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Acs0906 Organ Procurement
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Acs0906 Organ Procurement
1. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 1 6 ORGAN PROCUREMENT Talia B. Baker, MD, FACS, Anton I. Skaro, MD, PhD, FRCSC, Paul Alvord, MD, and Prosanto Chaudhury, MD, CM, MSc (Oxon), FRCSC Improvements in immunosuppression, organ preservation, then to transplant them into as many as nine recipients surgical technique, and recipient management have led to at multiple transplant centers. In addition, it is possible to the widespread adoption of transplantation as a viable thera- procure various nonvascularized tissues (e.g., bones, corneas, peutic option for end-stage organ disease. Consequently, blood vessels, valves, and skin), which can be used to help more patients than ever are beneﬁting from organ transplan- many more patients. tation. Unfortunately, the rate of organ donation has not kept One of the most important advances in the ﬁeld of pace with the increase in the number of recipients awaiting transplantation has been in the area of organ preservation. transplantation. For example, statistics from the United The widespread use of University of Wisconsin (UW) solu- Network for Organ Sharing (UNOS) reveal that in 2006, tion (Belzer solution) has improved the safety of organ more than 97,000 patients were awaiting transplantation, but preservation and relaxed the time constraints on the trans- only 28,000 transplants were performed.1 plantation of all organs [see Table 1]. In the past few years, a The relative shortage of organs has necessitated an increas- newer preparation, crystalloid-based histidine-tryptophan- ing reliance on creative strategies aimed at broadening or ketoglutarate (HTK) solution, has shown extremely promis- expanding the limits of the donor pool. For instance, organs ing results in liver, kidney, and pancreas transplantation.9–11 now are frequently obtained from so-called extended-criteria A better understanding of the molecular basis of ischemia- donors (i.e., donors who are elderly or who have signiﬁcant reperfusion injury will pave the way for further advances in comorbid conditions)2–4 or from non–heart-beating donors.5 the future. Kidneys from pediatric donors that previously would have In what follows, we outline the current state of organ gone unused are currently procured en bloc (i.e., together procurement from both cadaveric and living donors, includ- with a common patch of aorta and vena cava) for use in a ing donor evaluation, perioperative management, and the single adult.6,7 Transplant surgeons now also routinely split various donor procedures. Cadaveric and living donors are livers so that two recipients can receive transplants from a discussed separately because these two groups differ vastly, single donor liver.8 both from a technical or surgical standpoint and from a A particularly important strategy for alleviating the organ medical standpoint. shortage has been the broader application of living donor transplantation. In 2001, the number of organs transplanted Organ Procurement from Cadaveric Donors from living donors actually exceeded the number of those transplanted from cadaveric donors.1 Living kidney donation has been practiced for years, but technical advances in Because of advances in trauma and critical care medicine, laparoscopic donor nephrectomy have made it even more many critically ill patients now survive who previously would appealing. Since the early 1990s, segmental livers from living have succumbed to their illnesses. A patient does not become donors have been successfully transplanted into pediatric a potential donor until all lifesaving efforts have failed. recipients. Subsequently, transplantation of right or left Once the patient has been declared brain dead and the decision hemilivers from live donors into adult recipients has gained has been made to proceed with organ donation, management widespread acceptance.8 Living donor transplantation has of the donor is redirected toward optimizing potentially salvage- proved itself to be technically feasible; however, it has also able organs, a process that often necessitates aggressive ﬂuid raised certain new ethical and philosophical concerns that the resuscitation. transplant community has not yet fully resolved. It is imperative for health care providers to remember The procurement process includes not only the donor that whereas donors are not salvageable, dying patients operation but also the evaluation of donors and potential waiting for transplants may be, and the lives of the recipients recipients. Comorbid disease in a donor can render certain depend on the quality of the donated organs. Good donor organs unsuitable for transplantation into particular recipi- management with careful attention to details (e.g., sterile ents. Accordingly, careful consideration of any relevant technique, antibiosis, timely transfusion, and vasopressor factors affecting either the donor or the recipient is necessary management) is vital for achieving optimal transplantation to ensure optimal outcomes. Although clinical judgment is outcomes. In addition, it is important to demonstrate to still paramount, it is based on a rising level of technical exper- health care workers, lay people, and donor families that organ tise and surgical experience. Procurement of multiple organs donors are treated with respect and dignity. from a single cadaveric donor is now routine, and living donor options have been greatly expanded. It is possible to take the heart, one or both lungs, the kidneys, the liver (whole or After a potential donor has been identiﬁed, the donor split), the pancreas, and the intestines from one donor and coordinator from the local organ procurement organization DOI 10.2310/7800.2008.S09C06 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 2 Table 1 Composition of University of Wisconsin (UW) of the medical model for end-stage liver disease (MELD), a Solution* composite score based on total bilirubin, the international standardized ratio (INR), and the serum creatinine concen- Rafﬁnose, 30 mmol/L Potassium, 125 mmol/L tration, has dramatically changed the way in which cadaveric Lactobionate, 100 mmol/L Sodium, 125 mmol/L livers are allocated.13 Once organs are matched to speciﬁc recipients, the local Hydroxyethyl starch, 50 g/L Magnesium, 5 mmol/L OPO procurement coordinator arranges an operating room time Sulfate, 5 mmol/L Adenosine, 5 mmol/L for the donor procedure and organizes transportation of the Phosphate, 25 mmol/L Glutathione, 3 mmol/L participating surgical teams. Multiple-organ harvests require considerable coordination between the different institutions, Allopurinol, 1 mmol/L surgeons, and coordinators. In the meantime, it is important *Penicillin and heparin are added within 2 hours of use. that the donor be kept hemodynamically stable [see Cadaveric Donor Operation, below]. With the proliferation of experienced (OPO) obtains a detailed medical and social history. The transplant centers, it has become common for most organs to donor’s acute physiologic status is assessed on the basis of be procured by local procurement teams and shipped to the blood pressure (measured via an arterial line), central venous recipient institutions. This collaboration has improved the coor- pressure (CVP), urine output, arterial blood gas values, and dination of the retrieval process, reduced the transportation serum chemistry. Serologic analysis must be done for syphilis costs associated with long-distance procurements, and helped (Venereal Disease Research Laboratory [VDRL]), hepatitis B ease the burden on the recipient teams. Certain organs (e.g., surface antigen (HBsAg), hepatitis B core antibody (HBcAb), hearts, intestines, and multivisceral grafts) are still generally hepatitis C virus (HCV), cytomegalovirus (CMV), human procured by the recipient institution. immunodeﬁciency virus (HIV), and human T cell lympho- tropic virus type I (HTLV-1). In certain cases (e.g., kidney, pancreas, and intestinal transplants), inguinal lymph nodes The decision to use an organ is ultimately based on an must be removed through a small groin incision at the experienced transplant surgeon’s judgment at the time of the bedside to facilitate tissue typing, which takes an average of procurement. Careful evaluation of the donor, the prospec- 4 hours. For kidneys in particular, genetic matching of donor tive recipient’s medical history, and any pertinent laboratory and recipient has been shown to improve outcome.12 data is essential for ensuring the best outcome. As noted (see The OPO coordinator then contacts local and regional above), the persistent organ shortage and the resulting exten- transplant programs about their needs for renal and extra- sion of donor criteria have led to the retrieval of more organs renal organs. UNOS maintains a national computer registry from older, more marginal, or even non–heart-beating