Piggyback technique and selective use of veno-venous bypass in adult orthotopic liver transplantation

Background. The piggyback technique (PT), with preservation of the cava, is being used more frequently in adult orthotopic liver transplantation (OLT) . The advantages of PT include hemodynamic stability during the anhepatic p hase without a large-volume fluid infusion and obviating the need for veno- venous bypass (VVB). At our center, we changed our practice in July 1997 fr om the standard technique (ST) of OLT with routine use of VVB to PT and sel ective use of VVB. The purpose of the present study was to analyze the resu lts with the two different practices, ST-routine VVB versus PT-selective VV B. Methods. Forty OLTs were performed during the period July 1995-July 1997 us ing ST-routine VVB (group I) and 36 during August 1997-December 1998 using PT-selective VVB (group II). The etiology of liver disease was similar in t he two groups, with hepatitis C and alcoholic liver disease accounting for half of the patients in each group. The UNOS status, age, sex, and percenta ge of patients with previous upper abdominal surgery were also similar betw een the two groups. Results. In the PT-selective VVB era (group II), 34/36 patients (94%) under went OLT with PT and VVB was used for 8 (22%) patients. The decision to use VVB was elective for 3 patients (fulminant hepatic failure, 2; severe port al hypertension, 1) and urgent for 5 patients (hemodynamic instability duri ng hepatectomy). The intraoperative use of packed red blood cells (PRBC) (m ean +/- SD) was 15 +/- 12 units for group I and 9 +/- 8 units for group II (p = 0.023). Anastomosis time and total operating time (mean +/- SD) were 9 1 +/- 30 min and 9.5 +/- 3.2 h, respectively, for group I patients compared with 52 +/- 28 min and 7.6 +/- 1.6 h, respectively, for group II patients (p < 0.0001 and 0.002, respectively). Median post-operative stays in the in tensive care unit (ICU) and in the hospital were 5 and 17 d, respectively, for group I and 4 and 11 d, respectively, for group II (p = NS). Mean serum creatinine on day 3 was similar in the two groups. Median hospital charges for group I patients were $105 439 compared with S91 779 for group II pati ents (p = NS). The 1-year actuarial graft and patient survival rates were 7 8% and 82%, respectively, for group I, and 92% and 95%, respectively, for g roup II. Conclusions. PT is safe and can be performed in the majority of adult patie nts (> 90%) undergoing OLT. With the routine application of the piggyback p rocedure, the use of VVB has been reduced to 20% of OLTs at our center. The practice of piggyback technique with the selective use of VVB is associate d with shorter anhepatic phase and total operating time, lower blood produc t use, a trend towards shorter hospital length of stay, and reduced hospita l charges compared with standard technique of OLT with routine use of VVB.