Side Biting vs Cross Clamping For Hepatic Venous-Caval Anastomosis in Living Donor Liver Transplantation.

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Piggyback technique has shown to potentially have a protective effect on renal function in whole liver deceased donor liver transplantation when compared to conventional caval cross clamping for venous reconstruction. We investigated if a similar protective effect on kidney function could be demonstrated in the live related liver donor scenario. Methods Retrospective analysis of prospectively collected data of transplants performed between December 2012 to December 2013 was performed. Right, middle and inferior hepatic veins were anastomosed to the inferior vena cava with the cava cross clamped in group A and using a side biting, partially occluding clamp in group B. Renal function was assessed by measurement of serum creatinine preoperatively and daily after transplant for the first 14 days and when indicated subsequently. Adequacy of venous outfolw was assessed by doppler ultrasound (US) performed daily for the first 5 days and when clinically indicated subsequently. Results 31 transplants were performed in this period. There were 16 patients in group A and 15 in group B. 14 (45%) patients had preoperative renal dysfunction, 8 in group A and 6 in group B. Patients in group B showed significantly greater renal dysfunction on days 2 and 3, (day 2: 1.55 vs 1.01, p=0.04, day 3: 1.57 vs 0.95, p= 0.49) as compared to patients in group A. This was true for absolute creatinine values as well as increase from the base line. When we looked at the subgroup with preoperative renal dysfunction, patients in group B showed greater renal dysfunction in the immediate post operative period. This was seen by an increase in absolute serum creatinine as well as an increase from baseline as compared to group A, even though it did not reach statistical significance (day 2: 1.48 vs 1.19, p=0.35 day 3: 1.49 vs 1.18, p=0.89). The warm ischemia time was higher in group B (Mean 48 minutes vs 39 minutes). There was no outflow obstruction in either group and both groups showed a similar pattern on doppler US. Conclusion Contrary to expectations, our study shows that use of side biting clamps for outflow reconstruction in living donor liver transplantation has a detrimental effect on renal function.