Commonly Encountered Problems After Transplantation

Surgical Complications

Complications related to the surgical procedure are common and noted in nearly 50% of intestine transplant recipients,[53] but are an infrequent cause of graft failure. The most common complications include postoperative hemorrhage, vascular leaks or obstructions, and biliary leaks or obstruction. Other reported surgical-related events include intestinal perforation, wound dehiscence with evisceration, intra-abdominal abscess, and chylous ascites.[53]

Postoperative hemorrhage. Postoperative hemorrhage may be due to coagulopathy or portal hypertension from preexisting liver failure in patients requiring a combined small bowel-liver transplant or from vascularized adhesions due to previous surgeries.[17] Bleeding is usually resolved intraoperatively by normalizing coagulation through administration of blood products and cauterization, as well as implantation of a healthy donor liver. Postoperative intra-abdominal bleeding is usually a technical problem originating from anastomotic leaks or bleeding from the peritoneal surfaces. In the setting of normal coagulation, timely surgical re-exploration and repair are necessary.

Biliary complications. Biliary complications usually occur in the early postoperative period and may be seen in combined small bowel-liver grafts with the standard Roux-en-Y choledochojejunostomy.[38] Presenting symptoms include leakage through the abdominal wound, bilious fluid in the surgical drains, or unexplained sepsis. Surgical re-exploration is required for repair of dehiscence or revision of the anastomosis. In unexplained sepsis, all anastomoses should be assessed and a percutaneous cholangiogram completed to inspect the biliary anastomosis. Biliary obstruction is a later complication and may be seen following a biliary stricture. Symptoms are those of cholangitis, and diagnosis is confirmed through cholangiography. These complications have now been eliminated using the duodenal-sparing combined small bowel-liver graft technique in which the hepatic hilum is left intact (Figure 4).[53,54]

Composite small intestine-liver graft with preservation of the duodenum in continuity with the graft jejunum and hepatic biliary system. The pancreas is transected to the right of the portal vein. The single Carrell patch containing the celiac trunk and superior mesenteric artery is anastomosed to a conduit of donor thoracic aorta.[54]Source: Bueno J, Abu-Elmagd K, Marariegos G, Madariaga J, Fung J, Reyes J.Composite liver-small bowel allografts with preservation of donor duodenum and hepatic biliary system in children. J Pediatr Surg. 2000;35:292.

Vascular complications. Vascular complications are infrequent, but devastating when they occur. Thrombosis of the major arteries results in necrosis of the organs nourished by that arterial supply. Presentation is acute with obvious symptoms, including significant elevation of hepatic enzymes or pallor of the stoma with clinical deterioration, sepsis, and fulminant liver failure.[38] Diagnosis of arterial thrombosis is confirmed by assessing vessel patency via Doppler ultrasound. Isolated intestine transplant recipients may require graft enterectomy (removal of graft) and should recover. Recipients of composite grafts require timely retransplantation and may expire depending on organ availability and their condition prior to retransplantation.

Venous outflow obstruction may occur in patients receiving an isolated small bowel transplant consequent to the anastomosis of the superior mesenteric vein and portal vein axis.[38] Clinical presentation includes ascites and stomal congestion with subsequent mesenteric infarction. Incomplete obstruction of major vessels may also occur and can present with signs of organ dysfunction through clinical and laboratory findings or histology. Vascular radiologic studies with contrast are completed to confirm the diagnosis. Treatment consists of surgical intervention or balloon dilatation.[38]

GI Complications

Leaks from the proximal and distal anastomoses may occur within the first postoperative week due to operative technique and poor wound healing secondary to immunosuppression and malnutrition. Symptoms include peritonitis, abdominal distention, and fever. Decompression of the intestine through the proximal jejunostomy and distal ileostomy is maintained in the early postoperative period to minimize the risk of leaks.[62] Confirmation of leakage is obtained by contrast imaging. Surgical exploration and removal of peritoneal contamination is required in addition to full courses of antibiotic and/or antifungal therapies.

Bleeding is the most common GI complication in intestine transplantation and is usually caused by rejection or infection. Bleeding demands immediate attention with evaluation by endoscopy and biopsy. Rejection must be distinguished from infectious processes.[38] Bleeding from ulcerations caused by EBV or CMV can be differentiated from bleeding caused by rejection through endoscopy.

Hypermotility is common in the early posttransplant period. In the absence of rejection or infection, hypermotility is treated with antidiarrheal agents and fiber. Baseline motility of the transplanted bowel is altered, although motility patterns in the denervated allograft are not clearly understood.[63] Acute changes in motility, particularly when occurring in the setting of fever or abdominal distention, are indicative of rejection.

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