donors. of potential recipients for all organs (http://www.unos.org). Donor selection criteria show considerable variation from one setting to another, depending on the organ being transplanted Potential organ recipients are categorized according to (1) and the transplant center involved. ABO blood group, (2) degree of medical urgency, (3) length of time the patient has been on the transplant list (i.e., Liver waiting time), (4) weight, (5) acceptable weight range of the Several biochemical parameters are considered in the donor, and (6) distance the recipient team is willing to travel evaluation of liver grafts. With ideal donors, these parameters for procurement. normally include the serum aspartate aminotransferase Sharing of all organs is based on the principle that organs (AST), serum alanine aminotransferase (ALT), and bilirubin should be offered ﬁrst to patients in the local area and then levels. However, even with donors in whom the injurious to patients within a larger geographic region. (UNOS has event leading to death results in abnormal transaminase divided the United States into 11 geographic regions for the levels (which may be reversible), livers suitable for transplan- purposes of organ distribution [see Figure 1].) If no suitable tation can often be salvaged after appropriate resuscitation. recipient can be found locally or within the donor’s UNOS Livers from donors with viral hepatitis or alcoholism can region, the organ is offered to patients across the nation. An also be successfully used for transplantation if an acceptable exception to this rule exists for kidneys. For kidneys, when biopsy is performed. Sustained hypernatremia (serum sodium there is a six-antigen match (i.e., a perfect histocompatibility concentration > 170 mg/dl) is a recognized risk factor for match between a donor and a recipient on all six HLA-A, primary nonfunction14 and should be aggressively treated HLA-B, and HLA-DR antigens) or when there is at least with administration of free water. Hepatic steatosis, more phenotypic identity between a donor and a prospective commonly observed in livers from obese donors, has recipient (i.e., no HLA mismatch), the kidney must be offered been associated with liver graft dysfunction and primary ﬁrst to the matched recipient, regardless of geographic nonfunction. More speciﬁcally, the risk of dysfunction or location. nonfunction is associated with irreversible macrovesicular Speciﬁc medical criteria for prioritizing patients on the steatosis; microvesicular changes are often reversible, waiting lists for various organs are constantly being reevalu- typically occurring as a result of an acute insult.15 ated. Full discussion of these criteria is beyond the scope of When a liver is being considered for whole-organ this chapter. Brieﬂy, allocation of kidneys currently depends transplantation, the size of the graft and the amount of space most on waiting times, but new considerations related to net available within the recipient are important issues. In general, lifetime saved are being integrated into evolving algorithms. the mass of the liver graft to be transplanted must equal The system for distributing livers changed in spring 2002 at least 2% of the recipient’s ideal body mass.16 With from one that gave signiﬁcant priority to waiting time to one this stipulation in mind, the liver may be split or reduced in that stratiﬁed patients according to medical urgency. The use accordance with the principles of hepatic segmental anatomy 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 3 Figure 1 Shown are the 11 geographic regions employed by UNOS for distribution of organs. [see 5:23 Hepatic Resection], thereby enabling liver transplants x-ray and electrocardiogram. Donors are also closely matched to be supplied to multiple recipients, including even the to recipients with respect to size (though the matching must smallest of pediatric patients. Living donor transplantation also take into account the fact that recipients often have of the right or left hemiliver into adults has also been cardiomegaly as a consequence of heart failure). Echocar- popularized, thus making more options available to patients diography is valuable for documenting cardiac wall motion with end-stage liver disease.17,18 and the ejection fraction; however, coronary angiography is necessary in the assessment of older donors. The arterial Kidneys oxygen tension (PaO2) of lung donors should be at least When kidney transplantation is performed in a sensitized 350 mm Hg during ventilation, with a fraction of inspired recipient, a negative crossmatch is essential for avoiding oxygen (FIO2) of 1. In addition, bronchoscopy is useful in the accelerated rejection. For the kidney graft itself, anoxia time evaluation of lungs for donation. The ﬁnal determination of and hypoperfusion time correlate with graft dysfunction. whether to use the heart or lungs for transplantation is based Donor-related factors (e.g., age, diabetes, hypertension, on inspection of the organs at the time of procurement by an hypercholesterolemia, and obesity) contribute to native renal experienced thoracic transplant surgeon. disease, which may prevent use of the kidneys for transplanta- tion. Biochemical parameters (e.g., serum creatinine concen- Pancreas tration and creatinine clearance) are important indicators Pancreas transplantation is not lifesaving; therefore, of kidney function. If the donor is elderly and has multiple pancreas donors tend to be chosen more selectively than comorbid conditions, a renal biopsy is helpful in determining donors of other organs. Clearly, diabetes is an absolute con- suitability for transplantation. Generally, if a biopsy shows traindication to donation. Less commonly, ﬁbrotic or fatty less than 20% scarring, it is acceptable to proceed with trans- inﬁltration resulting from alcohol use and obesity may render plantation. Currently, many OPOs maintain extracorporeal pancreata unsuitable for transplantation. Serum amylase, perfusion of kidney grafts; this practice purportedly offers lipase, and glucose measurements may be useful. A negative some beneﬁt to the graft beyond the prolongation of potential crossmatch is a necessity in sensitized patients. Ultimately, cold ischemia time. Pump parameters (resistive indices the gross appearance of the gland in the donor during < 0.2 ml/min and ﬂow > 100 ml/min) are also objective procurement dictates whether the organ should be used for markers of graft function.19 Expansion of the kidney donor transplantation. Pancreata that are not used for whole-organ pool through cautious use of extended donor criteria is safe transplantation should be considered for clinical islet cell and effective.20 transplantation or research.21 Heart and Lung Intestine The criteria for heart and lung donors are strict. Donors Patients with intestinal failure can be supported with are usually young, with no cardiac disease and a normal chest total parenteral nutrition (TPN) until transplantation can 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 4 be undertaken. Frequent line infections, difﬁcult access, be conﬁrmed. Transport to the operative theater should and cirrhosis arising from TPN-related liver disease all pose be undertaken by skilled anesthesia personnel to ensure that substantial challenges to surgeons considering intestinal hemodynamic insults are avoided. In the OR, the anesthetic transplantation. Consequently, intestinal donors are chosen team is charged with maintaining donor stability, as well very carefully. The intestine is very sensitive to hypotension, as with facilitating the procedure through optimal muscle as well as to the vasoactive agents commonly used to resu- relaxation (often, spinal reﬂexes persist in the donor). scitate hypotensive donors, which cause mesenteric vasocon- striction and thereby potentiate graft ischemia. Consideration should be given to matching recipients who are CMV naïve The operation for multiple organ procurement must or Epstein-Barr virus (EBV) naïve with seronegative donors. proceed in such a way that all of the transplantable organs In patients with short-gut syndrome, loss of abdominal can be removed without being jeopardized. There are as domain is commonplace, making size matching between many ways to perform donor operations as there are surgeons donor and recipient a paramount concern. Laparostomy is a performing them. In general, however, regardless of which predictor of poor outcome; therefore, the donor ideally should organs are to be procured, the operation includes a prelimi- be 50% to 75% of the recipient’s size. To reduce ischemia nary dissection of the great vessels of the abdomen and the time, it is often necessary to begin the recipient operation chest. The aorta is isolated at preplanned levels to allow before the donor operation is completed. cross-clamping, so that the organs to be removed can be core- cooled in situ with intra-aortic and intraportal infusions, thereby avoiding warm