Fig. 1. (A) A female-to-female luer adaptor is secured to the distal common bile duct to act as a cholangioscope sheath. The sheath allows passage of the cholangioscope and for excess irrigation fluid to freely exit the biliary tree. (B) Cholangioscopy during cold static storage. The assistant is stabilizing the bile duct during cholangioscopy and providing intermittent irrigation. (C) Cholangioscopy is performed during liver splitting to identify a suitable location for transection. The line of biliary transection is indicated by the yellow dotted line.

Fig. 2. Cholangioscopy during cold static storage demonstrating significant debris and mucosal sloughing (red arrows) at the hepatic duct bifurcation (A) and subsegmental ducts (C). Repeat cholangioscopy during ex-vivo normothermic machine perfusion demonstrating hyperaemia and mucosal mottling at the hepatic bifurcation (B) and subsegmental ducts (D). Cross sectional biopsies collected during cold static storage (E) and after reperfusion (F) (×10 magnification, hematoxylin and eosin stain). Mucosal sloughing and ischemic injury (red arrows) can be seen during cold static storage. Reperfusion injury with severe mural stromal necrosis (asterisk) can be seen after reperfusion.

Fig. 3. Ex vivo cholangioscopy of grafts 1 to 4 during cold static storage and post-reperfusion. DCD, donation after circulatory death; DBD, donation after brain death.

Fig. 4. Ex vivo cholangioscopy of grafts 5 to 8 during cold static storage and post-reperfusion. DCD, donation after circulatory death; DBD, donation after brain death.

Graphical abstract