Arch Surg 1993 Sep;128(9):994-8; discussion 998-9

Diagnosis and treatment of bowel perforation following pediatric orthotopi
liver transplantation

Shaked A, Vargas J, Csete ME, Kiai K, Jurim O, Colquhoun S, McDiarmid SV, Ament
ME, Busuttil RW
Department of Surgery, University of California, Los Angeles.

Abstract
OBJECTIVE: Bowel perforation is a frequent cause of mortality after pediatric
orthotopic liver transplantation. The aims of this study were to identify the
cause of this phenomenon and to examine current methods of treatment. DESIGN:
This is a retrospective analysis of 246 pediatric patients who underwent
orthotopic liver transplantation at a large, urban, tertiary care medical center
between 1984 and 1992. We examined the frequency of bowel perforations after
transplantation and identified predisposing factors and signs. In this series,
bowel perforations occurred in 24 of 246 recipients and were common in those who
had previous liver-related surgery (22 patients). Clinical signs included fever
(13 patients), leukocytosis (14 patients), and free air on abdominal
roentgenograms (11 patients). RESULTS: Perforation occurred at the Roux-en-Y
limb in 15 of 24 recipients as well as in the right transverse colon (five
patients), terminal ileum (three patients), and duodenum (one patient). The
repair was resection and/or primary closure (18 patients), or diversion (six
patients). Recurrent perforations (nine patients) could not be attributed to the
method of the repair. Perforation-related sepsis was the primary cause of death
in 12 patients (50%) and was more common among patients who developed recurrent
perforation (seven [78%] of nine patients). CONCLUSIONS: The occurrence and
location of bowel perforation after pediatric orthotopic liver transplantation
suggests that the cause is related to bowel injury during difficult hepatectomy.
Mortality may be reduced by early second-look operations in high-risk patients