The multi-organ donor : a guide to selection, preservation and procurement

216 Pages·2018·40.778 MB·English

by  Higgins, Robert S. D., Sanchez, Juan A.

Current and Future
Developments in Surgery
(Volume 3)
(The Multi-Organ Donor: A-Guide to Selection,
Preservation and Procurement)
Edited by
Robert S.D. Higgins & Juan A. Sanchez
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Current and Future Developments in Surgery
Volume # 3
The Multi-Organ Donor: A-Guide to Selection, Preservation and Procurement
Editors: Robert S.D. Higgins & Juan A. Sanchaz
ISSN (Online): 2589-1758
ISSN (Print): 2589-174X
ISBN (Online): 978-1-68108-756-6
ISBN (Print): 978-1-68108-757-3
© 2018, Bentham eBooks imprint.
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CONTENTS
PREFACE ................................................................................................................................................ i
LIST OF CONTRIBUTORS .................................................................................................................. ii
CHAPTER 1 INTRODUCTION .......................................................................................................... 1
Juan Sanchez and Robert S. D. Higgins
CONSENT FOR PUBLICATION ................................................................................................ 2
CONFLICT OF INTEREST ......................................................................................................... 2
ACKNOWLEDGEMENTS ........................................................................................................... 3
REFERENCES ............................................................................................................................... 3
CHAPTER 2 THE ORGAN ALLOCATION SYSTEM ................................................................... 4
Karen Kennedy and Charles Alexander
INTRODUCTION .......................................................................................................................... 4
Legislative, Regulatory and Accreditation History Highlights ............................................... 4
Uniform Anatomical Gift Act ................................................................................................. 6
Organ Procurement Organization Accreditation Program ...................................................... 7
Organ Donor Clinical Processes ............................................................................................. 8
Referral and Evaluation .......................................................................................................... 8
Authorization Processes .......................................................................................................... 9
Clinical Donor Management ................................................................................................... 9
Donor Management Priorities ................................................................................................. 11
Organ Allocation Overview .................................................................................................... 12
Heart and Lung Wait Lists and Allocation: Excerpts from UNOS Policies 6, 10 [2] ............ 13
Liver Wait List and Allocation: Excerpts from UNOS Policy 9 [2] ....................................... 14
Intestine Allocation Algorithm: Excerpts from UNOS Policy 7 [2] ....................................... 15
Geographic Location [2] ......................................................................................................... 15
Medical Urgency [2] ............................................................................................................... 15
Additional Considerations ...................................................................................................... 15
Kidney Wait List and Allocation: Excerpts from UNOS Policy 8 [2] ................................... 16
KDPI Score [2] ....................................................................................................................... 16
EPTS Score [2] ....................................................................................................................... 16
CPRA Percentage [2] .............................................................................................................. 16
KAS System [2] ...................................................................................................................... 17
Kidney Allocation Points Score [2] ........................................................................................ 17
Antigen Mismatch [2] ............................................................................................................. 17
Geographic Proximity ............................................................................................................. 17
Double Kidney Allocation [2] ................................................................................................ 17
Pancreas Wait List and Allocation: Excerpts from UNOS Policy 11 [2] ............................... 18
CPRA Percentage [2] .............................................................................................................. 18
Antigen Mismatch [2] ............................................................................................................. 18
Geographic Proximity and Waiting Time ............................................................................... 18
Kidney - Pancreas Allocation: Excerpts from UNOS Policy 11 [2] ....................................... 19
ABO ........................................................................................................................................ 19
VCA Wait List and Allocation: Excerpts from UNOS Policy 12 [2] ..................................... 19
Surgical Recovery Processes .................................................................................................. 19
Follow-up Activities ............................................................................................................... 21
CONCLUSION ............................................................................................................................... 22
CONSENT FOR PUBLICATION ................................................................................................ 22
CONFLICT OF INTEREST ......................................................................................................... 22
ACKNOWLEDGEMENTS ........................................................................................................... 22
REFERENCES ............................................................................................................................... 22
CHAPTER 3 IDENTIFICATION OF THE BRAIN DEAD DONOR ............................................. 24
Justin Zamoyski and Diana Greene-Chandos
INTRODUCTION .......................................................................................................................... 24
PATHOLOGY AND PHYSIOLOGY ........................................................................................... 26
PREPARATION FOR CLINICAL EXAM ................................................................................. 27
Coma ....................................................................................................................................... 27
Neuroimaging Correlates ........................................................................................................ 27
Sedation Absent ...................................................................................................................... 27
