ALIMENTARY TRACT PERFORATION AFTER LIVER TRANSPLANTATION IN CHILDREN.

Abstract

A229 Alimentary tract perforation is well-recognized devastating entity that complicates up to 20 % of pediatric liver transplantation (LTx). Aims of the study are to assess the incidence, risk factors, treatment and outcome of alimentary tract perforation after pediatric LTx. Methods: 198 LTx in 182 patients were performed since 1990 to 2003 in our institution. There were 46 living related LTx, nine combined liver and kidney, and one liver and bowel transplantation. Patients older than 18 years old, and those who died before one month after LTx were excluded from further analysis. Children were classified into two groups: with (group I – 10) and without perforation (group II – 146). Age, body weight, UNOS status, previous surgery, duration of hepatectomy and unhepatic phase, blood transfusion during transplantation were retrospectively analyzed. The incidence of portal vein thrombosis, bacterial, fungal, and CMV infections, intensive steroid therapy because of acute rejection were assessed during the first posttransplant month. Results were statistically analyzed using Mann-Whitney, chi2, and t- test. Results: Alimentary tract perforations were diagnosed in 10 children (6,4%), including two who reperforated. Age of patients was between 7 months and 17 years. Indication for LTx in 8 children was biliary atresia, liver fibrosis - 1, cirrhosis of unknown etiology - 1. In three children perforations occurred after retransplantation. The interval between transplantation and perforation was from 6 to 22 days. Perforations were localized in: colon - 6 cases, jejunum - 5, duodenum - 3, stomach – 1. Two children developed recurrent perforations, one of them multifocal. The surgery of perforations consisted of: simple suture in 13 cases, resection and primary anastomosis – 1, ileostomy - 1. One patient died on 5th day after perforation and on 20th day after retransplantation due to multiorgan failure. The follow up of remaining nine patients is between 4 and 147 months. The incidence of perforation was higher (p < 0.05) after pretransplant laparotomy (especially Kasai procedure), and after retransplantation. Patients who perforated required more blood transfusions during LTx (p < 0.05). Between LTx and alimentary tract perforation they developed more frequently (p < 0.05) sever bacterial bowel infections in comparison to non-perforated group. There was no significant differences regarding: age, body weight, UNOS status, portal vein thrombosis, intensive steroid therapy, fungal infection, bacterial sepsis and CMV infection. The duration of hepatectomy and unhepatic phase were longer (not significantly) in the group of alimentary tract perforation. Conclusions: Alimentary tract perforations after pediatric LTx are related to pretransplant surgery (especially Kasai procedure), retransplantation, greater blood transfusions during LTx, and severe bacterial postransplant bowel infections. The mortality of alimentary tract perforation after pediatric LTx is low.