To the Editor:

We have read with interest the article by Schmitz et al[1]from Berlin entitled "Different cava reconstruction techniques in liver transplantation:piggy-back versus cava resection",which has been recently published in Hepatobiliary and Pancreatic Diseases International.The aim of this monocentric retrospective study was to compare outcomes and complications of the classical cava reconstruction (CR) versus piggy-back (PB) technique for cavocaval anastomosis in adult orthotopic liver transplantation (OLT).Whereas Schmitz et al reported an important series of 414 patients who had OLT either by CR (n=238) or PB (n=176),it seems relevant to us that some outcomes of the present study be further discussed.First,in 2010 we also reported from the experience of Strasbourg an important series of 423 consecutive adult PB OLT using the 3-hepatic veins for cavocaval anastomosis[2]as well.Furthermore,a very similar modified PB using the 3-hepatic veins was also reported in 2011 by Tayar et al from Paris.[3]These reports are missing in the present article.Second,whereas there is demographic comparability of the patient groups between our two study,Schmitz et al experienced a venous out flow problem in 3/176 (1.7%) in the PB group mainly due to a kinking of the hepatic veins.In our series,complications related to the 3-hepatic vein PB anastomosis occurred in 8/396 patients (2.0%); among them 1 patient presented an acute Budd-Chiari syndrome that required retransplantation and 7 patients presented a stenosis of suprahepatic anastomosis.Every patient was treated with angiographic balloon dilatation,which allowed restoring definitely the normal out flow of the liver transplant and total recovery.Third,the complication rates following PB observed in our center are contradictory with the present study.With regard of the PB OLT complication rates,we reported an incidence of abdominal bleeding of 3.5%,14/396 patients (vs 14.8%,26/176 by Schmitz et al.); an incidence of biliary leaks of 3.3%,13/396 (vs 9.1%,16/176 by Schmitz et al.); a perioperative red blood cells transfusion of mean 3.2 units (vs 6.1 units by Schmitz et al.).According to our extensive experience with the 3-hepatic vein PB technique,we have shown that this modified PB procedure allows optimal venous drainage of the liver transplant in a rapid and a safe procedure (partial inferior vena cava clamping).Moreover,this approach guarantees a low rate of arterial or biliary complications and should be routinely considered in OLT.

Tullio Piardi and Martin Lhuaire

Department of General,Digestive and Endocrine Surgery,

H?pital Robert Debré,

Centre Hospitalier Universitaire de Reims,

Université de Reims Champagne-Ardenne,

Reims,France

Email:tpiardi@chu-reims.fr

1 Schmitz V,Schoening W,Jelkmann I,Globke B,Pascher A,Bahra M,et al.Different cava reconstruction techniques in liver transplantation:piggyback versus cava resection.Hepatobiliary Pancreat Dis Int 2014;13:242-249.

2 Audet M,Piardi T,Panaro F,Cag M,Habibeh H,Gheza F,et al.Four hundred and twenty-three consecutive adults piggyback liver transplantations with the three suprahepatic veins:was the portal systemic shunt required? J Gastroenterol Hepatol 2010;25:591-596.

3 Tayar C,Kluger MD,Laurent A,Cherqui D.Optimizing out flow in piggyback liver transplantation without caval occlusion:the three-vein technique.Liver Transpl 2011;17:88-92.