*4.1.3. DCD retrievals*

handling the pancreas itself. The Harmonic Scalpel is also very useful in the dissection of the superior and inferior pancreatic borders, particularly the relatively vascular splenic flexure of the colon. The posterior surface of the pancreas can be mobilized with standard electrocautery in a relatively bloodless plane. The SMA/SMV pedicle inferior to the pancreas needs to be skeletonized such that it can be divided using a vascular stapler prior to pancreas removal in the cold phase. Superiorly, the bile duct is ligated and transected proximal to the point of ligation; residual bile is flushed out its open proximal end using saline instilled into the gallbladder. We will also free attachments around the gastroduodenal junction and duodenojejunal flexure, which are then identified with circumferential vessel loops for stapled division later in the cold phase. The inferior mesenteric vein is ligated *in situ* post perfusion as subsequent retraction of the divided vessel may make it difficult to identify on the back-table. Diluted povidoneiodine solution is instilled into the duodenum via a nasogastric tube as a decontamination step, and is subsequently removed through the same route. Some authors report concerns with subsequent duodenal mucosal toxicity related to instillation of povidone-iodine, and

160 Organ Donation and Transplantation - Current Status and Future Challenges

**Figure 2.** The harmonic scalpels utilization during pancreas procurement. (A) Mobilization of the greater curvature of the stomach, (B) creation of the superior mesenteric pedicle (cold phase), and back-table separation of (C) the liver-

pancreas block, and (D) the pancreas and spleen.

DCD pancreas retrieval is technically feasible, and can achieve excellent outcomes in selected donors certainly in the whole organ arena (see Outcomes, below). In contrast to DBD procurement, the first step in all DCD retrievals after a rapid laparotomy is cannulation and cold perfusion via the aorta [48, 49]. Venous venting is conducted via the IVC. Alternatively, if local laws allow, an *in situ* flush can be achieved using femoral cannulae inserted prior to the withdrawal of life support [49, 50]. Ante-mortem interventions including heparinization have been shown to also provide significant improvements to pancreas retrieval outcomes in the DCD setting [51]. Standard pancreas retrieval can then be undertaken as described for DBD donors, although donor hemostasis is no longer a concern and therefore sharp dissection is commonly utilized. The use of energy devices such as the Harmonic Scalpel at this stage may help minimize recipient bleeding however, as described in the DBD setting.

#### *4.1.4. Pancreas retrieval and multi-organ donors*

Pancreas retrieval is almost never undertaken in isolation, but rather it is usually procured in the context of a multi-organ retrieval, often in the presence of multiple retrieval teams. Meticulous retrieval technique therefore needs to be maintained and balanced in the presence of these competing factors, especially in the presence of concomitant liver procurement, which is still given preference owing to the critical requirement of liver transplant recipients. Pancreas-alone donors are uncommon in this day and age due to developments in procurement and preservation techniques. Some authors raised concerns that combined liver-pancreas retrieval, in contrast to pancreas retrieval alone, resulted in significant "flush" injury to the pancreas owing to a higher volume of perfusion solution and the utilization of dual aortoportal cannulation in the combined donors [52]. However, other studies clearly demonstrated that multi-organ retrieval, including combined liver-pancreas retrieval, was not detrimental to pancreas transplantation outcomes [53–58]. Another factor that previously precluded combined liver-pancreas procurement was aberrant hepatic arterial anatomy, in particular the presence of an aberrant or accessory right hepatic artery originating from the superior mesenteric artery [58]. Abandoning retrieval of the pancreas due to this situation is now rare, as a preserved length of the right hepatic artery originating from the SMA stump can effectively be anastomosed to the GDA as part of a back-table reconstructive procedure [45, 46]. It is only when the right hepatic artery is within the substance of the pancreas that whole pancreas retrieval should be precluded in favor of the liver [59] but the pancreas can still be retrieved for islet cell isolation as the pancreas can still be readily perfused, and on the back table the vessels readily separated, including if necessary taking them from the body of the pancreas [9]. However, if this is undertaken then care should be taken to not damage the parenchyma of the pancreas as this makes the distension of the pancreas with collagenase for digestion more difficult [9]. Over the last 25 years and more than 1000 retrievals the authors have never found any anatomical vascular anomaly to prevent an *en bloc* liver-pancreas retrieval, although this is cited as a common reason to decline pancreas retrieval worldwide.
