Clinical impact of right accessory hepatic artery injury in deceased donor livers

Drainage Pattern of Craniofacial Veins With Emphasis on its Influence on Facial Reconstruction Procedures

As the facial transplantation procedures are becoming more popular and frequent in recent years, for repairing facial trauma, variations in the veins of head and neck needs to be reported time and again. This study was undertaken to examine the course and drainage pattern of the facial vein and external jugular vein on this context and emphasize its surgical implications. The authors studied the head and neck region of 50 embalmed cadavers of both sexes to document normal and variant anatomy of facial, retromandibular, and external jugular veins. In 30% of the head and neck regions, different draining pattern of the above-mentioned veins were observed. One of the rare variation discovered was the splitting of the retromandibular vein to embrace the external carotid artery within the parotid gland. The data about variations in the termination of facial vein, retromandibular vein, and external jugular vein, as observed in the present study might be useful in avoiding accidental injury to these vessels during any surgical intervention in the face as well as neck. Level of Evidence: IV.

Procurement-related liver injury for transplantation: an analysis of the risk factors and consequences in an Australian transplant centre

BACKGROUND

Liver transplantation is an established treatment for liver failure, and its success relies on the quality of the donated organ amongst other factors. Studies on procurement-related liver injury (PRLI) are few and some may not apply to modern-day practice. This is the first Australian study examining risk factors and consequences of PRLI.

METHOD

The Victorian Liver Transplant Unit database was examined for deceased liver donors from 2010 to 2017. Information regarding the donor, retrieval and subsequent transplantation was obtained. PRLI details were sought from the 'organ retrieval report form'. PRLI risk factors and their complications were analysed.

RESULTS

A total of 420 transplants were included, with 45 injuries in 44 livers (10%), and significant injuries were observed in 4%. Variant anatomy was associated with an increased risk of PRLI (11% vs. 2%, p < 0.001). Complication rates were not significantly different between livers with and without PRLI however a reduction in early graft survival was observed.

CONCLUSION

This study shows that PRLI is common, and that variant anatomy is associated with an increased risk of injury. Appropriate feedback and benchmarking are important to maintain a high quality in donor surgery.

Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis

OBJECTIVE

To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors.

METHODS

This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25).

CONCLUSION

DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.

Right Accessory Hepatic Artery Arising From Celiac Trunk-Case Report of a Variation that Must Be Looked for During Multiorgan Procurement

Knowledge of the anatomy of the hepatic artery and its variations is important to hepatobiliary and liver transplant surgeons and interventional radiologists. We report a rare anatomic variation of liver hepatic arterial supply: a right accessory hepatic artery arising directly from the celiac trunk and observed at the time of multiorgan procurement. The anatomic variation described in this case occurs in up to 2% of cases and their knowledge is essential to avoid injuries during multiorgan procurement that could require multiple anastomoses or lead to inadvertent vessel injury. This variation is very rarely reported in the medical literature. We document successful deceased-donor liver transplantation with a graft that had an accessory right accessory hepatic artery from the celiac trunk.

Anatomical variation and its management in transplantation

Variant anatomy may be challenging at retrieval, with failure to identify variance being associated with organ damage, particularly vascular damage. On implantation, some variants demand nonstandard techniques of reconstruction or implantation. This review covers the common and less common anatomical variants of the liver, kidney and pancreas, and gives guidance as to how they may be managed during organ retrieval and implantation.

Safety and usefulness of warm dissection technique during liver graft retrieval from deceased donors

BACKGROUND

For deceased-donor liver graft retrieval, the warm dissection technique of hilar dissection before perfusion had been the standard procedure in the early period of liver transplantation. Thereafter, the cold dissection technique of in situ flushing and hilar dissection after perfusion has been preferred in many transplantation centers for rapid procurement of multiple organs. This study intended to assess the safety and usefulness of the warm dissection technique used in deceased-donor liver transplantation.

METHODS

This study analyzed a single surgeon's experience of the warm dissection technique for 165 cases of liver graft retrieval, regarding the prolongation of retrieval operation time, retrieval-associated graft injury, and recipient outcomes.

RESULTS

An additional 20 to 40 minutes was required for warm dissection. The incidence of retrieval-associated graft injury was 13 (7.9%), in which hepatic parenchymal injury was detected in 7 (capsular tear in 6 and subcapsular hematoma in 1) and vascular injury in 6 (celiac axis injury in 5 and common hepatic artery injury in 1). There was no other episode of injury at the branch artery, vena cava, portal vein, and bile duct. There was no significant difference of 1-year graft survival rates between liver grafts with and without graft injury (83% vs 83.3%, P = .73).

CONCLUSIONS

When the vital signs of deceased donor are stable, the warm dissection technique may be helpful to decrease the cold ischemic preservation time because the risk of graft injury is acceptably low and it provides more time for recipient preparation, thus giving potential advantages for marginal liver grafts.

A simple technique for procuring liver allografts while protecting arterial vessels

Arterial injury remains a common complication during organ procurement, with negative effects on postoperative morbidity and graft survival. We describe a simple technique that helps surgeons avoid vascular injuries during isolated liver procurement (without pancreas). This simple technique has been used in 200 liver procurements without any arterial injuries.

Donor Hepatic Artery Thrombosis Recognized During Organ Procurement for Liver Transplant

Arterial injuries in graft organs may be recognized during procurement and may contribute to organ waste. These injuries may be more likely in the presence of abnormal anatomy. We observed 2 liver grafts that had hepatic artery thrombosis in the donor vessels. The graft from a 64-year-old woman who had circulatory death was discarded because of potential decreased perfusion of the lobe and risk of thrombosis extending to the main hepatic artery after transplant. The graft from a 68-year-old woman donor who had brain death was used successfully as a reduced-size liver graft that included the caudate lobe. In summary, donor grafts that have hepatic artery thrombosis may or may not be used in transplant, depending on the cause of donor death, graft quality, and anatomic location of donor hepatic artery thrombosis.

Liver damage during organ donor procurement in donation after circulatory death compared with donation after brain death

BACKGROUND

During the past decade the number of livers recovered and transplanted from donation after circulatory death (DCD) donors has increased significantly. As reported previously, injuries are more frequent during kidney procurement from DCD than from donation after brain death (DBD) donors. This aim of this study was to compare outcomes between DCD and DBD with respect to liver injuries.

METHODS

Data on liver injuries in organs procured between 2000 and 2010 were obtained from the UK Transplant Registry.

RESULTS

A total of 7146 livers were recovered from deceased donors during the study, 628 (8·8 per cent) from DCD donors. Injuries occurred in 1001 procedures (14·0 per cent). There were more arterial (1·6 versus 1·0 per cent), portal (0·5 versus 0·3 per cent) and caval (0·3 versus 0·2 per cent) injuries in the DBD group than in the DCD group, although none of these findings was statistically significant. Capsular injuries occurred more frequently in DCD than DBD (15·6 versus 11·4 per cent; P = 0·002). There was no significant difference between DCD and DBD groups in liver discard rates related to damage.

CONCLUSION

There were no differences in terms of vascular injuries between DCD and DBD livers, although capsular injuries occurred more frequently in DCD organs. Continuing the trend for increased frequency of DCD liver recovery, and ensuring that there is an adequately skilled surgical team available for procurement, is vital to improving the utilization of DCD livers.