A 40-year-old male with primary sclerosing cholangitis and a previous history of colectomy with j-pouch for ulcerative colitis was listed for cadaveric liver transplant with a MELD of 33. During his preoperative work-up he was found to have complete PVT. He did not appear to have any enlarged venous collateral that could be used to reconstruct the portal system during transplant. Therefore, our team was prepared to perform a CPH if needed [1
The patient was taken to surgery after a 16-year-old cadaveric liver was procured for him. The hepatectomy was difficult secondary to adhesions from both his inflamed liver, percutaneous biliary tubes, as well as his prior surgeries. The dissection was carried out with standard piggyback technique dissecting the liver off the vena cava to the level of the hepatic veins [3
]. Thus, the vena cava was easily accessible distally to the level of the renal veins. No portal vein was found, and attempts to find suitable venous collaterals were unsuccessful.
At this point there was no other option to reconstruct the portal system except to perform a CPH. Because we had prepared the vena cava of the recipient during the hepatectomy, it was easily ligated below the hepatic vein—supracaval anastomosis allowing for maximal caval length. The donor portal vein was then anastomosed to the suprarenal vena cava in an end-to-end fashion (). Reperfusion proceeded without complication. Arterial flow was then re-established, and the biliary system was reconstructed with a choledochoduodenostomy [4
Ultrasonography documenting excellent flow through the cavoportal hemitransposition anastomosis (see arrow).
The patient had an uncomplicated postoperative course. His liver function normalized within the first week, and he has never had rejection with a 12 month followup. He did not experience any ascites, peripheral extremity edema, or renal insufficiency. Furthermore, he had return of bowel function similar to his preoperative j-pouch function. Both a postoperative ultrasonography and CT-venogram documented excellent flow through the portal vein (Figures and ).
CT venogram showing cavoportal hemitransposition with the donor liver anastomosed to the recipient vena in the piggyback fashion (see arrow).