We have read with interest the article by Schmitz et al^[1] from Berlin entitled "Different cava reconstruction techniques in liver transplantation: piggy-back versus cava resection", which has been recently published in Hepatobiliary and Pancreatic Diseases International. The aim of this monocentric retrospective study was to compare outcomes and complications of the classical cava reconstruction (CR) versus piggy-back (PB) technique for cavocaval anastomosis in adult orthotopic liver transplantation (OLT). Whereas Schmitz et al reported an important series of 414 patients who had OLT either by CR (n=238) or PB (n=176), it seems relevant to us that some outcomes of the present study be further discussed. First, in 2010 we also reported from the experience of Strasbourg an important series of 423 consecutive adult PB OLT using the 3-hepatic veins for cavocaval anastomosis^[2] as well. Furthermore, a very similar modified PB using the 3-hepatic veins was also reported in 2011 by Tayar et al from Paris.^[3] These reports are missing in the present article. Second, whereas there is demographic comparability of the patient groups between our two study, Schmitz et al experienced a venous outflow problem in 3/176 (1.7%) in the PB group mainly due to a kinking of the hepatic veins. In our series, complications related to the 3-hepatic vein PB anastomosis occurred in 8/396 patients (2.0%); among them 1 patient presented an acute Budd-Chiari syndrome that required re-transplantation and 7 patients presented a stenosis of suprahepatic anastomosis. Every patient was treated with angiographic balloon dilatation, which allowed restoring definitely the normal outflow of the liver transplant and total recovery. Third, the complication rates following PB observed in our center are contradictory with the present study. With regard of the PB OLT complication rates, we reported an incidence of abdominal bleeding of 3.5%, 14/396 patients (vs 14.8%, 26/176 by Schmitz et al.); an incidence of biliary leaks of 3.3%, 13/396 (vs 9.1%, 16/176 by Schmitz et al.); a perioperative red blood cells transfusion of mean 3.2 units (vs 6.1 units by Schmitz et al.). According to our extensive experience with the 3-hepatic vein PB technique, we have shown that this modified PB procedure allows optimal venous drainage of the liver transplant in a rapid and a safe procedure (partial inferior vena cava clamping). Moreover, this approach guarantees a low rate of arterial or biliary complications and should be routinely considered in OLT.

 

 

 

 

1 Schmitz V, Schoening W, Jelkmann I, Globke B, Pascher A, Bahra M, et al. Different cava reconstruction techniques in liver transplantation: piggyback versus cava resection. Hepatobiliary Pancreat Dis Int 2014;13:242-249. PMID: 24919606

2 Audet M, Piardi T, Panaro F, Cag M, Habibeh H, Gheza F, et al. Four hundred and twenty-three consecutive adults piggy-back liver transplantations with the three suprahepatic veins: was the portal systemic shunt required? J Gastroenterol Hepatol 2010;25:591-596. PMID: 19968745

3 Tayar C, Kluger MD, Laurent A, Cherqui D. Optimizing outflow in piggyback liver transplantation without caval occlusion: the three-vein technique. Liver Transpl 2011;17:88-92. PMID: 21254349

 

(doi: 10.1016/S1499-3872(14)60317-9)

Published online September 25, 2014.

I have read with interest the comment on our manuscript^[1] on different outcomes following cava reconstruction in liver transplantation using either cava replacement or piggy-back technique.

 

Since its initial publication by Tsakis in 1989,^[2] the piggy-back technique has been variously modified. The probably most common approach used today is the side-to-side cavostomy first described by Belghiti et al in 1992.^[3] The concept of a 3-hepatic veins reconstruction for caval anastomosis as quoted by the authors seems also feasible especially in regard to the low range of venous outflow complications in this series. However, it also becomes apparent that this method can be a little bit more challenging especially in cases with a large caudate lobe. Also, all three veins have to be divided and combined to a common ositium, which may take more time and effort for preparation. The smaller final diameter of the anastomotic ostium (22-34 mm) and the additional risk of anastomotic twisting could contribute to venous outflow problems, which were however only seen in 2% of the patients reported. Thus, published data prove that this further modification has its value as another adaption of piggy-back reconstruction, but further studies are necessary to exactly prove the superiority over classical side-to-side cavo-cavostomy especially considering the fact that in classical piggy-back also none of our patients required the use of a temporary porto-caval shunt. Regarding the other aspects mentioned, first, the difference in biliary complications in our piggy-back group was probably not related to the type of caval reconstruction and second, requirements for intra-operative transfusions were also significantly lower in our piggy-back group.

 

With no doubt for the possible advantages of piggy-back over caval replacement (shorter anastomosis time, preservation of caval blood flow and avoidance of veno-venous bypass, better preservation of kidney function), differences in the success rate of different modifications of piggy-back are probably also highly influenced by each center's individual experience.

 

 

 

 

1 Schmitz V, Schoening W, Jelkmann I, Globke B, Pascher A, Bahra M, et al. Different cava reconstruction techniques in liver transplantation: piggyback versus cava resection. Hepatobiliary Pancreat Dis Int 2014;13:242-249. PMID: 24919606

2 Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989; 210:649-652. PMID: 2818033

3 Belghiti J, Panis Y, Sauvanet A, Gayet B, Fékété F. A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion. Surg Gynecol Obstet 1992;175:270-272. PMID: 1514163

 

(doi: 10.1016/S1499-3872(14)60318-0)

Published online September 25, 2014.