Fig. 2.1
Cholangiogram depicting ischemic cholangiopathy in a donation after cardiac death (DCD) liver transplant
Of note, some single-center experiences with controlled-DCD liver transplants reveal excellent outcomes, comparable to DBD liver transplants (Grewal et al. 2009; Muiesan et al. 2005; Fukumori et al. 2003; Reich 2006; Manzarbeitia et al. 2004; Reich et al. 2000). These centers consistently utilize standardized DCD protocols and strict organ selection criteria. Several risk factors have been identified for worse outcomes after DCD liver transplantation, including donors over age 40–60, warm ischemia time more than 15–30 min, cold ischemia time longer than 8–10 h, older recipients, hemodynamically unstable recipients, and technically challenging recipients (Mathura et al. 2010; Merion et al. 2006; Lee et al. 2006; Mateo et al. 2006; Abt et al. 2004). Other factors that may be relevant to the better outcomes with DCD liver transplants at some centers include donor surgeon experience, local or regional share status of the donor, and specifics of the individual DCD protocols, such as use and timing of anticoagulant and/or vasodilator, withdrawal of ventilatory support in or out of the operating room, and duration of the wait time between the declaration of death and the start of surgery (Skaro et al. 2009; Reich and Guy 2012). The risk/benefit ratio of DCD liver transplantation is improved if donor and recipient risk factors are not compounded. Additional understanding is needed regarding the various risk factors, including details regarding warm ischemia time, and risk interactions (Skaro et al. 2009; Reich and Guy 2012).
The first single-center experience in which DCD liver transplants provided outcomes similar to those with DBD transplants was published in 2000 by Reich et al. (2000), who updated their results in 2006 (Reich 2006). Patient and graft survival rates were both 90 % at 1 year posttransplant and 85 % at 2 years; ischemic cholangiopathy developed in 13 % of recipients and caused graft failure in 10 %. The Mayo Clinic in Jacksonville, Florida, more recently reported that their patient and graft survival rates at 1 and 5 years were not significantly different between DCD and DBD groups, even though the DCD cohort had a higher rate of biliary necrosis (8.3 % vs 1.9 %) resulting in graft failure and a higher rate of retransplantation (14.8 % vs 9.3 %) (Grewal et al. 2009).
2.2.3 Pancreata
Relatively few DCD pancreas transplants are performed annually. Initial reports of the University of Wisconsin single-center experience and the SRTR results (Fernandez et al. 2005; Salvalaggio et al. 2006) reveal that patient and pancreas survival rates were each similar between DCD and DBD organs. Subsequent review of the SRTR data reveals that the DCD source of pancreata had become a marginally significant risk for graft failure (HR = 1.39, p = 0.10), likely a consequence of the expansion of organ selection criteria as comfort grows with this source of donor organs (Axelrod et al. 2010). The use of pancreata from hemodynamically stable, young, and slender DCDs should be considered in select circumstances to expand the donor pool.
2.3 Practice Guidelines for Donation After Cardiac Death
DCD protocols and techniques vary among OPOs and transplant centers. Best practice guidelines for DCD organ procurement and transplantation are available and cover many aspects of the endeavor, including donor criteria, consent, withdrawal of support, operative technique, ischemia times, recipient considerations, and biliary issues. In 2009, Reich and colleagues (Reich et al. 2009) published evidence-based recommendations on controlled DCD on behalf of the American Society of Transplant Surgeons (ASTS). The ASTS recommendations attempt to address the unique challenges posed by DCD organ procurement and transplantation and to facilitate improvement in outcomes. They complement guidelines published earlier by the United Network for Organ Sharing (UNOS) (United Network of Organ Sharing 2004; OPTN 2007; United Network for Organ Sharing 2013), the Institute of Medicine (IOM) of the National Academy of Science (Institute of Medicine, National Academy of Sciences 1997, 2000; Institute of Medicine 2006), and the Society of Critical Care Medicine (Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002), as well as a multiorganization national conference report (Bernat et al. 2006).
2.4 Ethicolegal Issues and Professionalism
DCD organ procurement honors the donor’s wishes, brings some comfort to the family, and benefits the recipients. Several ethicolegal principles are relevant to DCD (DeVita et al. 1993; Reich 2013; Reich et al. 2009; Institute of Medicine, National Academy of Sciences 1997; Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002; Koostra 1997; Whetstine et al. 2002; Bell 2003; Arnold and Younger 1995):
Individuals may not be killed for their organs or killed as a result of the removal of their organs (the “dead donor” rule).
Patients must not be jeopardized in order to facilitate organ procurement.
Euthanasia is prohibited.
Informed consent and respect for family wishes must not be violated.
The autonomous right of patients to refuse treatment must be upheld.
It is imperative to ensure that there is no conflict of interest between the duty to provide optimal patient care and the desire to recover organs for transplantation (Reich et al. 2009; Whetstine et al. 2002; Bell 2003; Arnold and Younger 1995). Specifically, the rationale for withdrawal of life support and the determination of death must be extricable from the decision to recover organs. Therefore, the patient care and organ donor teams must be completely separate.
Several issues related to the ethics and laws of DCD organ procurement remain sources of debate. Interventions that improve the chance of successful donation rather than directly benefiting the donor are permitted, as long as they are consensual, do not hasten death or harm the donor, and are not prohibited by the local procurement protocol. Medications routinely provided for patient comfort are permitted even if they might hasten death; these are given at the discretion of the patient’s treating care team, and procurement team members shall not participate in decisions regarding the use of such agents (Reich et al. 2009; Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002; Bernat et al. 2006). There are differing views, however, regarding use of anticoagulants, vasodilators, narcotics, and intravascular cannulae placed premortem (Reich et al. 2009; OPTN 2007; United Network for Organ Sharing 2013; Institute of Medicine 2006; Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002; Bernat et al. 2006; Bell 2003). Another issue that is debated is whether determination of DCD death requires loss of cardiac electrical activity or if the absence of heart sounds, pulse, and blood pressure are sufficient criteria, just as they are for patients who are not organ donors (DeVita et al. 1993; Institute of Medicine, National Academy of Sciences 2000). Ultimately, the donor hospital and care team have the responsibility for defining and declaring patient death.
Another important ethical question that affects the warm ischemic time endured by DCD organs relates to the duration of the waiting period used to ensure irreversible death. Autoresuscitation after 1 min of pulselessness has not been reported in the literature (Whetstine et al. 2002). However, various groups have prescribed different wait times from the determination of death to organ procurement, ranging from 2 to 10 min (Reich et al. 2009; Institute of Medicine, National Academy of Sciences 1997, 2000; Institute of Medicine 2006; Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002; Bernat et al. 2006; Koostra 1997; Whetstine et al. 2002; Bell 2003). The ASTS recommends 2 min (Reich et al. 2009), the Society of Critical Care Medicine recommends 2–5 min (Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine 2002), and the IOM recommends 5 min (Institute of Medicine, National Academy of Sciences 1997, 2000; Institute of Medicine 2006). The risks and benefits of DCD organ transplantation, including the possibility and implications of biliary complications or renal DGF, should be discussed with transplant candidates during the evaluation process (Reich et al. 2009).
2.5 Preoperative Maneuvers and Operative Strategy for DCD Organ Procurement
2.5.1 Preparation
The donor surgery should be performed by a surgeon who is familiar with the ethics and laws related to DCD and is experienced in rapid procurement techniques. Communication about the conduct of the operation among the DCD surgeon, the donor coordinator(s), and operating room personnel prior to withdrawal of support facilitates cooperation and speediness of the recovery. Upon withdrawal of support, a preprinted flow sheet (Fig. 2.2) should be filled out by a coordinator in the operating room, documenting hemodynamic measurements every minute and the times of discontinuation of mechanical ventilation, cessation of cardiorespiratory function, waiting period, declaration of death, incision, and perfusion of each organ. After procurement, this information is critical for assessing ischemic injury (Reich et al. 2009; United Network for Organ Sharing 2013; Bernat et al. 2006).
