"Intrapericardial Approach" for Venous Outflow Reconstruction in Living-Donor Liver Transplantation for Budd-Chiari Syndrome: Surgical Techniques and LongTerm Outcomes.

Unlike deceased-donor liver transplantation, living-donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS) presents distinctive challenges in hepatic venous (HV)-outflow reconstruction because diseased HV-inferior vena cava (IVC) cannot be entirely replaced with healthy donor vessels. In the Asia-Pacific region, where LDLT predominates, BCS frequently involves the hepatic IVC, thus requiring innovative surgical strategies for HV-IVC reconstruction. Here we introduce a novel series of surgical technique-"intrapericardial approach (IPA)"-which reconstructs HV-outflow tract in the pericardium using only healthy vascular tissues, thereby minimizing post-transplant BCS recurrence. Detailed procedures are illustrated for four typical LDLT scenarios, classified by graft-type (left- or right-lobe) and by the need for IVC reconstruction (acute or chronic BCS). A representative surgical video is also provided. Of our 2089 consecutive liver transplants, 20 patients underwent LDLT for BCS: 10 with conventional IVC-preserving techniques (cavoplasty and/or patch-plasty) and 10 using IPA. Across all four clinical scenarios aforementioned, the key concept of IPA-creating new HV-outflow with only healthy vessels-was consistently applicable. IPA was associated with significantly lower post-transplant BCS recurrence (p = 0.04) and improved both relapse-free and overall recipient survival (p = 0.02 and 0.03, respectively) compared to conventional techniques, yielding 100% graft and patient survival through 10 years. This report also highlights key considerations and pitfalls for pre-, intra-, and post-transplant management in BCS-LDLT. In conclusion, IPA appears to be associated with reduced post-transplant BCS recurrence and favorable short- and long-term outcomes, offering a novel practical solution for challenging HV-IVC reconstruction in BCS-LDLT.