ischemia. This technique has been Every effort is made to sustain the donor in a normal adopted as an international standard. physiologic state up to the organ procurement procedure. The most reﬁned version of in situ core cooling, commonly Aggressive monitoring of BP, arterial oxygenation, central known as the rapid-ﬂush technique, can be completed from venous pressure, and urine output is key to donor manage- beginning to end in less than 1 hour.24 The rapid-ﬂush techni- ment. Donor therapy is aimed at maintaining adequate circu- que is the procedure of choice for unstable donors and lation through aggressive restoration of intravascular volume in cases of donation after cardiac death (DCD). With this and optimal ventilation, thereby providing maximal organ approach, no dissection is done until after circulatory arrest perfusion. Anemia can exaggerate tissue hypoxia and should and in situ core cooling of the organs, at which point all that be addressed with blood transfusion as indicated. is required is rapid dissection and subsequent cannulation of Often, brain death results in perturbation of the neurohor- the infrarenal aorta. Some surgeons perform all of their organ monal axis, leading to donor instability; relatively expeditious procurements with this method. Its major drawbacks are (1) procurement is then necessary to preserve organ quality. that most of the dissection is done in bloodless organs that Severe neurogenic shock and unopposed peripheral vasodila- have been infused with preservative and are uniformly discol- tion ensue after brain death. Even with volume loading, ored white and (2) that cold ischemia times are generally vasopressor support must often be added to remedy the longer because no preliminary dissection was performed. inadequate peripheral vascular resistance. These agents commonly produce severe visceral vasoconstriction, and The procurement procedure begins with a generous inci- careful balancing is necessary to guard against injury to the sion from the sternal notch to pubis with an electrocautery transplantable organs. device [see Figure 2]. The sternum is opened with a sternal Severe head injury often leads to failure of pituitary func- saw or a suitable substitute. (If a previous sternotomy was tion and thus to an absence of antidiuretic hormone (ADH). done, the opening of the sternum is delayed until the abdom- The ensuing diabetes insipidus produces a profound diuresis, inal aorta has been encircled and cannulated. Although this giving rise to severe volume depletion and donor instability. approach provides more limited exposure at ﬁrst, it helps Volume resuscitation should aim at replacing hypotonic ensure that the organs will not be lost should the heart be losses with appropriately matched intravenous ﬂuids so as to injured during the reopening of the sternum.) The pericar- prevent hypernatremia, which can exert undue osmotic stress dium is opened and the heart inspected. The abdominal on the organs to be used for transplantation. Accordingly, and thoracic contents are grossly examined and palpated electrolyte levels should be monitored frequently, and con- after a large Balfour-type retractor is in place for exposure sideration should be given to I.V. administration of vasopres- [see Figure 3]. A cursory examination of the abdominal and sin to treat concomitant hypotension and diabetes insipidus. thoracic contents is made, and the organs are evaluated for Triple hormonal resuscitation—comprising injection of a their quality. It is critical that all occult pathologic conditions methylprednisolone bolus and infusion of both triiodothyro- be fully investigated and that biopsies be obtained when indi- nine and vasopressin—is also effective in improving the yield cated. The heart should be evaluated with respect to strength of transplantable organs from donors. In particular, hearts of contractions (i.e., snap), donor volume status, and possible procured from donors treated with neurohormonal replace- cardiac injuries (e.g. contusions). The liver should be exam- ment not only are more likely to be used for transplantation ined for contour, color, and consistency, which may provide but also exhibit enhanced early graft function.22 clues to the degree of ﬁbrosis or steatosis present. The Before the procurement procedure, the donor’s chart pancreas can be visualized through the lesser sac and should is carefully reviewed by the transplant surgeon to conﬁrm be evaluated for color and fat content. The intestines should satisfactory completion of the declaration of brain death and be examined for peristalsis and good arterial pulsations in the consent for organ donation.23 In addition, the blood type, the mesentery, which are reliable indicators of a healthy the serologic assays, and the laboratory test results should graft. 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 5 Figure 3 The left triangular and gastrohepatic ligaments are divided so that the left lobe of the liver can be retracted to the right. The diaphragmatic crura are divided between the esophagus and the vena cava to facilitate exposure and encirclement of the aorta at the level of the diaphragm. Figure 2 The incision used for multiple organ procurement is reached. At this point, exposure of the artery becomes is made from the suprasternal notch to the pubis. The easier, and the common hepatic artery can be exposed falciform ligament is divided and the pericardium opened. from the splenic artery to the gastroduodenal artery (GDA); however, dissection should not proceed beyond the GDA. The order in which the steps of the procurement procedure The peritoneum overlying the porta hepatis is opened to yield are done varies from surgeon to surgeon, as does the ratio of a clearer view of the structures beneath, including the common “warm dissection” to “cold dissection.” The approach we bile duct (CBD). The CBD is divided just as it enters the describe here is only one of the many viable methods. The pancreas, and the pancreas side is ligated (if the pancreas is white line of Toldt is taken down on the patient’s right side, being procured as well). Before division of the CBD, this area and the intestines are rotated medially until the aortic bifur- must be carefully examined and palpated to ensure that a cation is exposed. The aorta is encircled with a No. 2 silk right replaced or right aberrant artery is not inadvertently suture. This step is then repeated, and both ties are clamped injured. and set aside. The inferior mesenteric artery (IMA) may Once the CBD is divided, the gallbladder is opened be either ligated and divided or simply left alone, but care just enough to allow insertion of a suction device and is then must be taken not to injure any inferior-pole renal arteries emptied of its contents, with care taken not to spill bile that may be coming off the aorta or the common iliac artery throughout the operative ﬁeld. A bulb syringe is employed to aberrantly. If such an artery is present or if the distal aorta ﬂush any stones or debris through the CBD. At this point, it cannot be cannulated, the distal common iliac artery may be is reasonable to cross-clamp and then continue with either encircled and cannulated while the contralateral iliac artery is cold or warm dissection. (Often, different teams work at clamped. different paces, on different organs, and in different body Attention is then turned to the liver. The left triangular cavities, and cross-clamping must be coordinated across all of ligament is taken down, and the gastrohepatic ligament is the participating teams.) If a thoracic team is present, the examined for an accessory left hepatic artery. If such an artery supraceliac abdominal aorta should be clamped. This portion is discovered, it should be preserved [see Figure 3]. Otherwise, of the aorta is exposed by dividing the arcuate ligaments of the gastrohepatic ligament is divided; this measure may the diaphragm. It need not be encircled: it need only be sufﬁce for exposure of the common hepatic artery. A small, exposed sufﬁciently to permit proper clamping. (Small ﬁne right-angle instrument (or an equivalent device) is used branches to the thoracic spine, the diaphragm, and other to divide the tissue overlying the artery until the proper plane nearby structures are difﬁcult to see and easy to avulse.) If no 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 6 thoracic team is present, the aorta may be cross-clamped in packed around the organs. (Pockets are usually created the chest. The thoracic aorta is exposed by sliding a ﬁnger posterior to the kidneys and in the lesser sac to allow the or thumb between the posterior esophagus and the anterior maximum amount of surface area exposure to the ice [see thoracic aorta and working the overlying tissue back and forth Figure 5].) until the vessel is encircled. The preservation solutions are designed to maintain the Before the actual cross-clamping, 300 U/kg of heparin is organs’ cellular integrity. The impermeants