Paralytic Absent ...................................................................................................................... 28
Absence of Metabolic Abnormalities ..................................................................................... 28
Normothermia ......................................................................................................................... 28
Normotension .......................................................................................................................... 29
Absence of Spontaneous Respirations .................................................................................... 29
COMPONENTS OF BRAIN DEATH EXAMINATION ........................................................... 29
Pupillary Reflexes ................................................................................................................... 29
Corneal Reflexes ..................................................................................................................... 30
Oculocephalic Reflex .............................................................................................................. 31
Oculovestibular Reflex ........................................................................................................... 32
Facial Noxious Stimuli ........................................................................................................... 32
Pharyngeal and Tracheal Reflexes .......................................................................................... 32
Noxious Stimuli in Extremities ............................................................................................... 33
APNEA TESTING .......................................................................................................................... 33
ANCILLARY TESTING ............................................................................................................... 36
Electrophysiological Testing .................................................................................................. 36
Vascular Imaging .................................................................................................................... 37
SPECIAL CIRCUMSTANCES ..................................................................................................... 39
Pediatric Patients ..................................................................................................................... 39
“Brainstem” Death .................................................................................................................. 39
Maternal Death by Neurological Criteria ............................................................................... 39
Religious Exceptions .............................................................................................................. 39
CONSENT FOR PUBLICATION ................................................................................................ 40
CONFLICT OF INTEREST ......................................................................................................... 40
ACKNOWLEDGEMENTS ........................................................................................................... 40
REFERENCES ............................................................................................................................... 40
CHAPTER 4 MANAGEMENT OF PUBLIC HEALTH SERVICE (PHS) INCREASED RISK
DONORS AND HEPATITIS C OR HIV INFECTED DONORS ...................................................... 44
Nicole Theodoropoulos, Stephanie Pouch and Dorry Segev
INTRODUCTION .......................................................................................................................... 44
CONSENT FOR PUBLICATION ................................................................................................ 49
CONFLICT OF INTEREST ......................................................................................................... 49
ACKNOWLEDGEMENTS ........................................................................................................... 49
REFERENCES ............................................................................................................................... 50
CHAPTER 5 MANAGEMENT OF THE MULTI-ORGAN DONOR AND LOGISTIC
CONSIDERATIONS ............................................................................................................................... 53
Sharon Weeks, Shane Ottmann and Andrew Cameron
INTRODUCTION .......................................................................................................................... 53
DONOR MANAGEMENT ............................................................................................................ 54
Cardiovascular Dysfunction .................................................................................................... 54
Pulmonary Deterioration ......................................................................................................... 56
Endocrine Derangements ........................................................................................................ 57
Temperature Regulation .......................................................................................................... 58
LOGISTIC CONSIDERATIONS ................................................................................................. 58
Organizational Considerations ................................................................................................ 58
Logistics of Organ Recovery .................................................................................................. 60
CONCLUSION ............................................................................................................................... 61
CONSENT FOR PUBLICATION ................................................................................................ 62
CONFLICT OF INTEREST ......................................................................................................... 62
ACKNOWLEDGEMENTS ........................................................................................................... 62
REFERENCES ............................................................................................................................... 62
CHAPTER 6 CURRENT STATE OF ORGAN PRESERVATION ................................................ 66
Eliza Beal, Bryan Whitson and Sylvester Black
INTRODUCTION .......................................................................................................................... 66
Preservation Solutions ............................................................................................................ 67
Classification of Preservation Solutions ....................................................................... 67
Intracellular Vs. Extracellular Solutions ...................................................................... 68
Impermeants .................................................................................................................. 68
Antioxidants ................................................................................................................... 69
Buffers ........................................................................................................................... 69
Energy Precursors ........................................................................................................ 69
Abdominal Transplant ............................................................................................................ 69
Liver Preservation ......................................................................................................... 69
