20 June 2011
The UK should proceed with trials for laryngeal (voice-box) transplantation to restore power of speech, allow swallowing and improve breathing for the 1,000 people every year in the UK whose larynx is destroyed by trauma or benign or low-grade malignant tumours. This is the finding of a Royal College of Surgeons working group reviewing the ethics, technical evidence and patient services needed for the introduction of the procedure.
As the procedure is designed to improve quality of life rather than save it, there is an ethical balance to be struck – especially as the lifelong anti-rejection medication that the patient would need to take carries its own risks. The taskforce, which included a range of medical and lay representatives, concludes:
- The procedure should not be carried out on patients with locally advanced or recurrent cancer, such patients are at present considered unsuitable for laryngeal transplantation because of the high risk of further tumour.
- Further research is needed on nerve regeneration which is essential if the transplanted larynx can become a functional (allowing breathing, speaking and swallowing) and universal surgical procedure.
- Care needs to be taken in choosing suitable patients for this procedure by a multi-disciplinary team of doctors - a psychologist and/or a psychiatrist must be a core-member of the selection team.
- The transplant team must provide and monitor detailed functional and psychological outcomes at pre and post-operation stages.
At present patients with destroyed larynx 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. Many also experience additional challenges coming to terms with visible changes to their appearance.
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 in the United Kingdom. A team of US surgeons attempted the procedure ten years ago and this was the only transplant until recently when technical challenges were overcome and a second successful pilot procedure was conducted in the United States by an international team.
Working Group Chair Professor Tony Narula (RCS Council Member and Consultant Ear Nose and Throat Surgeon) said:
“New surgical techniques and a greater understanding of organ rejection are making an ever wider range of transplants possible. This presents exciting opportunities for treating conditions and improving quality of life in ways that simply were not possible in the past. But just because something is possible doesn’t necessarily mean it is in the best interests of patients. When trialling this procedure the medical team must meet the highest ethical standards and submit their plans to independent open scrutiny.”
Dr Daniel Sokol, working group member and Honorary Lecturer in Medical Ethics at Imperial College London said:
"This report confirms the surgical profession's commitment to ethical, patient-focused practice, looking to the future whilst learning from the lessons of the past. The committee's conclusion is that laryngeal transplantation is, in some circumstances, technically feasible and morally permissible, but due caution is needed to ensure that the risks of harm are minimised. We hope the report will assist the pioneers of this most promising procedure."
The working party report can be read here.
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