Does procurement technique affect posttransplant graft function in deceased donor liver transplantation?

Technical characteristics and quality of grafts in liver procurement from brain-dead donors: A single-center study in Vietnamese population

Introduction

Donor liver graft quality plays an especially important role that contributes to the success of organ transplantation. Almost all local and international authors are interested in the techniques and results of transplantation, however, in Vietnam, there have not been any studies that report the results of liver procurement from brain-dead donors from a technical perspective as well as the morphology and function of the transplanted organ.

Materials and method

This study is descriptive cross-section study with analysis of retrospective occurrences of a series of cases of liver procurement from brain-dead donors from March 2010 to March 2020. All cases were proceeded the multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion.

Results

The average age of brain-dead donors was 29.7 ± 10.7 (18–69), 92.16% of the harvested organs were of good quality macroscopically; and the rate of anatomical modification was 33.3% that occurred mostly in the left hepatic artery (LHA). Technically, warm dissection was proceeded in majority of cases (98,0%), the graft implantation was performed by this technique with mean cold ischemia time (CIT) of 190,0 ± 100,5 min and WIT of 74,0 ± 39,2 s. There were no complications relating to graft injuries occurring during procurement and no primary liver failure, good results accounted for 94.1% of the total number of transplants postoperatively.

Conclusion

Multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion was a safe technique and may be effective by avoiding any donor's damages in cold-phase dissection.

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Liver transplantation in brain-dead donors had developed rapidly in recent decades.

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Several techniques were proceeded depend on experience and faculties of institute.

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In vivo perfusion and warm dissection can avoid graft's damages in cold dissection.

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Long-term follow-up is needed to evaluate quality of graft and overall survival.

Organ Procurement in the Brain Dead Donors Without In Vivo Cold Perfusion: A Novel Technique

INTRODUCTION

We describe our technique of ex vivo organ perfusion and procurement in donation after deceased brain death (DBD) donors.

MATERIAL AND METHODS

This technique comprises warm dissection of liver, kidneys, and heart, in hemodynamically stable DBD donors and perfusing them ex vivo. The cardiac and abdominal dissection can take place simultaneously. As a precaution, the iliac arteries and the abdominal aorta are dissected and kept ready for rapid cannulation and perfusion, should the donor become unstable at any stage.The liver dissection is in principle similar to living donor hepatectomy, where portal dissection is combined with supra and infrahepatic caval dissection to completely mobilize liver to allow it to be removed and perfused ex vivo. The renal dissection is done after hepatic dissection is complete. The sequence of recovery of organ was modified where kidneys were procured first followed by hepatic and cardiac procurement simultaneously.

RESULTS

Twelve multivisceral (liver and kidneys in all and heart in four) procurements have been performed. The average perfusion fluid volume for liver was 3.4 L. All recipients had uneventful postoperative course.

CONCLUSION

Our technique has not affected recipient outcomes and with benefits of less use of preservation solution, shortening bench surgery time, and decreasing the propensity of procurement injuries by avoiding cold-phase dissection.

Primary non-function is frequently associated with fatty liver allografts and high mortality after re-transplantation

BACKGROUND & AIMS

The shortage of liver donations demands the use of suboptimal grafts with steatosis being a frequent finding. Although ≤30% macrovesicular steatosis is considered to be safe the risk for primary non-function (PNF) and outcome after re-transplantation (re-OLT) is unknown.

METHODS

Among 1205 orthotopic liver transplantations performed at our institution the frequency, survival and reason of re-OLT were evaluated. PNF (group A) cases and those with initial transplant function but subsequent need for re-OLT (group B) were analysed. Histopathology and clinical judgement determined the cause of PNF and included an assessment of hepatic steatosis. Additionally, survival of fatty liver allografts (group C) not requiring re-OLT was considered in Kaplan-Meier and multivariate regression analysis.

RESULTS

A total of 77 high urgency re-OLTs were identified and included 39 PNF cases. Nearly 70% of PNF cases were due to primary fatty liver allografts. The 3-month in-hospital mortality for PNF cases after re-OLT was 46% and the mean survival after re-OLT was 0.5 years as compared to 5.2 and 5.1 years for group B, C, respectively, (P<.008). In multivariate Cox regression analysis only hepatic steatosis was associated with an inferior survival (HR 4.272, P=.002). The MELD score, donor BMI, age, cold ischaemic time, ICU stay, serum sodium and transaminases did not influence overall survival.

CONCLUSIONS

Our study highlights fatty liver allografts to be a major cause for PNF with excessive mortality after re-transplantation. The findings demand the development of new methods to predict risk for PNF of fatty liver allografts.

Strategies to optimize the use of marginal donors in liver transplantation

Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors (ECD) are considered not ideal for several reasons but their use has dramatically grown in the last decades in order to augment the donor liver pool. Due to improvement in surgical and medical strategies, results using grafts from these donors have become acceptable in terms of survival and complications; nevertheless a big debate still exists regarding their selection, discharge criteria and allocation policies. Many studies analyzed the use of these grafts from many points of view producing different or contradictory results so that accepted guidelines do not exist and the use of these grafts is still related to non-standardized policies changing from center to center. The aim of this review is to analyze every step of the donation-transplantation process emphasizing all those strategies, both clinical and experimental, that can optimize results using ECD.