Rationale and technical constraints of a tertiary liver transplantation

Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n = 2) or hyperacute rejection (n = 1). Five patients had an elective third LT for ischemic cholangitis (n = 4) or chronic rejection (n = 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n = 1), "en bloc" clamping of both the infrahepatic vena cava and the hepatic pedicle (n = 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n = 5), and aortic resection with aortoaortic prosthetic reconstruction (n = 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n = 5) or intraperitoneal bleeding (n = 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity.