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The Impact of Deceased Donor Liver Extraction Time on Early Allograft Function in Adult Liver Transplant Recipients. “Vite fait, bien fait.”

Brustia, Raffaele MD1; Boleslawski, Emmanuel MD, PhD2; Danion, Jerome MD3; Savier, Eric MD1,4; Barrou, Benoit MD, PhD5,6; Scatton, Olivier PhD1,4

doi: 10.1097/TP.0000000000002724
Letters
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1 Department of Hepatobiliary and Liver Transplantation Surgery, Pitié–Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France.

2 Department of Transplantation and Digestive Surgery, Lille University Hospital, Lille, France.

3 Department of Digestive Surgery, Poitiers University Hospital, Poitiers, France.

4 Sorbonne Université, INSERM, Saint-Antoine Research Center (CRSA), Paris, France.

5 Department of Urology–Nephrology–Transplantation, Pitié–Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France.

6 Poitiers University, INSERM U1082 Ischemia Reperfusion in Organ Transplantation Mechanisms and Therapeutic Innovations, Poitiers, France.

Received 23 January 2019. Revision received 4 March 2019.

Accepted 12 March 2019.

The authors declare no funding or conflicts of interest.

R.B., E.B., J.D., E.S., B.B., and O.S. equally contributed to drafting, correction, and final approval of this letter.

Correspondence: Olivier Scatton, Hepatobiliary and Liver Transplantation Surgery, Hôpital de la Pitié–Salpêtrière, Assistance Publique-Hôpitaux de Paris, France. (olivier.scatton@aphp.fr).

We read with great interest the recent article by Adelmann et al1 reporting the impact of donor extraction time on posttransplant outcome. This retrospective study including 292 deceased donors showed that increasing donor extraction time by 15 minutes had a similar impact to increasing cold ischemia time by 2.5 hours. Factors found to significantly increase donor extraction time were thoracic organ procurement (odds ratio 6.21; 95% confidence interval [CI], 2.77-9.65) and recovery by inexperienced surgeons (odds ratio 7.06; 95% CI, 3.61-10.51). Along the same lines, Jochmans et al2 reported that a longer donor extraction time led to higher graft failure rate (hazard ratio 1.03 for every 10-min increase; 95% CI, 1.02-1.05) in a retrospective Eurotransplant-based cohort study of 12 974 recipients of deceased-donor livers.

Taken together, these results underline how liver graft extraction needs to be not just safe but fast too, which prompts us to add some insights to the discussion.

Our first comment concerns the technical aspect of procurement. There are essentially 2 different liver retrieval techniques3,4: “rapid en bloc recovery,” which minimizes the risk of vascular injury, or “selective dissection,” which requires more surgical experience as it involves vascular control and dissection. Selective dissection could be useful to reduce donor liver extraction time, especially when associated with thoracic or pancreatic procurement. However, both techniques come with risks and benefits, and there is no consensus on which technique should be preferred, which takes us to our main comment.

Overall, both Adelmann et al1 and Jochman et al2 stress the need for specific and supervised training. In France, this recurrent concern prompted the creation, back in 2009, of the Ecole Francophone de Prélèvement Multi Organe (EFPMO; French School for Multiorgan Procurement).5 This national training school aims to harmonize procurement practices by delivering not only technical training but also insights ischemia-reperfusion issues, extended criteria donors, donor disease transmission, ethics, and legal issues. Indeed, supervised surgical training usually improves resident skills, satisfaction, and patient outcomes.6,7 Note that the last 2 EFPMO sessions used a new deceased-donor model simulating pulse circulation and artificial respiration.8 This high-fidelity model was highly appreciated by trainees due to the realism of the procedure, including massive bleeding during dissection and a wide range of near-miss events.

At least 500 surgeons have attended EFPMO training sessions over the past decade. Recovery teams (thoracic organs, kidney, pancreas, and liver) from different regions of France have experienced immersive and intensive 1-week sessions, where training in technical skills and communication contributes to the strengthening of team building, with gains in confidence, safety, and rapidity.9

Indeed, there is hope that standardization and knowledge of the multiorgan recovery procedure can offset ongoing turnover in recovery teams.

Organ procurement is often seen as the less noble side of transplantation, but the study by Adelmann et al1 rightly stresses the message that specific training, to be promoted during surgical residency, can have important benefits for both trainees and recipients.

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REFERENCES

1. Adelmann D, Roll GR, Kothari R, et al. The impact of deceased donor liver extraction time on early allograft function in adult liver transplant recipients. Transplantation. 2018;102:e466–e471.
2. Jochmans I, Fieuws S, Tieken I, et al. The impact of hepatectomy time of the liver graft on post-transplant outcome: a Eurotransplant cohort study. Ann Surg. 2019;269:712–717.
3. Lechaux D, Dupont-Bierre E, Karam G, et al. Technical aspects of combined heart, liver and kidney procurement. Ann Chir. 2004;129:103–113.
4. Agence de la Biomédecine. Technical recommendations. Available at https://www.agence-biomedecine.fr/IMG/pdf/recommandations-techniques-concernant-le-donneur-en-etat-de_mort-encephalique.pdf. Accessed January 14, 2019.
5. Ecole Francophone de Prélèvement Multi organe. Available at http://www.efpmo.fr/. Accessed January 14, 2019.
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7. Enciso S, Díaz-Güemes I, Usón J, et al. Validation of a model of intensive training in digestive laparoscopic surgery. Cir Esp. 2016;94:70–76.
8. Faure JP, Breque C, Danion J, et al. SIM life: a new surgical simulation device using a human perfused cadaver. Surg Radiol Anat. 2017;39:211–217.
9. Xu R, Carty MJ, Orgill DP, et al. The teaming curve: a longitudinal study of the influence of surgical team familiarity on operative time. Ann Surg. 2013;258:953–957.
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