Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients' inferior vena cava and veno-venous bypass

Abstract

Preservation of the recipient's vena cava and LLC can reduce, but not avoid, the requirement for veno-venous bypass. In orthotopic liver transplantation, postoperative hemorrhage, as measured by surgical revisions and requirement for blood products, is significantly reduced with LLC with and without bypass. Early renal dysfunction also occurs in the group of LLC as compared with the termino-terminal cavostomy independent of the bypass. A technical failure resulting in patient death can be associated with LLC.

An Alternative Surgical Technique for Caval Preservation in Liver Transplantation

“…These may occur in patients who have undergone TIPS, those with aberrant hepatic veins, or in cases of a small common cuff of the left and middle hepatic veins. 12 The PB technique can be used successfully in the face of diffuse and tenacious peri-hepatic adhesions, along with the presence of giant collaterals in the retro-hepatic area. In fact, dangerous and long dissections can be minimized by following, in rapid sequence, a seven-step modified PB technique:…”

“…3,4,12,13 The results show less blood transfusion requirement, shorter operative time and anhepatic phase duration, decreased costs, better intraoperative hemodynamics, shorter ICU length of stay, and better patient outcomes using the PB technique, as compared to the standard technique.…”

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“…[11][12][13][14][15] Potential advantages of the piggyback technique, started in phase 2, may include decreased risk of bleeding problems (bleeding, hemodynamic instability, or transfusions); shorter operative time (1 less anastomosis with the piggyback technique), and avoidance of venovenous bypass (Table 3). [16][17][18][19][20][21] The improved survival in phase 2 may be attributed to these technical improvements (Table 3, Table 5, and Figure 1). In addition, we changed our vena cava anastomosis to a side-to-side cavocaval anastomosis (modified piggyback technique) after phase 1.…”

“…22,23 This simpler and faster anastomosis may be associated with decreased intraoperative bleeding, decreased blood product transfusion, and decrease in partial clamping of the inferior vena cava, and it has become a preferred technique by some centers. 7,19,[24][25][26][27] The experience with this technique likely decreased operative time after phase 1 (Table 3), but this could not be confirmed with statistical testing because of small number of transplants in phase 1.…”

Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature

“…Overall, no conclusive data in studies with high evidence exist. Most of the studies recently published show no benefit by using a porto-systemic shunt [34][35][36][37].…”