and colloids they infused and allowed to circulate. The inferior silk suture include prevent cell swelling, which is the major mechanism around the abdominal aorta is tied down to keep the infusate of organ injury. At present, UW solution is still the gold from circulating through the lower extremities. The aorta is standard for preservation of the kidney, the liver, the pan- then opened, the cannula is placed into the lumen, and the creas, and the small bowel. However, HTK solution is second silk suture is tied down. (With proper exposure of and increasingly being adopted by transplant centers for abdomi- pressure on the aorta, placement of the cannula can be nal organ preservation. HTK solution has a low viscosity accomplished without blood loss [see Figure 4].) Once the and contains less potassium than UW solution, which may be cannula is in place (but before infusion of the preservation advantageous in liver preservation. Another option is Celsior solution) and the heparin is circulating, the aorta is ready for (SangStat Medical Corporation, Fremont, California), an cross-clamping. The surgeon should communicate with the extracellular-type preservation solution that is primarily used other teams to coordinate the cross-clamping in the chest and for cardiac grafts, though it has been proved effective in pre- the abdomen. In addition, the surgeon should ensure that serving abdominal organs. Celsior possesses a strong buffer adequate amounts of cold preservation solution and sterile ice capacity and is an inert osmotic agent, thereby effectively are available to minimize potential injury to the organs during combining the characteristics of UW solution and the ischemic time. Once the preservation solution begins HTK solution. Other substances may be added to these pres- to ﬂow into the aorta, the supraceliac (or thoracic) aorta is ervation solutions, including heparin, antibiotics, and anti- clamped, and the right atrium (or the inferior vena cava oxidants (which mitigate the deleterious effects of reactive [IVC]) is opened to vent the vasculature. Ice is then carefully oxygen species) [see Table 1]. Static cold storage is the preferred organ preservation method in most centers. A 10°C fall in temperature results Figure 4 The small intestine is reﬂected, the distal aorta is Figure 5 The aorta is cross-clamped at the diaphragmatic exposed, and the inferior mesenteric artery is ligated and level and at the arch level in the chest at the time of rapid divided. A catheter is inserted into the distal aorta. infusion. 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 7 in a halving of the metabolic rate, so that at 4°C, residual metabolic activity is only about 10% to 12%. Despite the beneﬁcial effects of cooling, ongoing ischemia favors the depletion of cellular adenosine triphosphate (ATP), the switch to anaerobic metabolism with increasing acidosis, and the liberation of reactive oxygen species. Accordingly, every effort must be made to minimize cold ischemia time so as to maximize organ function in the recipient. Cold ischemia sets the stage for a complex cascade of inﬂammatory events occurring upon reperfusion, which result in early graft injury and dysfunction. Ischemia-induced activation of the endo- thelium leads to upregulation of permeability and adhesion molecules, which promote inﬁltration by immune effector cells. These leukocytes elaborate proinﬂammatory cytokines and reactive oxygen species, which cause cell death and organ injury.25 Hypothermic machine storage (in which pulsatile perfusion of donor organs is maintained during transport) can help mitigate these deleterious effects. In particular, machine perfusion can reduce the incidence of delayed kidney graft function and is superior for preserving kidneys retrieved from extended-criteria and non–heart-beating donors.19 The various organs differ in their ability to tolerate cold ischemia. Kidneys can be preserved for as long as 72 hours— often longer when hypothermic machine storage is employed. Thus, there is sufﬁcient time for tissue typing and matching, as well as for the subsequent export of kidneys to distant sites. Nonetheless, prolonging cold storage for more than 24 hours diminishes the likelihood that kidney grafts will function immediately in the recipient. Pancreas and liver grafts may be safely preserved for as long as 20 hours; however, the risk of primary liver graft nonfunction increases substantially when Figure 6 The heart is procured by dividing the aorta at the cold ischemic time exceeds 12 hours. The intestine may be level of the arch and the suprahepatic vena cava, with care preserved for as long as 12 hours, but it should be implanted taken to leave adequate caval length with both the heart and as soon as possible. Time constraints are more rigid for the the liver. heart and the lungs,: these organs should be transplanted within 6 hours. 25 The operative technique for lung procurement is generally similar to that for heart procurement [see Figure 7]. After Heart and Lung mobilization and isolation of the aorta and the superior vena After infusion of cold preservation solution, the cardiac cava (SVC), the trachea is dissected as far above the level team proceeds ﬁrst, removing the heart, the lungs, or both of the carina as possible. Prostaglandin E1 (PGE1) is given via as expeditiously as possible while the abdominal organs are a catheter in the main pulmonary artery, causing pulmonary covered with ice slush and perfused with the preservation vasodilation and thereby optimizing lung perfusion. After solution. (As noted, the heart tolerates cold ischemia rela- infusion of PGE1 and systemic heparinization, the SVC is tively poorly.) The heart is core-cooled with a potassium-rich ligated and divided. The distal ascending aorta is cross- clamped, the cardioplegic infusion is begun, and topical cold cardioplegic solution infused via a cannula inserted into the ice slurry is placed on the organs. The lungs are inﬂated, the ascending aorta. Blanching of the heart and cardiac arrest endotracheal tube is withdrawn, and the trachea is stapled from the cardioplegic infusion occur within a few seconds. and divided. The posterior pleurae are incised, and the heart At the same time, systemic venous inﬂow is discontinued and the double-lung complex are removed from the thoracic by bleeding the IVC into the chest. Care must be taken to cavity, taken to the back table, and separated. leave enough suprahepatic IVC for both the liver and the Once the thoracic organs have been procured and the heart [see Figure 6]. (In the event that the IVC within the abdominal aortic ﬂush completed, the ice is removed from pericardium is to be cross-clamped by the cardiothoracic the abdominal cavity—except for that around the kidneys, team, the infrahepatic IVC must be vented into the lower which are routinely the last organs to be removed. abdomen to prevent venous hypertension.) The aorta is divided distal to the innominate artery, and the pulmonary Liver, Pancreas, and Intestines artery is divided at its bifurcation. Most cardiac teams require Once the efﬂuent coming from the IVC is clear, the process approximately 10 minutes from the onset of cardioplegic of removing the abdominal organs begins. The remainder of infusion to complete the cardiectomy. The abdominal the celiac trunk is exposed down to the aorta. The left gastric viscera are blanching and cooling while the cardiac team is artery and the splenic artery are divided. (If the pancreas is completing its procurement. to be procured as well, a tag may be placed on the pancreatic 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 8 Figure 7 Shown is en bloc procurement of heart and lungs. portion of the splenic artery to help identify it.) The celiac trunk is then removed with a Carrel patch. A fair amount of ﬁbrous neural tissue must be transected to expose this area of the aorta. The hepatic artery is then dissected free from Figure 8 The junction of the superior mesenteric vein (SMV) surrounding tissue as far as the GDA, with care taken not to and the splenic vein is behind the pancreas, as depicted here. stretch the artery unduly and thereby risk intimal damage. A cannula is placed in the distal aorta. SMA—superior Near the GDA is the origin of the right gastric artery, a small mesenteric artery. branch that is easily avulsed if the surgeon is insufﬁciently careful. The GDA is then divided. Once the hepatic artery is reﬂected toward the liver, the portal vein should come into view. If the pancreas is being procured as well, the portal vein is usually divided at the level of the coronary vein. If the pancreas is being sacriﬁced, the portal vein is divided back at the splenic conﬂuence [see Figure 8]. Although the CBD was previously divided, some periportal neural tissue usually remains, and it is in this tissue that a careful search for a right replaced artery must be under- taken. If a right replaced artery is discovered, it should be traced back to the superior