GASTROINTESTINAL PERFORATION AFTER PEDIATRIC ORTHOTOPIC LIVER-TRANSPLANTATION

Purpose: The aim of this review was to determine the incidence of gast rointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earl ier diagnosis. Methods: A retrospective chart review of all children w ho presented with gastrointestinal perforation after liver transplanta tion at our institution between January 1, 1987 and August 1, 1996 was performed. Results: One hundred fifty-seven orthotopic liver transpla nts were performed in 128 children. Fifty-eight reexplorations, exclud ing those for retransplantation, were performed in 38 children. Ten pe rforations occurred in six children (incidence, 6.4%). Two children re quired multiple reexplorations because of several episodes of perforat ion. The sites of perforation were duodenum (n = 1), jejunum (n = 8), and ileum (n = 1). A single-layer closure was used to repair five perf orations, two-layer closures in four, and resection with primary anast omosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months ol d. Four children had undergone prior laparotomy. All children had chol edochoenteric anastomoses, but only one had a perforation associated w ith it. One child sustained bower injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their per foration, and none had been dosed with pulse steroids for rejection. A ll of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the re st of the children. Abdominal radiographs demonstrated pneumoperitoneu m in only one child. All children had positive culture findings from t heir abdominal drains. Cytomegalovirus developed in one child. Althoug h the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and sign ificant alterations in temperature and leukocyte counts suggest its pr esence. Pneumoperitoneum is rarely present. Conclusion: A high index o f suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this p otentially devastating complication of liver transplant. Copyright (C) 1998 by W.B. Saunders Company.