Fig. 2.2
Example of a preprinted flow sheet that should be filled out by a coordinator in the operating room after withdrawal of support. The information gathered is critical for assessing ischemic injury after procurement
2.5.2 Surgical Technique
Most surgeons who procure DCD organs use some modification of the super-rapid technique described by the Pittsburgh group (Casavilla et al. 1995; Reich et al. 2000, 2009; Olson et al. 1999). Ideally, patients undergo withdrawal of support in the operating room: transporting the DCD donor to the operating room after declaration of death may exclude subsequent liver transplantation because of excessive hepatic ischemia. To minimize operating and ischemic times, the potential donor should be prepared and draped prior to withdrawal of support. Instruments required for rapid entry and aortic cannulation should be chosen, including a scalpel, a pair of Kocher clamps, a moist towel, Metzenbaum scissors, a right-angle clamp, a moist umbilical tape, two Kelly clamps, a sternal saw, and abdominal and sternal retractors (Fig. 2.3). The cannula and tubing should be flushed and placed on the field, and the containers of preservation solution should be kept in an ice bucket to prevent warming. During this prepping and draping, it is critical to recognize that the potential DCD donor is a patient who is still alive.
Fig. 2.3
Instruments required for rapid entry and aortic cannulation in DCD organ procurement include a scalpel, a pair of Kocher clamps, a moist towel, Metzenbaum scissors, a right-angle clamp, a moist umbilical tape, two Kelly clamps, a sternal saw, and abdominal and sternal retractors
Following these preparatory maneuvers, the surgical team should leave the operating room, to avoid conflict of interest during withdrawal of support and declaration of death. If the patient is not declared dead within the time frame stipulated by the local procurement protocol, then donation is aborted and the patient is returned to the ward for comfort care (Reich et al. 2009; OPTN 2007; United Network for Organ Sharing 2013; Institute of Medicine, National Academy of Sciences 1997). In the rare instances when this has occurred in our OPO, the patient has always died within the next few hours.
After death, a midline laparotomy is performed. Upward traction on two Kocher clamps placed on each side of the umbilicus expedites rapid entry without injury to the viscera. A large scalpel is used to incise all layers of the abdominal wall. A moist towel is used to retract the small intestine to the right, while the sigmoid colon is retracted to the left. Although it is not pulsatile, the aorta is easily palpated just above its bifurcation on the left side of the vertebral column. Metzenbaum scissors are used to clear the retroperitoneum over a small segment of distal aorta in preparation for cannulation. There is no need to dissect out the inferior mesenteric artery. A right-angle clamp is used to pass a moist umbilical tape around the distal aorta, which will be used to secure the cannula. Distally, the aorta is clamped with a Kelly clamp. Next, the cannula is passed cephalad through an aortotomy (Fig. 2.4) and secured with the umbilical tape. The flush should be started immediately, without waiting to cross-clamp the proximal aorta or vent the vena cava. Using this approach, the flush is typically initiated within 2–3 min of incision.
Fig. 2.4
After the aorta is clamped with a Kelly clamp, the cannula is passed cephalad through an aortotomy (yellow arrow) and is secured with an umbilical tape
The surgeon should not be disturbed to see a dark, purple, and somewhat engorged liver at initial inspection, as this is the typical appearance of a DCD liver. Assessment of liver quality is best left until after perfusion, at which point the liver should appear normal. Next, the round and falciform ligaments are divided sharply. The knife is used to open from the suprasternal notch to the abdomen. Median sternotomy is performed with a pneumatic saw, and a Finochietto sternal retractor is placed. I prefer to clamp the thoracic aorta rather than the supraceliac aorta during super-rapid procurement. The descending thoracic aorta can be easily accessed through the left thoracic cavity just above the diaphragm. The vena cava is vented above the diaphragm. A Balfour retractor is placed across the upper abdomen. Ice slush should be placed on the abdominal organs simultaneously with the sternotomy. I infuse approximately 5 L of cold University of Wisconsin (UW) solution, containing dexamethasone (16 mg/L) and insulin (40 U/L), through the adult DCD aorta to provide a clear effluent, typically 1 L before sternotomy, cross-clamping, and venting, and then 4 L afterward. Approximately twice this volume is necessary when using HTK solution.