mesenteric artery (SMA), and the SMA should be kept with the liver for reconstruction on the bench [see Figure 9]. If no right replaced artery is identiﬁed, the tissue is divided, and the subhepatic IVC is exposed. The right and left renal veins are identiﬁed, and the IVC is divided cranial to them. With the liver’s vascular structures completely dissected, the liver is held solely by its diaphragmatic attachments. The left and right diaphragmatic surfaces are cut so as to Figure 9 The typical replaced right hepatic artery originates leave the bare area attached, the coronary ligament intact, from the ﬁrst 2 cm of the superior mesenteric artery (SMA) and a cuff of diaphragm still attached to the liver. (Caution near the aorta. It then runs posterior to the portal vein, with must be exercised in pulling up on the right hemiliver because the portal vein depicted here schematically being reﬂected the capsule of the liver can easily be torn while the right laterally. Also shown is the Carrel patch that will later be triangular ligament—the “rookie ligament”—remains intact.) created to preserve the celiac axis and the SMA (dashed red The right triangular ligament is taken down, and the perito- line). neum overlying the right adrenal gland is divided. The right preservation solution. Finally, the organ is packed in the adrenal gland is then transected, with a portion left attached efﬂuent remaining in the bag, placed in an ice-ﬁlled cooler, to the liver. The ﬁnal diaphragmatic attachments near the and transported to the recipient hospital, where it is cleaned spine are divided, and the liver is removed from the body. and prepared for implantation in a formal back-table With this technique, removal of a cold and bloodless liver procedure that takes approximately 30 minutes. requires 15 to 30 minutes. The organ is taken to the back The next step is procurement of the pancreas. Scissors are table and placed in a sterile, empty bag immersed in a basin employed along the greater curvature of the stomach to divide of ice-slush solution. The portal vein is then ﬂushed with the short gastric vessels all the way to the diaphragm. The 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 9 stomach is then divided with a stapler proximal to the pylorus completely free. It, too, is taken to the back table, where the and reﬂected cranially to expose the anterior surface of the duodenum is opened, ﬂushed with cold preservation solution, pancreas. All splenic attachments are sharply divided to allow and then stapled closed again. The pancreas is packed in cold complete mobilization of the spleen. A complete Kocher preservation solution and three sterile bags and placed on ice. maneuver (if not completed previously) is then undertaken. The shorter portal vein segment remaining with the pancreas The jejunum is divided with a stapler just distal to the liga- may be lengthened with an iliac vein graft from the donor. ment of Treitz. The stapler is reloaded and used to divide any The donor celiac axis and hepatic artery stay with the liver. remaining colonic mesentery. The root of the small bowel The splenic artery is divided near its origin from the celiac mesentery is then divided and stapled, resulting in mobiliza- axis, and the SMA stays with the pancreas. In the case of a tion of the entire pancreas except for the area around the replaced right hepatic artery, the SMA must be divided distal origin of the SMA. This area contains a fair amount of tough, to the replaced artery, and the SMA (including its aortic ﬁbrous neural tissue that must be divided before the root of origin) must remain with the liver graft. The pancreatic the SMA can be exposed. The artery is divided in such a way arterial supply is then reconstructed with a donor iliac artery as not to affect the cuff of aorta surrounding the oriﬁce of Y-graft anastomosed to the splenic artery and the SMA each renal artery [see Figure 10]. At this point, the pancreas is [see Figure 11]. Figure 10 With the lateral attachments to the spleen and the pancreas divided, the entire pancreaticosplenic complex can be reﬂected medially. The aorta is thereby exposed and can be incised anteriorly at the level of the superior mesenteric artery so that the oriﬁces of both renal arteries can be identiﬁed and preserved (inset). 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 10 –- ⁄ Since the mid-1970s, when the U.S. adopted the legal deﬁnition of brain death, the majority of cadaveric organs have been obtained from brain-dead donors.5 A brain-dead donor is fully supported with medication and mechanical ventilation throughout the donation process until the organs are ﬂushed with cold preservation solution; thus, warm isch- emia is eliminated entirely. As noted, however (see above), the ever-increasing disparity between the number of organs available and the number of patients awaiting transplantation has stimulated renewed interest in the procurement of organs from non–heart-beating donors (i.e., DCD). Donation from non–heart-beating donors begins after cardiopulmonary func- tion has ceased and the prescribed additional amount of time (2 to 5 minutes) has passed before death can be declared Figure 11 The pancreas is procured with a segment of and organ retrieval initiated. In other words, each DCD is duodenum. Shown is the posterior view of the pancreas associated with an unavoidable and variable period of warm and duodenum, with the spleen removed. The arterial reconstruction involves using a Y-shaped donor iliac artery ischemia. Accumulating data suggest, however, that despite graft and anastomosing it to the donor superior mesenteric the warm ischemia, kidneys, livers, lungs, whole pancreata, and splenic arteries. Occasionally, a vein graft (not shown) is and pancreatic islet cells from non–heart-beating donors can needed for use as an extension graft for the portal vein. be used for transplantation in selected situations.20,26–32 The Institute of Medicine position paper regarding dona- tion after cardiac death speciﬁed seven recommendations: Kidneys (1) written, locally approved DCD protocols; (2) public The last organs to be procured are the kidneys. The two openness in regard to DCD protocols; (3) antemortem organs may be removed either individually or en bloc; here, administration of medications (e.g., heparin) done on an we describe the en bloc method. individual case basis; (4) antemortem cannulation only The two ureters are located and divided as far distally as after consent from the next of kin; (5) policies to limit the possible, with care taken not to strip the ureters of their blood potential for conﬂict of interest; (6) support of the donor supply. Each ureter is then freed back as far as the inferior family by allowing attendance at the time of withdrawal of pole of the kidney. Each kidney should have been freed to care and protection from costs associated with the organ rotate medially when the pockets were created for the ice; if procurement; and (7) with controlled DCD, determination any attachments remain at this point, they are sharply divided. of death after 5 minutes of cardiac standstill as measured by The two kidneys are brought to the midline, and the two arterial pressure and ECG monitoring.23,33 In keeping with ureters are tagged and reﬂected cranially to protect them. the recommendation for local approval of protocols, policies The IVC is then divided at the level at which the aorta was (including the timing of heparin administration, where the opened for placement of the infusion cannula. The cannula patient is extubated, when and where the patient’s death is is removed, and both great vessels are completely transected. declared, and whether or not antemortem cannulation is The aorta and the IVC are then clamped together, and scis- allowed) differ not only from one OPO to another but sors are used to remove the entire specimen by dividing the also from one hospital to another. attachments of the vessels to the anterior spine [see Figure 12]. If the patient does not progress to cessation of cardiopul- Everything is then reﬂected caudally and protected as the monary function within a prescribed period (usually 60 to suprarenal aorta is divided (the IVC was previously divided 90 minutes), he or she is returned to the intensive care unit. at this level during the hepatic dissection), and any remaining If the donor does progress to cessation of cardiopulmonary attachments are severed. function and the procurement process begins, cannulation The kidneys are then taken to the back table and placed on and ﬂushing of the organs is started as soon as possible ice. The left renal vein is divided as it enters the IVC. The to shorten the duration of warm ischemia. The remainder aorta is divided longitudinally, with equal cuffs left on the left of the procurement procedure is identical to that for a and right renal arteries. All oriﬁces are carefully examined to brain-dead donor. identify any separate renal arteries. The longitudinal