“Left at Right” Adult Liver Transplantation: The Feasibility of Heterotopic Implantation of Left Liver Graft

Abstract

†Both authors contributed equally to this work. Left liver grafts have been widely utilized in adult liver transplantation (LT) and yielded acceptable results.However, the conventional orthotopic implantation of a left liver graft imposes the potential risk of perioperative vascular complications. We report herein an alternative modified technique for adult left liver LT and evaluate its feasibility in LT. In this study, 10 recipients had their left liver graft rotated 180• , and heterotopically implanted at the right subphrenic space, which we termed "left at right" liver transplantation (LAR-LT). The sequence of vascular and biliary reconstruction was performed as standard techniques, and no perioperative vascular complications related to LAR-LT were encountered. There were two mortalities in this series, one due to a small-for-size graft dysfunction and the other due to postoperative internal hemorrhage. Two recipients had biliary strictures that were successfully managed by percutaneous biliary dilatation and Roux-en-Y hepaticojejunostomy. The clinical characteristics and outcomes of patients undergoing LAR-LT were also compared with patients undergoing conventional orthotopic left liver LT (n = 14). Although the results showed no significant difference between the two groups, according to our experience, the satisfactory outcome and easier technical reconstruction suggest that the LAR-LT modification could be a feasible alternative to left liver LT.

Stent Placement for Treating IVC Stenosis Following “Left at Right” Adult Liver Transplantation

“…The reason of this phenomenon might be that the enlarged grafted liver parenchyma compressed the IVC directly and also shifted the portion of the anastomosis between the hepatic vein and IVC toward the right side, resulting in the stretch of the IVC. According to the Chan's report, 1 out of 10 LAR‐LT cases suffered from massive ascites and this case might suffer from the IVC stenosis similar to our cases.…”

“…We read with great interest the paper by Chan et al reporting “left at right” adult liver transplantation (LAR‐LT): the feasibility of heterotopic implantation of left liver (LL) graft. The authors reported that this new procedure enables the anastomosis of portal vein, hepatic vein, hepatic artery and biliary duct to be performed smoothly without any tension.…”

The Concerns of “Left at Right” Adult Liver Transplantation

“…In fact, none of the LAR‐LT recipients in our study had any vascular complications including portal inflow, venous outflow or IVC stenosis similar to that reported in the patients in Dr. Mizuno's study. The LAR‐LT recipient who suffered from massive ascites might have been due to severe bacterial infection that led to graft dysfunction and hyperbilirubinemia, as we previously described in the article .…”

“…We appreciate the interest of Mizuno et al in our recent article regarding heterotopic implantation of a left liver graft in the right abdominal cavity, which we termed as “Left at Right” liver transplantation (LAR‐LT) . The authors had applied this procedure using a left liver graft in living donor liver transplantation in three patients, and confirmed that the LAR‐LT is a relatively easier approach for performing implantation of the left liver graft.…”

“…Technically, we believe that while performing LAR‐LT, the length of the hepatic vein between the graft and the IVC, as well as the position of the graft, is very important. As specifically described in our previous study, the graft's hepatic vein is cut at the edge of the liver parenchyma during donor hepatectomy and it is then directly anastomosed to the recipient's IVC during graft implantation (Figure A) . With the use of this technique for reconstruction of the graft's venous outflow, redundancy of the hepatic vein between the liver graft and the IVC could be avoided, suggesting that the risk of outflow complications resulting from distortion and stretching of the redundant hepatic vein during growth of the liver graft might also be decreased.…”