Procurement of Liver for Transplantation

Malay B. Shah

Erin C. Maynard

DEFINITION

Liver procurement is the removal of a liver from a living or deceased donor for the purposes of replacing a liver in a recipient with end-stage liver disease or hepatocellular carcinoma. For the purposes of this chapter, we describe the procurement from a deceased donor. There are numerous indications for liver transplantation (Table 1). In liver procurement, it is critical to safely remove the liver, hepatic artery, portal vein, bile duct, and inferior vena cava (IVC) in such a manner to allow for safe reimplantation into the recipient.

PATIENT HISTORY AND PHYSICAL FINDINGS

The initial donor evaluation is conducted by the local organ procurement organization (OPO). The local OPO staff will complete a thorough medical and social history, including a history of substance abuse. A comprehensive physical examination is also conducted. Laboratory testing typically will consist of ABO blood type verification, basic metabolic profile, liver function panel, complete blood count, coagulation parameters, hepatitis panel, HIV, rapid plasma reagin (RPR), and cytomegalovirus (CMV).

Table 1: Indications for Liver Transplantation

Acute liver failure	Autoimmune hepatitis Viral (hepatitis A, B, & C) Drug toxicity (e.g., acetaminophen) Wilson’s disease Budd-Chiari syndrome Cryptogenic
Chronic liver disease	Viral (hepatitis B & C) Alcoholic liver disease Autoimmune hepatitis Cryptogenic liver disease Nonalcoholic fatty liver disease
Malignancy	Hepatocellular carcinoma Carcinoid tumor Islet cell tumor Epithelioid hemangioendothelioma Cholangiocarcinoma
Metabolic liver disease	Wilson’s Disease Hereditary hemochromatosis α₁-antitrypsin deficiency Glycogen storage disease Cystic fibrosis Crigler-Najjar syndrome Galactosemia Type 1 hyperoxaluria Familial homozygous Hypercholesterolemia Hemophilia A and B
Cholestatic liver disease	Primary biliary cirrhosis Primary sclerosing cholangitis Biliary atresia Alagille syndrome Byler’s disease
Miscellaneous	Adult polycystic liver disease Nodular regenerative hyperplasia Caroli’s disease Amyloidosis Sarcoidosis Trauma

Blood, urine, and sputum cultures are generally obtained if the patient is hospitalized for a prolonged period of time. Nucleic acid testing (NAT) is frequently being performed by OPOs on all donors for HIV and hepatitis C, regardless of Centers for Disease Control and Prevention (CDC) high-risk status.
Once an offer is made to the transplant center, it is essential for the accepting transplant surgeon to thoroughly review all medical and social history, exam findings, and laboratory parameters to determine suitability for a given recipient.
Donor characteristics associated with optimal outcomes are as follows:
- Donors after brain death
- Normal liver function and coagulation parameters
- Age younger than 50 years
- Minimal to no steatosis
- Minimal to no vasopressor requirements
- Cold ischemia time less than 12 hours
Donor characteristics associated with poorer outcomes are the following:
- Donors after cardiac death are associated with a higher incidence of biliary complications posttransplant.
- Abnormal transaminases at the time of procurement, particularly transaminases that are continuing to rise
- Age older than 50 years
- Macrosteatosis greater than or equal to 30%
- Hemodynamic instability is associated with decreased hepatic arterial blood flow and can lead to higher rates of early graft dysfunction.
- Cold ischemia time greater than 12 hours
- Positive hepatitis C status
  - All donors with hepatitis C should undergo preoperative or intraoperative liver biopsy to rule out fibrosis or cirrhosis.
  - All donors with hepatitis C, older than 50 years of age, have extremely high risk of hepatitis C recurrence posttransplant.
- Hypernatremia greater than 155 mmol/L associated with early graft dysfunction

SURGICAL MANAGEMENT

Preoperative Planning

Review any preoperative imaging, particularly computed tomography (CT) scans of the abdomen. This may aid in identifying aberrant anatomy and help with intraoperative dissection.
Use preoperative antibiotic prophylaxis to prevent risk of posttransplant infection.

TECHNIQUES

Two different techniques for liver retrieval can be used to safely remove the liver for transplant. One technique, although technically less challenging, renders the pancreas unsuitable for transplantation. The technique presented here will allow for safe retrieval of both the liver and pancreas for transplantation.
When retrieval of the liver and pancreas is conducted, both organs are typically procured en bloc and separated on the back table. The procedure described here presents preparation of the liver for en bloc retrieval. The dissection of the pancreas for en bloc retrieval is described elsewhere.

POSITIONING OF DONOR

The donor should be placed supine with both arms tucked to allow for maximum surgeon mobility during procurement. The patient should be prepped and draped from chin to the upper thighs.

INCISION

A median sternotomy and midline laparotomy should be performed for recovery of abdominal organs. A chest retractor and large Balfour abdominal retractor should be used for maximum visualization (FIG 1).