2.5.2.1 Liver Procurement
Because all the visceral dissection is performed in the cold, without blood flow and without having had opportunity to assess pulses, particular care must be taken not to damage vital structures. The hepatoduodenal ligament is divided from right to left as close to the duodenum as possible, taking care to preserve the hepatic artery. First, the common bile duct is divided and the biliary tree is flushed with chilled preservation solution through an opening in the gallbladder and through the common duct directly. Expeditious performance of this maneuver may reduce bile-induced epithelial damage and ischemic-type biliary strictures following DCD liver transplantation. The portal vein is divided at the confluence of the superior mesenteric and splenic veins. The gastroduodenal and right gastric arteries need not be clearly delineated.
The left lateral segment of the liver is elevated by dividing the left triangular ligament. It is safest to assume that there is a replaced or accessory left hepatic artery arising from the left gastric artery. Therefore, the lesser omentum and left gastric artery should be separated from the lesser curvature at the level of the stomach. The splenic artery is divided to the left of the midline, far from the celiac axis, and then dissected toward the aorta, so that it can be rotated to the right for exposure of the superior mesenteric artery, which lies deep to it.
Unless the plan is to procure the DCD pancreas (discussed below), the head of the pancreas should be taken with the liver to avoid transecting an aberrant right hepatic artery and to expedite organ extraction time. After a Kocher’s maneuver, the duodenum and pancreatic head are elevated and retracted caudally to expose the superior mesenteric artery, which is then dissected down to the aorta. Care is taken not to transect an accessory or replaced right hepatic artery by avoiding dissection on the right side of the superior mesenteric artery. Rather than taking extra time to search for a right branch, it is safest to assume that one exists and to take a common patch of superior mesenteric and celiac arteries with the liver. An aortotomy is performed between the superior mesenteric and right renal arteries and is extended to provide the arterial patch.
The left diaphragm is then divided down toward the Carrel patch. The suprahepatic inferior vena cava is divided. The right diaphragm is then divided down to the upper pole of the right kidney. The infrahepatic inferior vena cava is then transected just above the renal veins. The liver is extricated and an immediate back-table portal flush with 1 L of chilled UW solution is performed; some surgeons cannulate and flush the portal system in situ via the inferior mesenteric vein. The liver is then packaged for transport to the transplant center.
2.5.2.2 Kidney Procurement
Bilateral nephrectomies are then performed. The kidneys may be kept en bloc for machine perfusion, or they may be separated and sent directly to the recipient centers. Even though DCD organ procurement is a rushed procedure, it is still crucial to perform careful donor exploration to look for unrecognized malignancy or infection.
2.5.2.3 Pancreas Procurement
Adding whole-organ pancreatectomy to hepatectomy during a super-rapid recovery carries risk for transecting an aberrant right hepatic artery because there is no opportunity to palpate arterial pulsations in the DCD donor. Meticulous in situ dissection in search of a right branch can significantly increase extraction time. Therefore, the DCD liver is typically removed with the pancreatic head to avoid injuring an aberrant right hepatic artery. We do not routinely procure whole pancreata when procuring DCD livers, unless the features of the individual case are optimal, including favorable donor body habitus, short warm ischemia time, and other aspects (Jeon et al. 2002). Alternatively, the liver and pancreas may be removed en bloc.
2.5.3 Premortem Cannulation Technique, with or Without ECMO
The premortem cannulation technique, described by the group at Madison, Wisconsin (D’Alessandro et al. 1995), decreases the inherent rush with the super-rapid recovery technique and may decrease warm ischemia time, particularly if withdrawal of support is performed outside the operating room. The technique requires consensual pre-extubation (premortem) femoral vessel cannulation (Reich et al. 2009; OPTN 2007; United Network for Organ Sharing 2013; Institute of Medicine, National Academy of Sciences 1997, 2000; Institute of Medicine 2006; Bernat et al. 2006). Femoral artery and femoral vein cannulae are inserted under local anesthesia. After the declaration of death, cold preservation solution is immediately infused via the femoral artery cannula, and the femoral vein cannula is opened to gravity to decompress the venous system. Thereafter, median sternotomy and midline abdominal incisions are made and the intra-abdominal organs are topically ice-cooled and then removed en bloc or separately.
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