Conversion to termino‐terminal cavo‐cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation

Orthotopic liver transplantation (OLT) is a well standardized therapeutic alternative in the management of irreversible hepatic diseases. The standard operative technique with the ‘en bloc’ hepatectomy along with the native retro hepatic vena cava (RHVC) originally described by Starzl [1,2] has been modified over the years to minimize risks and operative time and to introduce more flexible techniques. Particularly, the caval implant underwent gradual evolution through the introduction of several variants with the aim of developing a more flexible technique. The common feature among these techniques is the preservation of the recipient RHVC by its complete dissection during hepatectomy [3]. This approach allows anastomosis of the donor’s caval vein by three different methods of which the classic ‘piggyback’ (PB), described in the original series by Tzakis [4], has been adopted by many transplant surgeons because of several advantages when compared with the others [5–7]. However, one of the drawbacks of this technique is the potential for caval return occlusion by compression of the native infrahepatic caval vein with subsequent haemodynamic instability and high risk of RHVC thrombosis [8]. We retrospectively reviewed our experience in management of acute infrahepatic caval obstruction after classic PB OLT procedure performed in 89 adult cases out of 90 OLT, between 3/2004 and 7/2007. Two patients out of 89 PB procedures (2.4%) experienced in the postoperative course a haemodynamically significant obstruction of the preserved native retrohepatic caval vein as a result of its compression by the hepatic graft implanted in a piggyback fashion. Both cases presented with an associated ongoing intra-abdominal bleeding requiring urgent re-laparotomy. In one case, the patient’s stable condition allowed performing a computerized tomography scan with vascular reconstruction (angio-CT) before the operation (Fig. 1). In both cases, active bleeding was localized at the site of the inflamed pericaval tissue and retrohepatic native caval vein; this was also caused by the heavy compression exerted by the graft. Because of the impossibility in obtaining a satisfactory caval haemostasis and the significant compression of the vessel, it was decided to restore subhepatic venous outflow by using the graft infrahepatic caval vein. After complete dissection and isolation of the native infrahepatic caval vein, from the suprarenal tract to the native hepatic veins cuff, the caval segment was cut off by vascular stapler. The cul-de-sac of the donor infrahepatic caval vein was prepared by minimal dissection and end-to-end cavo-cavostomy between the native suprarenal caval vein and the donor infrahepatic caval vein was carried out, using running 3/0 Prolene suture for the back wall and single-stitches 3/0 Prolene suture for the front wall (Fig. 2). In both cases, haemostasis was easily achieved once the native RHVC was resected and caval flow was restored without signs of compression by the graft. The patency of the cavostomy and absence of turbulence were confirmed by Doppler ultrasound. The patients had an uneventful postoperative course and they are not experiencing caval Figure 1 Acute stenosis of the recipient vena cava as a result of its compression by the graft (line) and perihepatic haematomas caused by active bleeding (arrow) from native vena cava and retrohepatic surfaces.