division In a 10-year analysis of DCD published in 2005, the of the aorta is completed by sharply dividing the posterior average number of organs transplanted from each DCD surface between the paired lumbar arteries [see Figure 13]. donor was 2.02, compared with 3.18 from each brain-dead The kidneys are then packed in cold preservation solution in donor.34 In other studies, the average number of kidneys three sterile bags and placed on ice. obtained from each DCD donor (1.6) was identical to that The iliac arteries and veins are then removed with as from each brain-dead donor.28 Such ﬁndings suggest that much length as possible. These vessels may be used, if DCD is an important potential source of organs for patients needed, either as conduits in liver transplantation or as on the kidney waiting list. In terms of long-term graft grafts in pancreas transplantation. The skin is closed with a survival, outcomes with kidneys from DCD donors appear continuous baseball stitch, and the procurement procedure is to be equivalent to those with kidneys from brain-dead complete. donors. Nationally representative data from the U.S. Renal 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 11 Figure 12 Shown are en bloc nephroureterectomies being performed from below upward (i.e., cranial to caudal). grafts with that of brain-dead donor grafts for the period between 1993 and 2001.35 At 1 year, the survival rates were 70.2% for livers from DCD donors and 80.4% for livers from brain-dead donors; at 3 years, the respective rates were 63.3% and 72.1%. Although liver transplantation from controlled DCD donors results in similar patient survival and a similar incidence of posttransplant complications, it also results in a higher incidence of primary nonfunction and reduced allograft survival. Although the unavoidable period of warm ischemia may predispose hepatic allografts to an increased incidence of ischemic biliary strictures and cholangiopathy,30 the results of liver transplantation from controlled DCD donors are encouraging. This approach should continue to be cautiously pursued as one way of helping to alleviate the current shortage of donor livers.31 To date, experience with transplantation of whole pan- creata and islet preparations from DCD donors has been limited. Nevertheless, there is growing interest in islet cell Figure 13 The aorta is opened posteriorly between the transplantation from brain-dead donors, and some successes paired lumbar arteries. have been reported. A study performed in 2003 demon- Data System have documented 6-year graft survival rates strated that islet cells isolated from a single DCD pancreas of 73.2% for DCD donors and 72.5% for brain-dead can also result in stable insulin independence.32 These donors.29 ﬁndings suggest that the use of DCD donors may help A retrospective evaluation from 2004 used the national overcome the currently insufﬁcient supply of cadaveric UNOS database to compare the survival of DCD donor liver pancreata. 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 12 Organ Procurement from Living Donors subclinical maladies are diagnosed in potential donors during the evaluation. Blood testing should be comprehensive and should include, at a minimum, a full set of blood chemistries; Living donor transplantation is not a new concept. In fact, a complete blood count; a coagulation proﬁle; thyroid func- the earliest successful kidney transplants were performed with tion tests; serologic tests for hepatitis viruses (A, B, and C), living donors.36 What began with kidneys has been extended HIV, cytomegalovirus, Neisseria gonorrhoeae, a1-antitrypsin, to livers and, in some centers, to pancreata, intestines, and ferritin, ceruloplasmin, a-fetoprotein, antinuclear antibodies, lungs. With living donors, even more than with cadaveric antimitochondrial antibodies, and anti–smooth muscle anti- donors, good judgment and a high degree of technical skill bodies; a lipid proﬁle; serum protein electrophoresis; urinaly- are crucial for successful recipient and donor outcomes. sis; and pregnancy testing. An ECG and a chest x-ray should Regardless of which organ is considered for donation, donor also be obtained. Additional tests should be ordered as safety must be paramount. Informed, uncoerced consent is clinically indicated on an individual basis. essential, and every effort should be made to ensure that Imaging studies must include computed tomography or nothing less is obtained. magnetic resonance imaging for estimating hepatic volumes Evaluation of a living donor must be careful and compre- and for determining details of the hepatic arterial, hepatic hensive37: it is a substantially more complex process than venous, and portal venous anatomy. With MRI scanning, evaluation of a cadaveric donor. A multidisciplinary group cholangiography is also possible. Some centers may require of physicians, both medical and surgical, should be involved endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation, along with social workers and mental for complete biliary tract evaluation, angiography for com- health professionals. It is imperative that there be no ﬁnancial plete vascular evaluation, or both. Many centers require arrangements between recipients and donors. By the that potential donors undergo liver biopsy in speciﬁc circum- provisions of the National Organ Transplantation Act of stances (e.g., a history of alcohol abuse, obesity, or hypercho- 1984, the sale of organs is illegal in the United States, and lesterolemia), and some require this of all potential donors. this practice should be universally condemned.38 Matching an appropriate donor with an appropriate recipient Evaluation for living donation begins with the identiﬁcation is complex and requires an understanding of and an appre- of a willing donor. In general, subjecting a healthy volunteer ciation for multiple variables, including the severity of portal to physical or emotional distress is antithetical to the basic hypertension in the recipient, the volume of liver required principles to which all physicians subscribe. Primum non by the recipient, the volume of liver remaining with the nocere (“ﬁrst, do no harm”) is the basis of the Hippocratic donor, and the anatomy of the donor (including the hepatic oath. If the supply of cadaveric organs were sufﬁcient to meet portal and venous anatomy, as well as the biliary anatomy). the demand and if patients were not dying on the waiting list Successful transplantation and donor outcome depend on 16 because of organ shortages, it would be difﬁcult to justify appropriate matching. living donation on ethical grounds. Living donation should be considered warranted when the donor procedure has been shown to be safe and technically feasible and when the Liver donor has at least an emotional attachment to the recipient. Living donor liver transplantation Although inherently Even this deﬁnition is difﬁcult to fully realize on a daily somewhat riskier than living donor kidney transplantation, basis as more and more Good Samaritan donors are living donor liver transplantation (LDLT) has been per- volunteering their organs to complete strangers. Practice formed since the late 1980s. The ﬁrst successful LDLT guideline recommendations regarding living donors have procedure was performed in 1989, when a mother donated been outlined by the Live Organ Donor Consensus segments 2 and 3 to her son.42 This achievement was quickly Group.39 repeated by Nagasue and colleagues in Japan43 and by For kidney and liver donation, donors and recipients must Broelsch and colleagues in Chicago.44 These initial successes be compatible with respect to major blood types. Recipients gave impetus to the growth of LDLT, which not only has of any blood type may receive an organ from a type O donor. spread rapidly across Asia, where cadaveric donors are Type O liver recipients may successfully receive livers from scarce, but also has become increasingly popular in Western type A donors in subgroup 2.40 In rare circumstances (i.e., nations. acute fulminant liver failure) and in very young infants, Transplantation of the left lateral section evolved into blood group barriers may successfully be crossed in liver transplantation of the left hemiliver into larger children, transplantation, but such cases are exceptional. In other adolescents, and eventually small adults. Initial experience settings, blood type incompatibility leads to hyperacute showed these small-for-size grafts to be frequently associated rejection. Currently, however, many living donor kidney with morbidity. The ﬁrst adult-to-adult transplantation of transplant centers are introducing protocols allowing trans- the right hemiliver was performed by Lo and coworkers in plants across incompatible blood groups; the preliminary Hong Kong; this has since become the preferred graft for experience is encouraging. 