To the Editor:
We appreciate the interest of Mizuno et al  in our recent article regarding heterotopic implantation of a left liver graft in the right abdominal cavity, which we termed as “Left at Right” liver transplantation (LAR-LT) . The authors had applied this procedure using a left liver graft in living donor liver transplantation in three patients, and confirmed that the LAR-LT is a relatively easier approach for performing implantation of the left liver graft. However, in the authors' study, all the recipients encountered stenosis of the inferior vena cava (IVC) that required stent placement to maintain patency of the graft's venous outflow. In fact, none of the LAR-LT recipients in our study had any vascular complications including portal inflow, venous outflow or IVC stenosis similar to that reported in the patients in Dr. Mizuno's study. The LAR-LT recipient who suffered from massive ascites might have been due to severe bacterial infection that led to graft dysfunction and hyperbilirubinemia, as we previously described in the article .
Although the left liver graft with the caudate lobe in order to increase the graft volume is proposed by numerous transplantation centers [3-5], we rarely include the caudate lobe in the left liver graft for LT. The left liver grafts were used only if the desired graft size could be obtained, and it seems unnecessary to include the caudate lobe with the left liver graft in terms of technical issue and graft function. However, we agree with the author's observation that the IVC might have been compressed by the enlarged liver parenchyma of the caudate lobe. We also noticed that in the authors' study, the recipient's hepatic vein between the liver graft and the IVC was relative longer than that observed in the case of our patients; we speculate that it could have led to venous outflow stretched and distorted by the growing liver graft.
Technically, we believe that while performing LAR-LT, the length of the hepatic vein between the graft and the IVC, as well as the position of the graft, is very important. As specifically described in our previous study, the graft's hepatic vein is cut at the edge of the liver parenchyma during donor hepatectomy and it is then directly anastomosed to the recipient's IVC during graft implantation (Figure 1A) . With the use of this technique for reconstruction of the graft's venous outflow, redundancy of the hepatic vein between the liver graft and the IVC could be avoided, suggesting that the risk of outflow complications resulting from distortion and stretching of the redundant hepatic vein during growth of the liver graft might also be decreased.
Additionally, in LAR-LT, we observed that all liver grafts could be stably placed in the right subphrenic space without the need of a tissue expander to hold the liver graft. Consequently, the left liver graft could grow anteriorly and posteriorly to fit well into the right abdominal cavity without distortion of venous outflow (Figure 1B). Therefore, it is worth recommending that LAR-LT could be safely applied as a feasible alternative in implantation of a left liver graft because of its easier reconstruction technique and satisfactory outcome, considering that all the concerns mentioned here are addressed.
K.-M. Chan and W.-C. Lee*
Chang Gung Transplantation Institute, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
* Corresponding author: Wei-Chen Lee, firstname.lastname@example.org
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.