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Published on: August 20, 2007
Small bowel obstruction after pediatric liver transplantation: the unusual is the usual
Truman M Earl1, Jason R Wellen, Christopher D Anderson
1Department of Surgery, Washington University in St Louis, St Louis Children's Hospital, MO 63110, USA.
Insights
Unusual causes like diaphragmatic hernia and post-transplantation lymphoproliferative disorder (PTLD) are common in pediatric liver transplant recipients experiencing intestinal obstruction. Early surgical intervention is recommended for these rare but serious complications.
Area of Science:
- Pediatric Surgery
- Hepatology
- Transplantation Medicine
Background:
- Intestinal obstruction is a rare but serious complication following liver transplantation in children.
- Unlike adult cases where adhesions are common, pediatric liver transplant recipients may experience obstruction due to less common causes.
Observation:
- A review of pediatric liver allograft recipients from 1990-2009 identified 7 patients requiring reoperation for intestinal obstruction.
- None of the obstructions were due to adhesions; causes included diaphragmatic hernia (4 patients) and post-transplantation lymphoproliferative disorder (PTLD) (3 patients).
Findings:
- Diaphragmatic hernia presented earlier post-transplantation (mean 4.2 months) compared to PTLD (mean 59.3 months).
- PTLD presented as an obstructing mass or intussusception.
- Six of the seven patients survived with a median follow-up of 5.8 years.
Implications:
- Pediatric liver transplant recipients with intestinal obstruction often have unusual etiologies, necessitating a high index of suspicion.
- Early surgical intervention is crucial as conditions like diaphragmatic hernia and PTLD are unlikely to resolve with conservative management.
Background:
Intestinal obstruction is a rare but serious complication after liver transplantation. Adhesions are the most common cause of obstruction in the nontransplantation setting; however, after pediatric liver transplantation unusual causes must be considered.
Study Design:
A prospectively maintained institutional database was analyzed for all reoperations for intestinal obstruction on pediatric liver allograft recipients from 1990 to 2009.
Results:
During the study period, 181 pediatric patients underwent liver transplantation at the study center. The most common indication for transplantation was biliary atresia. Seven patients required reoperation for intestinal obstruction. All 7 patients had abdominal operations before transplantation and 5 of 7 received reduced-size grafts. No patients had adhesive small bowel obstruction. The cause was right-sided diaphragmatic hernia in 4 and post-transplantation lymphoproliferative disorder (PTLD) in 3. Diaphragmatic hernia was demonstrated by chest radiograph in 3 of 4 patients. The fourth was taken to surgery with a presumptive diagnosis of intestinal obstruction and a diaphragmatic hernia was found at exploration. In patients with PTLD causing obstruction, 2 presented with an obstructing mass and the third presented with intussusception. Mean time to reoperation was 29 months after liver transplantation. Patients with diaphragmatic hernia presented earlier post-transplantation than those with PTLD (4.2 ± 2.4 months versus 59.3 ± 54.6 months, respectively; p = 0.0003, Fisher's exact test). Six patients are alive at a median follow-up of 5.8 years. One patient succumbed to recurrent B-cell lymphoma.
Conclusions:
Intestinal obstruction after pediatric liver transplantation is commonly related to what would conventionally be considered unusual causes. A high index of suspicion must be maintained and early operative therapy considered as obstruction because causes such as diaphragmatic hernia and PTLD are unlikely to resolve with conservative measures.
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