Side-to-side caval anastomosis in liver transplantation

Abstract

Sir: We read with interest the report by Lerut and Gertsch regarding side-to-side cavo-cavostomy in complicated piggyback liver transplantation [2]. They describe a patient in whom the liver implantation piggyback method resulted in a severe stenosis of the recipient's inferior vena cava, a complication that, to the best of our knowledge, has not been reported before. The stenosis was corrected successfully by a side-to-side cavo-cavostomy. This observation prompted the authors to devise a technical modification of the piggyback procedure, and they concluded that the side-to-side cavocavostomy is a useful rescue aid in this situation. In our view, an alternative conclusion is that the side-to-side caval anastomosis may be recommended as the first choice procedure for caval reconstruction, as described recently by Belghiti et al. [1]. In addition to obviating the need for veno-venous bypass, this approach would reduce the indications of the piggyback technique, except in the situation where the recipient's inferior vena cava is agenetic or thrombosed up to the level of the hepatic veins. Our recent experience with 22 transplants using Belghiti's procedure, without morbidity or mortality related to the technique, strengthens this alternative conclusion.