Feasibility of vena cava preservation during liver transplantation for polycystic liver disease

Liver Transplantation (LT) for Polycystic Liver disease (PLD) is indicated in case of massive hepatomegaly. Total hepatectomy with caval-preservation during LT for PLD is technically diffi cult because the liver often surrounds the inferior vena cava (IVC). The increasing use of partial grafts inspired our group to preserve the IVC. We report our experience of LT for PLD with the purpose to preserve the IVC in all cases. From 1992 to 2006, 20 patients underwent LT for PLD. There were 3 men and 17 women (mean age 51 years). Sixteen patients underwent LT associated with renal transplant. Previous treatments for PLD were performed in eight cases, including cysts fenestration in four and hepatic resection in four. In order to facilitate the IVC approach, the LT procedure included extensive cyst fenestrations and portocaval anastomosis in all cases; in two cases a partial hepatectomy was used for better control of IVC. Full grafts were used in 17 cases and partial grafts in 3, including 2 split grafts and one living donor. IVC preservation was possible in 18 patients (90%), including the 3 cases of partial graft transplantation. Failure to preserve the IVC occurred in 2 cases, one case of diffi cult dissection due to a previous liver resection and one case of intraoperative death from massive bleeding due to IVC injury. Total hepatectomy time ranged from 130 min to 420 min with a mean blood loss of 3364 ml and a blood transfusion rate of 8.9 U. Total IVC clamping during hepatectomy was required in 7 cases (35%), including 5 cases with poor hemodynamic tolerance. Veno-venous bypass was used in four cases: in these patients the IVC preservation was always possible and the IVC clamping was also well tolerated. Total hepatectomy duration and blood loss were signifi cantly higher in patients who had undergone previous liver resection respectively: 327±76.2 min vs 243±55.2 min (P=0.036) and 8000±2743cc vs 1050±1891cc (P=0.013). Postoperative mortality was of 15.8% (3 patients), all from septic complications (pulmonary, colonic perforation and multiorgan failure). IVC preservation was feasible in 90% of LT for PLD and could be facilitated by veno-venous bypass, extensive cyst fenestrations and partial liver resection. IVC preservation should be expected to be more diffi cult in case of previous hepatectomy.