Renal Preservation ........................................................................................................ 70
Pancreas Preservation .................................................................................................. 70
Intestinal Preservation .................................................................................................. 71
Cardiac and Pulmonary Transplant ......................................................................................... 71
Heart Transplantation ................................................................................................... 71
Lung Transplantation .................................................................................................... 71
CONCLUSION ............................................................................................................................... 72
CONSENT FOR PUBLICATION ................................................................................................ 72
CONFLICT OF INTEREST ......................................................................................................... 73
ACKNOWLEDGEMENTS ........................................................................................................... 73
REFERENCES ............................................................................................................................... 73
CHAPTER 7 ORGAN SPECIFIC CONSIDERATIONS: HEART ................................................. 80
Vincent Nardy, Ahmet Kilic and Arman Kilic
INTRODUCTION .......................................................................................................................... 80
Donor and Recipient Selection ............................................................................................... 81
Patient Management and Preservation Strategies ................................................................... 84
Procurement Technique .......................................................................................................... 84
FUTURE DIRECTION S ............................................................................................................... 88
CONSENT FOR PUBLICATION ................................................................................................ 88
CONFLICT OF INTEREST ......................................................................................................... 88
ACKNOWLEDGEMENTS ........................................................................................................... 88
REFERENCES ............................................................................................................................... 89
CHAPTER 8 ORGAN SPECIFIC CONSIDERATIONS: LUNG .................................................... 90
Jinny Ha, Stephen Broderick and Errol Bush
INTRODUCTION .......................................................................................................................... 90
Donor Criteria ......................................................................................................................... 90
Age .......................................................................................................................................... 91
Smoking History ..................................................................................................................... 92
ABO Compatibility ................................................................................................................. 92
Size Criteria ............................................................................................................................ 92
Graft Ischemia ......................................................................................................................... 93
Radiographic Findings ............................................................................................................ 93
Bronchoscopy and Gram Stain ............................................................................................... 93
Gas Exchange .......................................................................................................................... 94
Techniques for Donor Lung Extraction .................................................................................. 94
Initial On-site Evaluation of the Donor Organ ............................................................. 94
Positioning .................................................................................................................... 95
Initial Gross Evaluation of the Donor Lungs ................................................................ 95
Donor Lung Dissection ........................................................................................................... 95
Donor Lung Excision .............................................................................................................. 98
CONCLUSIONS AND FUTURE DIRECTIONS ........................................................................ 99
CONSENT FOR PUBLICATION ................................................................................................ 99
CONFLICT OF INTEREST ......................................................................................................... 99
ACKNOWLEDGEMENTS ........................................................................................................... 99
REFERENCES ............................................................................................................................... 100
CHAPTER 9 LIVER PROCUREMENT: THE DONOR HEPATECTOMY ................................. 102
Marcos E. Pozo, Russell Wesson, Benjamin Philosophe, Andrew Cameron and Jacqueline
Garonzik-Wang
INTRODUCTION .......................................................................................................................... 102
General Considerations ........................................................................................................... 102
Technique for Liver Procurement ........................................................................................... 103
Before Incision .............................................................................................................. 103
Warm Dissection ........................................................................................................... 103
Organ Cold Perfusion ............................................................................................................. 109
Cold Dissection ....................................................................................................................... 110
Special Scenarios .................................................................................................................... 113
Unexpected Intraabdominal Findings ........................................................................... 113
Alternative Cannulation and Cross-Clamp Sites .......................................................... 113
Donation after Cardiac Death (DCD) ..................................................................................... 113
CONCLUSION ............................................................................................................................... 114
CONSENT FOR PUBLICATION ................................................................................................ 114
CONFLICT OF INTEREST ......................................................................................................... 114
ACKNOWLEDGEMENTS ........................................................................................................... 114
