To the Editor:
We read with great interest the paper by Chan et al  reporting “left at right” adult liver transplantation (LAR-LT): the feasibility of heterotopic implantation of left liver (LL) graft. The authors reported that this new procedure enables the anastomosis of portal vein, hepatic vein, hepatic artery and biliary duct to be performed smoothly without any tension. We applied this procedure for the consecutive three recipients using LL graft plus caudate lobe (CL). Actually, every anastomosis was easy to perform; however, all of them needed to undergo stent placement for the stenosis of the inferior vena cava (IVC) cranial to the anastomosis of hepatic vein.
Case: Sixty-four-year-old male underwent LAR-LT for hepatitis B with hepatocellular carcinoma (HCC). His graft recipient weight ratio (GRWR) was 0.74, and the model for end-stage liver disease (MELD) score was 11. On postoperative day (POD) 11, the ascetic fluid volume increased up to more than 2500 mL, and a Doppler ultrasound examination revealed flat waveforms and slightly low flow velocities in hepatic vein. A CT scan showed compression and stretch of the IVC by the regenerated grafted liver parenchyma (Figure 1A and B). The hepatic venograph showed no evidence of stenosis, but IVC stenosis was visualized cranial to the anastomosis of hepatic vein by venacavography and there was a pressure gradient of 13 mmHg (Figure 1C). A 30-mm-diameter, 5-cm-long Cook-Z stent (Cook, Bloomington, IN) was placed at the stenosis of the IVC according to our previous report , and the pressure gradient immediately decreased to 1 mmHg (Figure 1D). After stent placement, the daily ascitic fluid volume rapidly decreased and he was discharged on POD 46. The other two recipients (67-year-old female, liver cirrhosis with HCC, GRWR: 0.47, MELD score: 14; and 69-year-old female, primary biliary cirrhosis, GRWR: 0.87, MELD score: 11) also needed to undergo stent placement for the stenosis of the IVC on POD 65 and 11, respectively. However, all of three recipients experienced no complications regarding the anastomoses of portal vein, hepatic vein, hepatic artery and biliary duct, and they have been well 11, 10 and 7 months after LAR-LT, respectively.
In living donor liver transplantation (LDLT) for adult patients, using the LL graft is thought to be first choice because of the donor safety, and LL graft plus LC is used often to increase the volume of an LL graft [3, 4]. Although the CL seems not to be included in the “original” LAR-LT, we used the LL graft plus LC for LAR-LT to prevent small-for-size graft syndrome, resulting in the stenosis of the IVC in all cases. The reason of this phenomenon might be that the enlarged grafted liver parenchyma compressed the IVC directly and also shifted the portion of the anastomosis between the hepatic vein and IVC toward the right side, resulting in the stretch of the IVC. According to the Chan's report, 1 out of 10 LAR-LT cases suffered from massive ascites  and this case might suffer from the IVC stenosis similar to our cases.
LAR-LT seems to be a feasible alternative to LL graft liver transplantation; however, the stenosis of the IVC should be considered in case of the massive ascites, especially when using the LL graft plus LC.
S. Mizuno1,*, K. Yamakado2, A. Tanemura1, N. Kuriyama1, M. Kishiwada1, H. Sakuma2 and S. Isaji1
1 Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
2 Department of Radiology, Mie University School of Medicine, Tsu, Mie, Japan
* Corresponding author: Shugo Mizuno, firstname.lastname@example.org
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.