Outcome of bowel perforation after pediatric liver transplantation

Abstract

Bowel perforation is one of the causes of mortality after pediatric liver transplantation. The aim of this study was to evaluate the incidence, risk factors, clinical presentations, and outcomes of bowel perforation in pediatric liver recipients. This is a retrospective analysis of all pediatric patients who underwent liver transplantation at a single liver transplant center in Iran between 1999 and 2006. During this period 72 liver transplantations were performed in children <18 yr. Twenty-two children underwent 33 re-explorations after liver transplantation. Five bowel perforations occurred in four children (incidence, 6.9%). One patient required two re-explorations. The median time between liver transplantation and the diagnosis of the bowel perforation was seven days. All patients had abdominal distention before re-exploration. The sites of perforation were jejunum (n = 3) and ileum (n = 2), and simple repair was performed in all cases. Three children had a history of prior Kasai operation. One of them received high dose of methylprednisolone before bowel perforation. Two children expired after bowel perforation (mortality rate, 50%). Bowel perforation is relatively frequent after pediatric liver transplantation. Among risk factors, prior Kasai operation may have a role. We observed that abdominal distention is a sign of bowel perforation and a high index of suspicion is required for rapidly diagnosis of this complication. The outcome of bowel perforation is poor and its mortality is high. Further studies are needed to establish real risk factors for this complication.

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“…Further, 115 (95%) of the 121 perforation cases were pediatric, whereas the remaining 6 were adult cases. [1][2][3][4][8][9][10][11][12] We documented that most of the pediatric GIP cases were patients who had undergone a portoenterostomy owing to biliary atresia. Thus, a portoenterostomy procedure performed before LT in children appears to be a serious risk factor.…”

“…2,3 However, complications can still occur after LT. Gastrointestinal perforation after LT is a cause of surgical morbidity, and a delayed diagnosis may create a life-threatening situation. The cause of GIP after LT is unclear, but contributing factors include previous abdominal surgery (particularly the Kasai procedure for biliary atresia in children), serosal injury or devascularization of the bowel wall, prolonged LT procedure, retransplant, transfusions, posttransplant intra-abdominal bleeding requiring reoperation, early portal vein thrombosis, high-dose steroid therapy, poor nutritional status, and CMV infection.…”

“…The cause of GIP after LT is unclear, but contributing factors include previous abdominal surgery (particularly the Kasai procedure for biliary atresia in children), serosal injury or devascularization of the bowel wall, prolonged LT procedure, retransplant, transfusions, posttransplant intra-abdominal bleeding requiring reoperation, early portal vein thrombosis, high-dose steroid therapy, poor nutritional status, and CMV infection. [2][3][4][9][10][11] The incidence of GIP after LT is 1% to 5.3% in adults and 8.3% to 14% in children. 1, 3, 4, 9-11 The higher incidence in children is most likely attributable to tight adhesions of the liver and formation of intestinal loops during portoenterostomy before LT.…”

“…1 The cause of GIP after LT is unclear; possible risk factors include previous laparotomy, prolonged surgery, subsequent laparotomy, portal vein thromboembolism, treatment with high-dose steroids, and cytomegalovirus (CMV) infection. [2][3][4] Here, we report the results of GIP after LT in adult and pediatric patients and analyze the associated risk factors, with specific emphasis on ostomies.…”

“…Given that the liver is highly susceptible to iatrogenic injury during transplant, circulatory dysfunction may occur upon portal clamping, and damage to the gastrointestinal mucosal barrier can be induced by high-dose steroids, posttransplant complications are observed most commonly in gastrointestinal organs. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] Gastrointestinal complications are common among patients who undergo solid-organ transplant and range from mild to moderate conditions, such as diarrhea or nausea, to more severe, life-threatening complications such as digestive bleeding and gut perforation. 5 Gastrointestinal perforation (GIP), which is potentially lethal, may occur at any point in the gastrointestinal tract, including the stomach, jejunum, ileum, and colon.…”