We read with great interest the recent article by Geenen et al., 1 who described the utilization and outcomes of deceased donor liver allografts with preprocurement injury from blunt trauma. Marginal grafts 2 are increasingly being used to reduce waiting list mortality and minimize the gap between the demand for liver transplantation and the number of available organs. However, blunt trauma to the liver remains a concern for transplantation, with no consensus on the utilization of such grafts and, in particular, the optimal surgical approach. There are very few reports on the use of livers with blunt trauma, 3,4 and this series is a significant addition, describing the largest experience to date with all grades of liver trauma. 5 The authors identified a 4.8% contribution to the donor pool from livers that had sustained blunt trauma. Most injuries were minor (grades I and II), whereas 30% were major (grades III-V). However, it is unclear from the article whether the 2 additional cases with intimal injuries to the cava and celiac axis had associated liver parenchyma injuries, which would make them suitable for this series.
The first important message of this article is the excellent outcome achieved in all patients. This appears to be a recurring theme in all published reports and supports a revision of the discarding policy for traumatized livers. In addition to the 15 cases in their report, the authors identified another 42 potentially suitable livers that were discarded. These findings suggest that such a revision could provide an increase in the number of available livers, particularly in countries in which trauma remains a significant cause of death for potential donors.
A second key but controversial message concerns the surgical strategy for severe injuries (Ͼgrade II) that are known pre-procurement. Geenen et al. 1 suggested that these livers should undergo resection of the injured area of the graft, either on the back-table or as an in situ split. Although the former option could be indicated in severe injuries with significant capsular damage, the latter is likely to be the exception rather than