Small bowel obstruction post-living liver transplantation.

Abstract

A 59-year-old male patient with history of alcoholic cirrhosis with a MELD of 14 underwent right lobe living donor liver transplantation 4 years previously. The graft weighed 1000 g and had a single right portal vein and a single right hepatic artery that were anastomosed in an end-to-end fashion to the recipient’s right portal vein and right hepatic artery, respectively. The right anterior and right posterior bile ducts separated by >1 cm were joined together and anastomosed in an end-to-end fashion to the recipient common hepatic duct. The donor right hepatic vein was anastomosed to the orifice of the right hepatic vein and a reconstructed polytetrafluoroethylene (PTFE) graft draining the anterior sector was anastomosed to the middle hepatic vein orifice. His postoperative course was complicated by a bile leak that failed initial management with endoscopic retrograde cholangiopancreatography (ERCP) and stenting and eventually required creation of a roux en Y hepaticojejunostomy to the two separate ducts on postoperative day 23. He recovered well and was discharged to rehab. He presented a year later with a partial small bowel obstruction secondary to an incisional hernia that was initially managed conservatively and electively repaired with a mesh. He presented 4 years after transplantation with abdominal pain, nausea, and vomiting. His physical exam was significant for diffuse abdominal distension and a reducible recurrent incisional hernia. His laboratory work was notable for a mildly elevated bilirubin (3 mg/dL) and alkaline phosphatase (801 units/L). He underwent a CT scan of the abdomen and pelvis showing a small bowel obstruction (Figures 1 and 2).FIGURE 2Computed tomography of the pelvis on admissionView Large Image Figure ViewerDownload Hi-res image Download (PPT) 1What is the most likely etiology of the small bowel obstruction in this case?aAdhesive small bowel obstructionbFecal impactioncIncarcerated incisional herniadInternal herniaeIntraluminal obstruction2What is the optimal management for this patient?aExploratory laparotomy with lysis of adhesionsbExploratory laparotomy with repair of the incisional herniacExploratory laparotomy with reduction of the internal herniadExploratory laparotomy with small bowel resectioneNothing by mouth, hydration, and nasogastric decompression3Which of the following factors predisposed the patient to develop this complication?aBiliary leak and subsequent interventionsbEtiology of liver diseasecHernia repairdRejectioneUndiagnosed Crohn’s disease4What is the advantage of optimizing the venous outflow of a partial liver graft?aDecrease the risk of bile leakbDecrease the risk of graft rejectioncDecrease the risk of portal vein thrombosisdDecrease the risk of small for size syndromeeDecrease the warm ischemic time5Which of the following could potentially decrease the incidence of this complication?aAutogenous hepatic vein reconstructionbMicrovascular arterial anastomosiscPlacing drainsdPortal vein interposition grafteUsing a smaller liver graft