valid consent for an experimental procedure that has only been performed once? How will the surgical team be trained to perform the operation? Is total laryngeal transplantation premature in the current state of knowledge? These are among the questions that will be discussed when the taskforce meets for the first time in March.
The taskforce is formed of:
- Chair: Professor Tony Narula – Member of RCS Council and Consultant Ear Nose & Throat surgeon at St Mary’s Hospital.
- Professor Martin Birchall – who recently led the world’s first use of stem-cells in transplantation for a trachea transplant in 2008 and is based at UCL.
- Professor Patrick Bradley – leading consultant in head & neck cancer and expert in voice restoration surgery from Nottingham University Hospitals NHS Trust.
- Professor Nadey Hakim – Surgical Director of transplant unit at St Mary’s Hospital.
- Professor Paul Carding – Professor of voice pathology at Newcastle University.
- Dr Daniel Sokol – Medical Ethicist, St George’s, University of London
Professor Martin Birchall:
“Despite decades of efforts, patients with serious laryngeal disease are still having a mutilating operation that is 150 years old. Complete replacement of functions is unlikely to be possible with reconstructive techniques for many more years, so transplantation may prove a good solution.”
Dr Daniel Sokol, a medical ethicist at St George’s, University of London, and a member of the Taskforce:
“Laryngeal transplantation is an exciting prospect, but in our enthusiasm we should not forget a key ethical principle in medicine: above all, do no harm. We must be satisfied that the benefits of this experimental procedure will outweigh the inevitable harms that will result.”
Notes to Editors
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