The evolution of caval implantation in liver transplantation.

Conventional orthotopic liver transplantation (CON-LT) involves resection of recipient cava, usually with extra-corporeal circulation (veno-venous bypass, VVB), while in the piggyback technique (PC-LT) the cava is preserved. Along with a temporary portacaval shunt (TPCS), better haemodynamic maintenance is purported with PC-LT. A prospective, consecutive series of 384 primary transplants (2000-2003) were analysed, 138 CON-LT (with VVB) and 246 PC-LT (54 without TPCS). Patient/donor characteristics were similar in the two groups. PC-LT required less usage of fresh-frozen plasma and platelets, intensive care stay, number of patients requiring ventilation after day 1 and total days spent on ventilator. The results were not different when comparing, total operating and warm ischaemia time (WIT), red cell usage, requirement for renal support, day 3 serum creatinine and total hospital stay. TPCS had no impact on outcome other than WIT (P = 0.02). Three patients in PC-LT group (three of 246; 1.2%) developed caval outflow obstruction (P = 0.02). There was no difference in short- or long-term graft or patient survival. PC-LT has an advantage over CON-LT using VVB with respect to intraoperative blood product usage, postoperative ventilation requirement and ITU stay. VVB is no longer required and TPCS may be used selectively in adult transplantation. (Transpl Int 2006;19:795-801.)