Impact of the Procurement Technique on Liver Transplantation Outcome

Purpose: The impact of the surgical liver graft procurement technique on liver transplantation (LT) outcome remains unexplored. Therefore, we compared a group of LT after "selective" procurement (selective group) with liver pedicle dissection to a group of LT after "en bloc" or massive procurement without liver pedicle dissection (en bloc group). Method: Monocentric retrospective study from a prospective database. Non-inclusion criteria: combined transplantation, split graft, death before postoperative day 1, unknown procurement technique. Main outcome was the 1 year arterial or biliary complication-free survival (ABCFS) after LT which is more sensitive than graft or patient survival to detect factors influencing on LT outcomes (DOI: 10.1002/lt.26269). Survival analysis was performed with the online application EasyMedStat (version 3.19; www.easymedstat.com) using a Cox univariate model to identify prognostic factors for all LT. All variables with p<0.2 were included in a step-up multivariate regression. Results: Between 2008 and 2020, from 1014 LT, 663 (65%) fulfilled inclusion criteria. The selective (n=248) and en bloc (n=415) groups did not differ except minor differences regarding the cold ischemia time (selective versus en bloc, respectively, 7.1h vs. 7.3h, p=0.021), the donor age (53 vs. 59 years, p<0.001) and the median year of LT (2015.0 vs. 2015.5, p=0.04). After 1 year, the ABCFS was 75% (95% CI: 70-80) for selective procurement and 67% (95% CI: 62-71) for en bloc procurement (p=0.02). In multivariate analysis, (risk factor HR > 1, protective factor HR <1) the factors that significantly influenced ABCFS were the selective technique (HR=0.75, p=0.04), a LT for cancer (HR=1.54, p=0.02), a biliary drain (HR=1.45, p=0.008), the donor age (HR=1.01, p=0.045) and a postoperative early allograft dysfunction (HR =1.59, p=0.002). The rate of treatment for an arterial complication after LT (angioplasty, surgical refection, medical treatment, retransplantation) was lower in the selective group compared to the en bloc group (15 (6%) versus 32 (8%), p=0.002). Patient survival at 2 years was 86% (95% CI: 81-89) and 85% (95% CI: 82-88), graft survival 83% (95% CI: 78-87) and 82% (95% CI: 78-86) and not significantly different. Conclusion: The “selective” liver graft procurement technique with hepatic pedicle dissection could improve long-term results of LT compared to the “en bloc” technique. The surgical technique may influence the rate of arterial complications that is suggestive of a relation between procurement technique and long-term result of the LT. Our results indicate a large multicenter controlled study.