Retrograde oxygen persufflation as a supplement of cold storage during the preservation period has the potential to better utilize ischemically damaged marginal livers in the experimental setting. Retrograde oxygen persufflation was applied in selected livers to demonstrate feasibility in the clinical setting and to investigate potential beneficial effects. Between 4/04 and 3/05 5 marginal otherwise discarded livers with warm ischemic damages from deceased donors (age 52 ) were accepted for transplantation. All organs were distantly procured and shipped to our center. Immediately after arrival, filtered humidified gaseous oxygen was given via the hepatic veins for at least 60 minutes with a pressure up to 18 mm mercury. Liver biopsies were analyzed for ATP content before and after persufflation. All patients (age 55 [46 -66]) survived without retransplantation, had good initial function and are alive and well after minimum follow-up of two years. Bleeding from pinpricks stopped spontaneously after 5-10 minutes after reperfusion but was prolonged in one patient with severe coagulopathy until correction. One patient developed arterial thrombosis at postop day 0. He fully recovered after thrombectomy. Another patient developed subcapsular hematoma, which was removed at postop day 10. On routine postoperative biopsies vascular structures appeared undamaged. ATP levels in pre-reperfusion biopsies revealed a more than twofold increase of ATP content compared to biopsies before persufflation. Retrograde oxygen persufflation preservation is feasible and save in the clinical setting, improves early aerobic metabolism and therefore potentially improves primary organ function after liver transplantation. Organ shortage is the main problem in liver transplantation leading to a high mortality rate on the waiting list. Possible mechanisms to alleviate this difficulty include extension of living donations, split liver transplantation, and, increasingly, the use of marginal organs. 1 The outcome of the use of potentially critical marginal organs could be enhanced by the improvement of preservation and revitalization techniques applied during the cold ischemia time period.Experimental studies investigating the effect of hypothermic liver perfusion pump systems with oxygenation reveal promising results. 2,3 However, these perfusion system machines are expensive, technically complex, and not yet fully developed for clinical application. 4 Machine perfusion, although analyzed in experimental studies up to now, does not have a clinical impact on the preservation of livers.In several ex vivo studies and recently in an in vivo study, we demonstrated successful extension of ischemic tolerance of porcine livers by cold preservation including postconditioning with gaseous oxygen [retrograde oxygen persufflation (ROP)]. 5,6 Also, the detrimental effects of 60 minutes of warm ischemia for kidneys were completely reversible with ROP. 7 On the basis of our experimental results, we applied ROP in Abbreviations: ALAT, alanine aminotransferase;...

Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences could be detected between patients with or without sentinel bleeding before delayed massive hemorrhage. The only difference found was that non-surviving patients were significantly older than surviving patients. Delayed massive hemorrhage is a common cause of death after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of sentinel bleeding should lead to emergency angiography and dependent from the result to emergency relaparotomy to increase the likelihood of survival.

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