REFERENCES ............................................................................................................................... 115
CHAPTER 10 ORGAN SPECIFIC CONSIDERATIONS: PANCREAS AND KIDNEY ............. 116
Iyore James, Ashraf El-Hinnawi and Amer Rajab
INTRODUCTION .......................................................................................................................... 116
Donor Selection [Pancreas] ..................................................................................................... 117
Donor Selection [Kidney] ....................................................................................................... 117
Procurement ............................................................................................................................ 118
Preservation ............................................................................................................................. 122
CONCLUSION/FUTURE DIRE CTION .................................................................................... 123
CONSENT FOR PUBLICATION ................................................................................................ 123
CONFLICT OF INTEREST ......................................................................................................... 123
ACKNOWLEDGEMENTS ........................................................................................................... 123
REFERENCES ............................................................................................................................... 123
CHAPTER 11 LIVING DONATION .................................................................................................. 125
Ben Philosophe, Jaime Glorioso, Shane Ottmann, Iyore James and Amer Rajab
INTRODUCTION .......................................................................................................................... 125
Living Donor Liver Transplantation (LDLT) ......................................................................... 125
Patient Selection ...................................................................................................................... 126
Surgical Technique ................................................................................................................. 128
Donor Right Lobe Hepatectomy .................................................................................... 128
Donor Left Lobe Hepatectomy ............................................................................................... 131
Donor Left Lateral Hepatectomy ............................................................................................ 134
LIVING DONATION- KIDNEY .................................................................................................. 135
Introduction ............................................................................................................................. 135
Benefits of Living Donor Kidney Transplant ......................................................................... 136
Donor Evaluation .................................................................................................................... 136
Operative Approach ................................................................................................................ 140
Complications ......................................................................................................................... 142
CONCLUDING REMARKS ......................................................................................................... 143
CONSENT FOR PUBLICATION ................................................................................................ 144
CONFLICT OF INTEREST ......................................................................................................... 144
ACKNOWLEDGEMENTS ........................................................................................................... 144
REFERENCES ............................................................................................................................... 144
CHAPTER 12 PEDIATRIC ISSUES: SPLIT LIVER/LIVING LIVER DONATION .................. 147
Kyle Jackson, Ben Philosophe and Andrew Cameron
INTRODUCTION .......................................................................................................................... 147
SPLIT LIVER TRANSPLANTATION ........................................................................................ 148
Introduction ............................................................................................................................. 148
Technical Aspects ................................................................................................................... 148
Donor and Recipient Selection ............................................................................................... 150
Potential Complications and Issues ........................................................................................ 151
Modern Outcomes ................................................................................................................... 152
LIVING DONOR LIVER TRANSPLANTATION ..................................................................... 152
Introduction ............................................................................................................................. 152
Donor Issues ............................................................................................................................ 153
Technical Issues ...................................................................................................................... 154
Potential Complications and Issues ........................................................................................ 154
Modern Outcomes ................................................................................................................... 155
SUMMARY ..................................................................................................................................... 155
CONSENT FOR PUBLICATION ................................................................................................ 155
CONFLICT OF INTEREST ......................................................................................................... 155
ACKNOWLEDGEMENTS ........................................................................................................... 156
REFERENCES ............................................................................................................................... 156
CHAPTER 13 ISLET CELL DONATION ......................................................................................... 160
Jill Buss and Amer Rajab
INTRODUCTION .......................................................................................................................... 160
Donor Characteristics .............................................................................................................. 161
Donor Scoring ......................................................................................................................... 163
Organ Procurement ................................................................................................................. 163
Organ Preservation .................................................................................................................. 164
CONCLUSION ............................................................................................................................... 165
CONSENT FOR PUBLICATION ................................................................................................ 166