41 adult-to-adult LDLT.45 Any healthy adult (i.e., age >18 years) can be considered Because initially there were no comprehensive registries as a potential living liver donor. Many programs have upper for either the donors or the recipients of LDLT, the results age limits; virtually all would be reluctant to consider donors of the procedure have been difﬁcult to assess. The difﬁculty older than 60 years. The evaluation process should proceed is compounded by the fact that LDLT is sometimes employed in a logical and stepwise fashion, beginning with the conﬁr- for patients who are outside the currently accepted listing mation of ABO compatibility. For most people, an evaluation criteria (e.g., non-Milan hepatocellular carcinoma [HCC]). for liver donation is the most intense physical and mental Overall, however, outcomes seem to be improving: 1-year examination they have ever undergone. Not infrequently, graft survival now approaches 85%,46 and at least one center 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 13 has found there to be no difference in overall survival between Furthermore, ischemic injury to the liver section to be donated LDLT and cadaveric donor liver transplantation.47 Most must be limited. The dissection must therefore proceed centers have found morbidity and mortality to be low among without vascular exclusion. donors; however, at least 11 donor deaths have been reported.48 Open left lateral sectionectomy. In a left lateral sectionec- In the United States, nine transplant centers are parti- tomy, dissection is performed to isolate the left hepatic vein, cipating in a National Institutes of Health (NIH)–sponsored the left portal vein, and the left hepatic artery. The portal vein prospective study of LDLT called the A2ALL (Adult- branches to segments 1 and 4 are ligated to expose the main to-Adult Living donor Liver transplantation) Cohort Study. left portal vein. The arterial dissection begins distal to Preliminary results from this study document a 1-year graft the branching of the right hepatic artery; the artery supplying survival rate of 81%,49 which is consistent with other registry segment 4 may have to be sacriﬁced. The parenchymal tran- data worldwide. The continuing reﬁnement of the operative section plane is just to the right of the falciform ligament technique and the ongoing dearth of deceased donors have and extends to the hilar plate. The hilar plate and the left bile gained LDLT an important place in the ﬁeld of adult and duct are sharply transected. The liver parenchyma is then pediatric liver transplantation. transected; this may be accomplished with any of a variety of instruments (see below). The left hepatic vein may be Donor evaluation Central to the ethical debates sur- either clamped and transected or stapled with an endoscopic rounding LDLT is the recognition that an otherwise healthy gastrointestinal anastomosis (GIA) stapler. The specimen is person is undergoing an operation that is associated with removed from the donor and immediately ﬂushed with cold considerable morbidity and potential mortality. Obviously, preservation solution (UW or HTK) on the back table. rigorous screening of the donor is essential. Donor evaluation should progress in several steps, and both the donor and Open donor right hepatectomy. In performing a right (or the recipient should be provided with ample information left) hepatectomy, it is necessary to isolate the inﬂow and about LDLT and sufﬁcient time in which to assimilate that outﬂow vessels in the hepatic hilum on the appropriate side; information. The least invasive tests should be done ﬁrst, great care must be taken to neither injure nor devascularize beginning with the determination of ABO compatibility. the opposite side. After mobilization of the liver, the initial Psychological assessment is critical for ensuring that the steps are cholecystectomy and intraoperative cholangiogra- donor’s decision to provide a liver graft is truly voluntary and phy to delineate biliary anatomy. Once the biliary anatomy is free of coercion. deemed suitable, hilar dissection can continue. Intraoperative As noted (see above), comprehensive blood testing should ultrasonography to identify venous anatomy, once a common be carried out. An ECG and chest x-ray should also be practice, has now been essentially replaced by preoperative obtained. Additional tests should be ordered as required on imaging. an individual basis. Comprehensive imaging of the liver— Hilar dissection is begun laterally, and the right artery including high-quality MRI or CT to demonstrate the hepatic is exposed to the right of the CBD. Segment 4 arteries are arterial, hepatic venous, and portal venous anatomy—is preserved whenever possible. The right portal vein is also essential. Magnetic resonance cholangiopancreatography identiﬁed and isolated. To diminish the risk of devasculariza- (MRCP) or CT cholangiography is indicated for preoperative tion, extensive dissection of the CBD is avoided. The hilar assessment of the biliary anatomy. After cross-sectional plate is lowered and the right bile duct (or ducts) sharply imaging is performed, liver volumes should be estimated. A transected. Again, preservation of the donor’s CBD is of residual liver volume of 30% to 35% is generally considered paramount importance. The right hepatic vein is isolated, safe for the donor, whereas a graft that provides at least 40% and mobilization of the right hemiliver is completed. The of the estimated standard liver volume or whose weight is liver parenchyma is then transected just to the left of Cantlie’s at least 0.8% of the recipient’s body weight is considered line, along the border of the middle hepatic vein. Whether to acceptable for the recipient.50 include the middle hepatic vein with the graft remains some- Liver biopsies from the donor are not required by every what controversial.48,51 Temporary inﬂow occlusion may be program, but they may be indicated in certain cases (e.g., employed to help mark the transection line along the liver when the patient is obese or hypercholesteremic or has a surface. history of alcohol abuse). Fatty liver disease is dangerous for The aim of transection is to leave as little necrotic tissue both the recipient and the donor and should be factored into as possible in both the donor and the recipient. To this the process of donor selection. end, various different instruments may be employed, such as crushing clamps, an ultrasonic dissector (e.g., Harmonic Operative technique The overriding principle of the Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio), a donor operation is to ensure the safety of the donor. hydro-jet dissector, a LigaSure device (Valleylab, Boulder, Accordingly, only fully trained and experienced hepatobiliary Colorado), or a monopolar or bipolar saline-linked electro- and transplant surgeons with a good understanding of cautery (e.g., Aquamantys; TissueLink, Dover, New Hamp- segmental liver anatomy [see Figure 14] should undertake liver shire). Hydro-jet dissectors and ultrasonic dissectors allow procurement from living donors. the most precise dissection and may be used in combination The main anatomic liver resections are discussed in greater with one of the other devices to achieve parenchymal detail elsewhere [see 5:23 Hepatic Resection]. In a living transection with minimal blood loss. donor hepatectomy, the primary emphases are on limiting Once parenchymal transection is complete, the inﬂow blood loss and preserving the anatomy of both the donated and outﬂow vessels are divided. Large short hepatic veins portion of the liver and the hepatic remnant. To this end, and signiﬁcant segment 5 and 8 veins are preserved with high-quality intraoperative cholangiography is essential. the right hemiliver graft for subsequent reconstruction and 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 14 Figure 14 Illustrated are the anatomic divisions of the liver according to the Brisbane 2000 terminology, including ﬁrst-order divisions (hemilivers), second-order divisions (sections), and third-order divisions (segments). reimplantation in the recipient. Laparoscopic vascular Laparoscopic-assisted donor right hepatectomy. One of the staplers may be used to transect the right hepatic vein and major impediments to more widespread adoption of LDLT right portal vein. has been donor morbidity. The application of minimally The graft is then removed and ﬂushed on the back table invasive techniques to this operation has the potential to with UW or HTK solution. If the middle hepatic vein has reduce this impediment and thereby broaden the pool of been preserved, venoplasty is performed on the back table. willing donors. If the middle hepatic vein has not been included, vascular The technique of laparoscopic-assisted donor right hepa- conduits are created to restore continuity to large segment 5 tectomy was ﬁrst described by Koffron and colleagues in and 8 veins. 2006.52 With the patient in the supine position, an upper Before closure, the hepatic remnant is carefully examined midline incision is made to allow placement of a hand for bile leakage. A repeat cholangiogram is obtained. Bile port. Two laparoscopic trocars are placed, one through the may leak from the hilar plate, from the transected bile duct umbilicus and one in the right lower quadrant. A bipolar stump, from the caudate lobe, or from the cut edge of the coagulating/cutting device (e.g., LigaSure V) or an ultrasonic liver. Meticulous suturing is required to repair bile leaks dissector (e.g., Harmonic Scalpel) is inserted through the without compromising the donor ducts. The hepatic remnant lower quadrant port, the camera is inserted through the (i.e., the left hemiliver) should be reanchored to the anterior umbilical port, and the surgeon’s right hand is inserted abdominal wall by recreating the falciform ligament. through the hand port. The right hemiliver is completely 04/08
© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 15 mobilized by means of a hand-assisted technique. Once the mannitol, both for its diuretic effects and for its antioxidant liver has been fully mobilized and the vena cava exposed, the effects. Upon removal from the donor, the kidney is ﬂushed hand port and the laparoscopic instruments are removed, with cold UW or HTK solution on the back table. appropriate retractors are placed, and the remainder of Although open donor nephrectomy has historically been the the dissection is carried out in the same manner as for the standard, the laparoscopic alternative is now the procedure of equivalent open procedure (see above). Once the parenchyma choice, particularly for left kidneys. Because of the relatively has been transected and the vascular and biliary pedicles shorter vessels on the right side, some surgeons are reluctant divided, the right hemiliver can safely be delivered through to perform laparoscopic right nephrectomy, being concerned the upper midline incision. that the vessel shortening invariably caused by the stapler may make implantation more difﬁcult. In addition, many donors Kidney have multiple renal arteries, an anomalous venous anatomy Kidney donation from a live donor may be accomplished (e.g., a retroaortic left renal vein), or both, and these anatomic either via an open approach or laparoscopically. Open donor variations may preclude, or at least signiﬁcantly complicate, nephrectomy is performed through a right or left ﬂank inci- laparoscopic donation. sion, depending on which kidney is to be removed. The ﬂank muscles are divided, and the perinephric space is developed. Lung, Pancreas, and Intestines The renal artery and vein are dissected free, and the ureter Single-lung transplantation from a living donor has been 53 is identiﬁed and divided at the pelvic brim. The vessels on performed with some success. Procurement of the pancreas the right side, particularly the renal vein, are signiﬁcantly and the small intestine from living donors has been shown to shorter than those on the left; in addition, exposure is often be technically possible; however, serious concerns remain about more challenging on the right side as a consequence of the the adequacy of partial grafts for correcting diabetes or short- subhepatic location of the right kidney. Before the vessels are gut syndrome. Such procedures are currently considered clamped and the kidney removed, donors are routinely given experimental. References 1. United Network for Organ Sharing. 12. Ceck JM: Clinical Transplants 1997. UCLA mission for the Study of Ethical Problems http://www.unos.org, accessed December 10, Tissue Typing Laboratory, Los Angeles, in Medicine and Biomedical and Behavioral 2007 1998 Research. Guidelines for the determination of 2. Tullius SG, Volk H-D, Neuhaus P: Trans- 13. Kamath PS, Wiesner RH, Malinchoc M, et death. JAMA 246:2184, 1981 plantation of organs from marginal donors. al: A model to predict survival in patients with 24. Emre S, Schwartz ME, Miller CM: The Transplantation 72:1341, 2001 end-stage liver disease. Hepatology 33:464, donor operation. Transplantation of the 3. Tenderich G, Koerner MM, Stuettgen B, 2001 Liver. Busuttil RW, Klintmalm GB, Eds. WB et al: Extended donor criteria: hemodynamic 14. Powner DJ: Factors during donor care that Saunders Co, Philadelphia, 1996, p 392 follow-up of heart transplant recipients may affect liver transplantation outcome. 25. Jamieson RW, Friend PJ: Organ reperfusion receiving a cardiac allograft from donors > or Prog Transplant 14:241, 2004 and preservation. Front Biosci 13:221, 2008 = 60 years of age. Transplantation 66:1109, 15. Fishbein TM, Fiel MI, Emre S, et al: Use of 26. Foley DP, Fernandez LA, Leverson G, et al: 1998 livers with microvesicular fat safely expands Donation after cardiac death: the University 4. Emre S, Schwartz ME, Altaca G, et al: Safe the donor pool. Transplantation 64:248, of Wisconsin experience with liver transplan- use of hepatic allografts from donors older 1997 tation. Ann Surg 242:724, 2005 than 70 years. Transplantation 62:62, 1996 16. Ben-Haim M, Emre S, Fishbein TM, et al: 27. Fernandez LA, Di Carlo A, Odorico JS, 5. Kootstra G, Kievit J, Nederstigt A: Organ Critical graft size in adult-to-adult living et al: Simultaneous pancreas-kidney donors: heartbeating and non-heartbeating. donor liver transplantation: impact of the transplantation from donation after cardiac World J Surg 26:181, 2002 recipient’s disease. Liver Transpl 11:948, death: successful long-term outcomes. Ann 6. Nghiem DD, Schlosser JD, Hsia S, et al: En 2001 Surg 242:716, 2005 bloc transplantation of infant kidneys: ten- 17. Broelsch CE, Whitington PF, Emond JC, 28. Abt P, Fisher CA, Singhal AK: Donation year experience. J Am Coll Surg 186:402, et al: Liver transplantation in children from after cardiac death in the US: history and use. 1998 living related donors: surgical techniques and J Am Coll Surg 203:208, 2006 7. Stratta RJ, Bennett L: Preliminary experience results. Ann Surg 214:428, 1991 29. Rudich SM, Kaplan B, Magee JC, et al: with double kidney transplants from adult 18. 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© 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 6 ORGAN PROCUREMENT — 16 35. Abt P, Desai NM, Crawford MD, et al: 43. Nagasue N, Kohno H, Matsuo S, et al: donor liver transplant recipients: a report Survival following liver transplantation from Segmental (partial) liver transplantation from from the A2ALL Consortium. Ann Surg non-heart-beating donors. Ann Surg 239:87, a living donor. Transplant Proc 24:1958, 242:314, 2005 2004 1992 50. Kiuchi T, Kasahara M, Uryuhara K, et al: 36. Michon L, Hamburger J, Oeconomos N, 44. Broelsch CE, Emond JC, Whitington PF, Impact of graft size mismatching on graft et al: Une tentative de transplantation renale et al: Application of reduced-size liver prognosis in liver transplantation from living chez l’homme: aspects medicaux et biologi- transplants as split grafts, auxiliary orthotopic donors. Transplantation 67:321, 1999 ques. Presse Med 61:1419, 1953 grafts, and living related segmental trans- 51. Florman S, Miller CM: Live donor liver 37. Schiano T, Kim-Schluger L, Gondolesi G, plants. Ann Surg 212:368, 1990 transplantation. Liver Transpl 12:499, 2006 et al: Adult living donor liver transplantation: 45. Lo CM, Fan ST, Liu CL, et al: Adult- 52. Koffron AJ, Kung R, Baker T, et al: Laparo- the hepatologist’s perspective. Hepatology to-adult living donor liver transplantation scopic-assisted right lobe donor hepatectomy. 33:3, 2001 using extended right lobe grafts. Ann Surg 38. Public Law No. 98–507, Title I, 1984. Am J Transplant 6:2522, 2006 226:261, 1997 53. Harringer W, Wiebe K, Struber M, et al: National Organ Transplant Act 46. Lo CM, Fan ST, Liu CL, et al: Lessons Lung transplantation—10 year experience. 39. Abecassis M, Adams M, Adams P, et al: learned from one hundred right lobe living Eur J Cardiothorac Surg 16:546, 1999 Consensus statement on the live organ donor. donor liver transplants. Ann Surg 240:151, The Live Organ Donor Consensus Group. JAMA 284:2919, 2000 2004 40. Fishbein TM, Emre S, Guy SR, et al: Safe 47. Liu CL, Fan ST, Lo CM, et al: Operative transplantation of blood type A2 livers to outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative Acknowledgments blood type O recipients. Transplantation 67:1071, 1999 study with cadaveric whole-graft liver trans- 41. Gloor JM, Stegall MD: ABO incompatible plantation in a single center. Ann Surg Portions of this chapter are based on a previous kidney transplantation. Curr Opin Nephrol 243:404, 2006 iteration written for ACS Surgery by Sander S. Hypertens 16:529, 2007 48. Fan ST: Live donor liver transplantation in Florman, MD, FACS, Thomas E. Starzl, MD, 42. Strong RW: Living-donor liver transplanta- adults. Transplantation 82:723, 2006 PhD, FACS, and Charles M. Miller, MD, FACS. tion: an overview. J Hepatobiliary Pancreat 49. Olthoff KM, Merion RM, Ghobrial RM, The authors wish to thank Drs. Florman, Starzl, Surg 13:370, 2006 et al: Outcomes of 385 adult-to-adult living and Miller. 04/08
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