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

BACKGROUND AND AIMS: The potential advantages of vena cava-preserving recipient hepatectomy in orthotopic liver transplantation are reduced hemorrhage, improved cardiovascular stability and preserved renal perfusion without the requirement of veno-venous bypass as compared with recipient hepatectomy including the vena cava. No detailed information is available on the use of veno-venous bypass during complicated vena cava preserving recipient hepatectomy and liver transplantation. In the present study, the peri- and postoperative courses of adult liver transplant recipients in whom the hepatovenous reconstruction was performed according to three different techniques with and without the use of veno-venous bypass were investigated. PATIENTS/METHODS: During primary orthotopic liver transplantation, an end-to-end (ETE) cavo-caval interposition of the donor vena cava to the recipient's vena cava was performed in 75 patients (group I). In 15 patients, a termino-terminal piggyback (PB) anastomosis was constructed to the remnant of the recipient's hepatic vein (group II), and in 72 transplantations a latero-lateral cavo-cavostomy (LLC) of donor-to-recipient's vena cava (group III) was performed. The use of bypass, operative time and cold ischemia time, perioperative blood product requirements, incidence of relaparotomy, the evolution of postoperative renal function, technical complications and the survival were analyzed and compared using multivariate statistics and actuarial techniques for statistical evaluation. RESULTS: No differences could be found in preoperative patient conditions, donor conditions, operating time, anastomosing time or cold ischemia time. In groups I-III, the veno-venous bypass was used in 50 (67%), 8 (53%) and 6 (8%) cases respectively (P=0.02 for group III). The mean preoperative packed cells requirements were 20.4 vs 29.6 vs 10.8 units (P=0.01 for group III), while postoperative blood product requirements (first 24 h) were 2.6 vs 5.0 vs 0.20 units of packed cells (P=0.02 for group III). Relaparotomy for diffuse retroperitoneal hemorrhage was performed 14 times (19%) in group I, 3 times (20%) in group II and 7 times (8.3%) in group III (P=0.002). The incidence of posteropative early renal dysfunction (increase of > or =1.3 mg% serum creatinine) in group I vs group II vs group III was 24% vs 60% vs 16.7% (P=0.001 for group II) for patients without the use of veno-venous bypass. No significant difference was observed concerning early renal dysfunction in patients where a veno-venous bypass was used. The survival at 12 months was 81% for group I, 86% for group II and 93.0% for group III. In group III there were four complications (P=0.03) at the hepatovenous anastomosis of which two were eventually fatal. CONCLUSION: 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.