Back table procedure for the modified piggyback technique of liver transplantation: a simple test to identify caval...

In October 2001, we elected to change from the standard orthotopic liver transplantation procedure to the modified piggyback technique with side-to-side cavo-cavostomy, and to document complications such as caval leaks prospectively. Failure to identify and ligate caval tributaries during bench preparation of liver allografts results in troublesome hemorrhage after reperfusion. After our experience with the first 30 piggybacks, we introduced a simple leak test to resolve this problem.

The leak test consists of inflating the inferior vena cava with preservation solution via the infrahepatic inferior vena cava after closure of the suprahepatic inferior vena cava at the end of the bench procedure. Between October 2001 and July 2002, 112 whole liver transplants were performed in 108 adults. Standard orthotopic liver transplantation (group 1) was performed in 25, modified piggyback without leak test (group 2) was performed in 30, and modified piggyback after leak test (group 3) was performed in 57 patients. The incidence of caval leaks before and after introduction of the test was compared using the chi-square test.

Nine patients in group 1 (36%) and 13 in group 2 (43%) required additional sutures to control bleeding from caval branches after reperfusion. In group 3, the leak test identified caval tributaries that required ligation in 20 livers (35%) before implantation; none bled after reperfusion. Of the 37 cases with negative leak test results, 3 (8%) subsequently bled from missed caval branches. Sensitivity, specificity, and accuracy for the leak test were 100%, 92.1%, and 94.7% respectively.

Nearly all small branches of the inferior vena cava can be successfully identified during the back table procedure by performing a leak test.