LAUSR

In this issue, McElroy and colleagues report an important reappraisal of the outcomes of technical variant (TV) liver grafts in the multicenter Society of Pediatric Liver Transplantation (SPLIT) database.1 A total of 1839 children were analyzed for the report of which 18% received living donor grafts, 26% received deceased donor TV grafts, and 56% received whole grafts over the 8 year study period. Patient and graft survival were comparable between TV grafts and whole organ graft recipients. This important contribution updates the previous SPLIT analysis from an earlier era that found inferior outcomes with TV grafts. Of note, the analysis also gives insight into some of the challenges inherent in performing TV implantation; biliary complications were more frequent in the TV group but did not contribute to graft or patient loss. Portal venous complications were infrequent but increased in TV graft recipients compared with whole grafts. The authors note the potential limitation of sampling as the SPLIT registry captures a subset of the overall OPTN data. During the reported analysis period, SPLIT included approximately 47% of the overall pediatric liver transplants reported in OPTN data.2 Nonetheless, these findings align with OPTN contemporary reports on the equivalency of technical variant grafts and represent multicenter outcome results. Given these findings, it is surprising that the use of technical variant grafts in the United States has not changed in the last decade.3 The authors appropriately advocate for continued allocation policy to prioritize children, which may lead to increased use of TV grafts; these policies also have a strong ethical foundation.4 The authors highlight the need for additional education and training in technical variant transplantation. The challenge now is how to best move forward. A threestep framework and a call to action are suggested herein. First, the quality improvement process identified in highperforming North American centers as first suggested by SPLIT5 must be followed up and shared. This study confirmed the impact of surgical complications on the outcome that was first shown in the SPLIT experience.6 Reduction of vascular complications in pediatric transplantation remains an important opportunity. The authors' finding that whole grafts in infants were associated with a greater risk of hepatic arterial thrombosis supports earlier work analyzing results in biliary atresia.7 Continued focused attention on areas of other TV graft morbidity such as reducing portal or biliary complications and optimizing their management8 is critical. The consideration of microsurgical technique in biliary reconstruction, for example, is a newer area of the study.9 Preemptive strategies in avoiding technical complications must also be coupled with defined graft rescue strategies.10,11 Second, we need to expand our horizon and where appropriate learn from and contribute to global expertise. Global progress, both in terms of allocation policy, as discussed by McElroy et al, but also in protocol and technical expertise, particularly from those centers with large expertise in living donor TV grafts, is critical to apply whenever possible.12 This concept extends to the consideration of wider, global training, or learning experiences, not only for trainees but also for faculty who commit themselves to develop ongoing expertise in pediatric liver transplantation. Finally, innovative methods to spur the dissemination of techniques, training methods, and best practices that also incorporate all available knowledge leaders and technology will be important. Learning networks, such as the Starzl Network for Excellence in Pediatric Transplantation, may be critical in this regard to develop agreedupon benchmarks, protocol standardization, and metrics for implementation across other centers.13 Of note, one applicable finding in a first of its kind adult liver transplantation benchmarking effort14 was a demonstration that biliary complication rates were reduced in centers with a higher acuity case mix. Benchmarking of this kind can be a useful tool in quality improvement and innovation. Of course, learning networks also allow for better incorporation of the patient voice and development of patientprioritized research and insights into outcomes that matter most to patients such as posttransplant quality of life.15 Children across North America deserve to have all appropriate liver graft techniques applied by expert transplant centers, so that no child dies waiting for a transplant and optimal posttransplant outcomes are obtained. The data presented by McElroy and colleagues support that technical variant graft expertise needs to be part of the solution. Collectively, this is a path the pediatric liver transplant community must now embrace.