An Alternative Technique for Harvesting Marginal Liver Grafts with a Replaced or Accessory Right Hepatic Artery

We continue to look optimistically toward novel techniques in liver organ recovery that will potentially enhance the pool of viable organs, while preventing organ injury, in order to meet the ever-increasing need for liver organs to serve our transplant candidates. This manuscript titled ‘‘An alternative technique for harvesting marginal liver grafts with a replaced or accessory right hepatic artery’’ touches on a technique to help realize this goal. The authors describe a procurement technique that affords a safe and effective use of liver organs with a replaced or accessory right hepatic artery, as well as other vascular anomalies. Occurrence of a replaced or accessory right hepatic artery ranges from 8 to 10 % of donors [1] while that of all vascular anomalies occurs in the range of 20–49 % of donor liver organs [2, 3]. The authors report no evidence of arterial thrombosis of the reconstructed vessels in the setting of a replaced or accessory right hepatic artery during the immediate or late follow-up in 72 consecutive liver recoveries over a 2-year period. Organ recovery injury is a relatively frequent, but underreported complication of organ procurement and very few studies in the literature have focused on the prevalence of this problem or the clinical impact on graft outcome of such injuries. In fact, a PubMed literature search using the key search words to include ‘organ procurement/recovery/ harvest organ injury’ cited only 16 publications addressing this problem in the past 20 years. In 1996 Wigmore et al. [4] reported the largest series on donor organ injury during organ recovery, reporting 1,729 of 9,014 (19 %) of kidneys. Importantly, when the injuries could be repaired, there was no difference in renal transplant survival: 96 of 9,014 (1 %) of the kidneys were discarded due to high severity of injury. Similar results have been reported by UNOS in the United States [5]. Nijkamp et al. analyzed the incidence, risk factors, and clinical outcomes of surgical injuries sustained while recovering 241 adult liver grafts, and found 40 (17 %) had vascular injury [6]. The organ recovery region was the only risk factor significantly associated with surgical injury, and the rate of hepatic artery injury was significantly higher in livers with aberrant arterial anatomy, underscoring the importance of addressing recovery techniques that provide safe and effective approaches to donors with such aberrancies. Importantly, hepatic arterial thrombosis was found in 23 % of the patients who received a liver with arterial injury compared with 4 % without arterial injury (P = 0.001). The current manuscript proposes a technique that is globally protective of any potential anomalous vascular anatomy. The authors offer a nice step-by-step anatomical lesson, both verbally and with clear drawings, in the conduct of liver organ recovery, and provide important pearls in preventing vascular injury in the event of any vascular anomaly in the liver. Albeit, in step 4 (celiac trunk) the authors misstate the anatomy: ‘‘The transection proceeds along the greater curvature of the stomach through the ligation of the left gastric artery (LGA). When a replaced left hepatic artery arising from the LGA is present, the dissection follows the greater curvature until...’’ while they actually mean to state ‘‘the lesser curvature of the stomach.’’ I applaud the authors’ attempt to standardize the organ recovery operation when appropriate, as this would result in fewer recovery errors, particularly in those involving S. L. Orloff (&) Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Department of Surgery, Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland VA Medical Center Transplant Program, Portland, OR, USA e-mail: orloffs@ohsu.edu