Use of the Piggyback Hepatectomy Technique in Liver Transplant Recipients With Hepatocellular Carcinoma

Abstract

The piggyback hepatectomy technique (PGB) is avoided in liver transplant patients with hepatocellular carcinoma (HCC) to decrease the theoretical risk of a positive vena cava margin or hematologic metastases. This study reports the routine use of PGB in 138 consecutive adult, deceased donor liver transplant recipients with HCC. Piggyback hepatectomy technique was used in 119 subjects, with 19 recipients receiving the conventional bicaval technique (CONV). Median follow-up was 34 months. There were 95 patients (69%) within and 43 patients (31%) outside, Milan criteria at transplant. Hepatocellular carcinoma recurrence rate was 13% and survival was 84.1% (1-year) and 77.4% (2-years). The PGB and CONV study groups did not differ in survival within or outside Milan criteria. Cox proportional hazards modeling of posttransplant survival demonstrated statistically similar survival for PGB and CONV. In conclusion, the presence of HCC in liver transplant patients should not preclude the use of PGB.

Comparison of three caval reconstruction techniques in orthotopic liver transplantation: A retrospective review

“…Malignancy was previously described as a contraindication to utilizing the PB technique but has since been safely performed in transplants done for hepatocellular carcinoma. 4 Technical scenarios that may preclude caval preservation include an enlarged caudate lobe or juxtacaval malignancy. 5 Early studies comparing caval reconstruction techniques in orthotopic liver transplant primarily compared PB without VVB to the classic method with VVB, with mixed results.…”

Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living‐donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

“…On the other hand, in the field of LT, the PB technique, a cava‐sparing technique allowing continuous return of venous flow from the lower body to the heart, has gained acceptance in OLT in the past few years, based on the advantages of a shorter operation time, shorter anhepatic time, shorter warm ischemic time, and less blood loss [8, 12]. Clinically and conventionally, the PB technique is avoided in patients with hepatic malignancies because of the theoretical increased risk of a positive vena cava margin and the potential for metastatic spillage of tumor through the hepatic vein [13]. In contrast, Mangus et al [13], in their comparison of overall survival and recurrence rates after OLT for HCC, according to the transplant technique, between a group with the PB technique and a group with the conventional OLT technique, showed no significant difference between the groups, even among patients beyond the MC.…”

“…Clinically and conventionally, the PB technique is avoided in patients with hepatic malignancies because of the theoretical increased risk of a positive vena cava margin and the potential for metastatic spillage of tumor through the hepatic vein [13]. In contrast, Mangus et al [13], in their comparison of overall survival and recurrence rates after OLT for HCC, according to the transplant technique, between a group with the PB technique and a group with the conventional OLT technique, showed no significant difference between the groups, even among patients beyond the MC. They argued that preservation of the hepatic IVC in OLT did not result in a worsening of prognosis after LT for HCC.…”

Contemporary Strategies in the Management of Hepatocellular Carcinoma

“…The shorter waiting time for LDLT may remove the observation period that occurs on the waiting list to assess tumor biology and a 3 month cooling off period has been advocated before undertaking LDLT. Surgical oncological clearance may also be compromised as the IVC has to be preserved for LDLT [34]. In addition, an element of institutional bias may lead to LDLT in HCC with a higher risk of recurrence.…”