H. Vilca Melendez P. Muiesan P. Andreani G. Mieli-Vergani M. Rela N. D. Heaton v. Vougas zyxwvutsrqp Received: 8 December I997 Received after revision: 17 February 1998 Accepted: 2 March 1998 H. Vilca Melendez zyxwvutsrqpo . V. Vougas P. Muiesan . P. Andreani . M. Rela N.D. Heaton (B) Liver Transplant Surgical Service, King’s College Hospital, Denmark Hill, London SE5 9RS, UK Fax: + 44 171 346 3575 zyxwvutsrq e-mail:hector.vilca-melendez@kcl.ac.uk G. Mieli-Vergani Department of Child Health, King’s College Hospital, Denmark Hill, London SES 9RS. UK zyxwvutsrqp Bowel perforation after paediatric orthotopic liver transplantation Abstract Bowel perforation is a Key words Liver transplantation, well-recognized complication fol- lowing orthotopic liver transplanta- tion. Of 194 paediatric liver trans- plantations performed in our hospi- tal, 13 patients (6.7 zyxwvut YO) developed bowel perforation post-transplanta- tion. Contributory factors included previous operation, steroid therapy and viral infection. The incidence was higher in children who under- went transplantation for biliary atresia after a previous Kasai por- toenterostomy. Seven patients (53 Yo of this group) reperforated. Diagno- sis may be difficult and a high index of suspicion is needed. intestinal perforation . Intestinal perforation, liver transplantation Introduction Bowel perforation following orthotopic liver transplan- tation (OLT) is a cause of surgical morbidity and, if the diagnosis is delayed, may become life-threatening [9]. Contributing factors include previous surgery [8, 9, 111, steroid therapy [7], cytomegalovirus (CMV) infection [5, 6, 101, prolonged portal venous crossclamp time [8, 91 and poor nutritional status [8]. Perforations may oc- cur early or late. Early perforations are related either to anastomotic leak or to perforation of areas of denu- ded submucosa and diathermy injury. Late perforations are observed foliowing regression of lymphoprolifera- tive disease [LPD) [3]. Children who undergo transplan- tation for biliary atresia appear to be particularly at risk [8, 91. We report our experience of bowel perforation following paediatric liver transplantation and review the literature. Materials and methods From October 1989 to January 1996,194 paediatric liver transplan- tations were performed at King’s College Hospital. Thirteen pa- tients (6.7 %) developed bowel perforation post-transplantation (Table 1). There were eight girls and five boys with a median age of 1.1 year (range 1 month to 12 years) and a median weight of 10.8 kg (range 3-58 kg). The underlying liver disease was biliary atresia in ten patients, acute hepatic failure due to Non-A Non-B hepatitis in two and Langerhans’ cell histiocytosis in one. All re- ceived cadaveric grafts except for one (case 7) who underwent liv- ing related liver transplantation (LRLT). Venovenous bypass was not used. Biliary drainage was re-established with hepatico-jejun- ostomy. Immunosuppression was achieved with cyclosporin A (5-10 mg/kg), azathioprine (I mg/kg) and steroids (1 mg/kg and gradually tapered), except for one patient (case 8) who was con- verted to tacrolimus for intractable acute rejection unresponsive to steroid therapy. Data was collected from our surgical database and medical notes. Values are expressed as median, using the descriptive statis- tics of Microsoft Excel Analysis ToolPak (GreyMatter Interna- tional, Cambridge, Mass., USA).