Yilmaz Mehmet, Akbulut Sami, Yilmaz Sezai
Department of Surgery, Inonu University Faculty of Medicine, Division of Liver Transplantation, 44280 Malatya, Turkey.
Exp Clin Transplant. 2017 Apr;15(2). doi: 10.6002/ect.2012.0061. Epub 2012 Nov 21.
The aim of this study was to evaluate the incidence, possible risk factors, clinical presentation, and follow-up of patients with a gastrointestinal perforation after liver transplant.
We did a retrospective chart review of all patients who presented with a gastrointestinal perforation after liver transplant at our liver transplantation center between December 2009 and June 2011.
In total, we performed 271 liver transplants during this period. Nine patients (3.3%), 5 pediatric and 4 adult patients (median age, 21.3 ± 16.2 y; range, 1-55 y), developed a gastrointestinal perforation after liver transplant. Six of the patients had living donors, and 3 had deceased-donor transplants. Four patients underwent prior abdominal surgery for unrelated reasons. The mean time between liver transplant and diagnosis of the gastrointestinal perforation was 12.9 ± 9.3 days (range, 4-30 d), and the mean hospitalization length was 50 ± 29.3 days (range, 18-102 d). Perforations were located in the stomach (n = 1), jejunum (n = 3), ileum (n = 2), jejunum and ileum (n = 1), and colon (n = 2). Seven patients were managed by ostomies, and 2 by primary repair. Despite administration of proper antibiotic therapy and fluid resuscitation to all patients, 2 adults died of septic shock: 1 was caused by perforation and 1 was caused by anastomotic leakage after colostomy closure.
A gastrointestinal perforation after a liver transplant is a rare but mortal complication. Considering delayed wound healing owing to immunosuppression, potentially larger ischemic tissue around the perforation site owing to cautery burns and the atypical clinical course that may be further masked by bile leakage, ostomy treatment should be preferred to primary repair. A loop ostomy for small and large bowel perforations after the liver transplant decreases mortality and morbidity.
本研究旨在评估肝移植术后胃肠道穿孔患者的发生率、可能的危险因素、临床表现及随访情况。
我们对2009年12月至2011年6月期间在我院肝移植中心出现胃肠道穿孔的所有患者进行了回顾性病历审查。
在此期间，我们共进行了271例肝移植手术。9例患者（3.3%），5例儿童患者和4例成人患者（中位年龄21.3±16.2岁；范围1 - 55岁）在肝移植后发生了胃肠道穿孔。其中6例患者为活体供肝移植，3例为尸体供肝移植。4例患者曾因无关原因接受过腹部手术。肝移植至胃肠道穿孔诊断的平均时间为12.9±9.3天（范围4 - 30天），平均住院时间为50±29.3天（范围18 - 102天）。穿孔部位位于胃（1例）、空肠（3例）、回肠（2例）、空肠和回肠（1例）以及结肠（2例）。7例患者接受了造口术治疗，2例接受了一期修复。尽管对所有患者都给予了适当的抗生素治疗和液体复苏，但2例成年患者死于感染性休克：1例由穿孔引起，1例由结肠造口关闭后吻合口漏引起。
肝移植术后胃肠道穿孔是一种罕见但致命的并发症。考虑到免疫抑制导致伤口愈合延迟、烧灼伤导致穿孔部位周围潜在更大的缺血组织以及胆汁漏可能进一步掩盖的非典型临床过程，造口术治疗应优于一期修复。肝移植后小肠和大肠穿孔采用袢式造口术可降低死亡率和发病率。
