Approach to Intraoperative Consultation for Donor Liver Biopsies

Abstract

Context.— As demand for organs to treat end-stage liver disease increases, donor livers once deemed only marginally suitable for donation are being considered for transplantation. Pathologists are increasingly being asked to evaluate these livers for acceptability. This article provides guidelines for frozen section evaluation of livers for transplantation. Objective.— This article concentrates on the histopathologic features of transplant suitability with appropriate clinicopathologic correlation for the practicing pathologist. Recommendations for proper handling and sampling of tissue are discussed. Relative and absolute contraindications as well as artifacts and benign conditions are emphasized. Data Sources.— Sources include a compilation of the authors' experiences in academic and community liver transplantation centers. In addition, relevant medical literature was reviewed, as well as Web sites specializing in organ transplantation, such as Transplant Pathology Internet Services and the Organ Procurement and Transplantation Network. Conclusions.— Malignancy and extensive necrosis in the liver are absolute contraindications to transplantation. Evaluation of macrosteatosis, fibrosis, hepatitis, and necrosis depends on the severity of disease and correlation with the clinical situation. Donor age of greater than 60 years does not preclude transplantation. Artifacts and benign conditions need to be understood to prevent wastage of precious organs and to ensure that an appropriate organ is provided for the recipient.

The impact of donor liver allograft fibrosis on patients undergoing liver transplantation

“…Throughout a compilation of personal experience, in addition to review of relevant medical literature and web sites specializing in organ transplantation, Melin et al provided guidelines for evaluation of livers for transplantation. The authors considered liver allografts with fibrosis stage 2 and above unsuitable for transplantation …”

“…Fibrosis stage 2 or greater in the Ishak/Knodell classification has generally been considered unsuitable for transplantation, but there is no clear evidence to support this notion. From a glass‐half‐full perspective, authors considered the use of stage 1 fibrosis livers, and even reported anecdotal observations of favorable outcome of stage 3 fibrosis livers, although not based on scientific evidence. While reviewing our initial experience using HCV (+) allografts, we identified 17 patients transplanted with liver allografts with early‐stage fibrosis (stages 1 and 2), and showed that the amount of liver allograft fibrosis pretransplant did not appear to impact on the overall fibrosis progression or survival of patients undergoing LT using HCV (+) allografts …”

Successful donation after cardiac death liver transplants with prolonged warm ischemia time using normothermic regional perfusion

“…No diffuse necrosis was observed in the livers accepted for transplant. Frozen section biopsy, although it may be not accurate in detecting early signs of ischemic damage after circulatory arrest, assured that steatosis and fibrosis were acceptable for transplantation, not adding further risk to the procedure.…”

Aspectos histopatológicos de la evaluación del donante en trasplante hepático, una aproximación a la consulta intraoperatoria

“…Estas razones son suficientes para que estemos familiarizados con los posibles hallazgos histopatológicos, las dificultades que se pueden presentar y sus diagnósticos diferenciales. Así cada grupo transplantador establecerá los pros y contras de esta metodología y decidirá la mejor conducta, para obtener el injerto que minimice al máximo los riesgos para el receptor (2,3).…”

“…La hiperplasia nodular puede confundirse para el patólogo con cirrosis, en especial si no conoce el aspecto macroscópico que al cirujano le plantea una lesión tumoral. Si los microhamartomas y los granulomas son múltiples pueden hacer pensar que se trata de metástasis (2). El rol del patólogo en el estudio intraoperatorio es especialmente útil cuando durante la cirugía de rescate se encuentra una masa hepática o de otro órgano, lograr identificar lesiones benignas, cicatriciales, granulomas antiguos inactivos hacen que no se contraindique un trasplante, estas entidades son considerados sin riesgo (Figuras 11, 12 y 13).…”