Gastrointestinal Complications of Hepatic Transplantation L. J. Koep, T. E. Starzl, and R. Weil III N THE largest series of orthotopic liver was withheld because bleeding was felt to be I transplants, now numbering 150 patients, only one factor in an otherwise terminal the largest number of major complications patient. The remaining 22 patients all have arisen in the gastrointestinal (GI) tract. required surgical intervention for enteric Of these, hepatic complications comprise the bleeding. Of these, only 5 ultimately survived majority. and they have been previously this complication. described by both leading centers.12 A Peptic ulcer disease was the most fre­ smaller number of complications have arisen quent etiology of gastrointestinal bleeding elsewhere in the gastrointestinal tract, but (Table I). Duodenal ulcers occurred in five because of their alarming mortality. they patients, of which two survived this complica­ have depressed the otherwise improving tion. One survivor responded to vagotomy and picture of hepatic transplantation. gastroenterostomy, while the other required first a vagotomy and pyloroplasty followed by CLINICAL MATERIAL antrectomy. Gastroenterostomy or resection Gastrointestinal complications occurring in alone were not successfuL Two patients devel­ this series of hepatic transplants include oped gastric ulcers. One patient with high bleeding from both upper and lower GI tracts, fundal ulcers required subtotal gastrectomy perforations and fistula, and abdominal for ulcer resection and survived. The other abscesses. Many of these complications have patient underwent vagotomy and gastroen­ previously been described in renal transplan­ terostomy but the bleeding site was not recog­ nized. The 12 patients with untreated termi­ tation.' h Problems with biliary drainage have arisen both in the transplant, as has been nal enteric bleeds all demonstrated peptic described, and also in the gastrointestinal ulcer disease. Gastric ulcer was most tract where biliary--enteric continuity is rees­ frequent, followed by gastritis and duodenal tablished. Enteric leaks at this site constitute ulcer. Various types of gastric lavage were one group of gastrointestinal complications employed without benefit. unique to hepatic transplantation. The colon Nonpeptic upper gastrointestinal bleeding complications also appear distinct from those arose in a variety of cases (Table 2). Four encountered in renal transplantation and have patients bled from esophageal varices. While occurred in a much younger age group.7 varices persist endoscopically following he- Abdominal abscesses have been related to a variety of causes, and wide peritoneal drain­ From the Deparrmenl of Surgery. University oj age is advocated. Colorado Medical Center. and the Veterans Administra­ tion Hospital, Denver, Colo. Hemorrhage Suppor/ed in part by research grants from the Veter­ ans Administration, by Grants AM-I7260 and AM- Gastrointestinal bleeding has been one of 07772 from the National Institutes oj Health; and by the more frequent complications following GranIs RR-00051 and RR-00069 from the General liver transplantation. Relatively small enteric Clinical Research CenIers Program oj the Division of bleeds chemically detectable in stools or Research Resources, National Institutes of Health. gastric aspirate occur in the majority of trans­ Reprint requests should be addressed 10 L. J. Koep, Department of Surgery, Unil'ersily of Colorado Medical plant recipients. Clinically significant hem­ Center. Denver, Colo. 80262. orrhage occurred in 34/150 patients (23%). .c 1979 by Grune & Stratton. Inc In 12 of these 34 patients, definitive therapy 0041-/345/19/1101-0056$01.00/0 Transplantation Proceedmgs, Vol. XI, No. 1 (Marchi, '979 257 258 KOEP, STARZL. AND WElL Table 1. Upper Gastrointestinal Bleeding: Peptic Disease Etiology Therapy Number Duodenal ulcer 5 Vagotomy and gastroenterostomy 1 (s) Vagotomy and pyloroplasty 3 (s) Gastric resection 2 (s) Gastroenterostomy only Gastric ulcer 2 Subtotal gastrectomy 1 (s) Vagotomy and gastroenterostomy Terminal peptic bleed No therapy 12 (s), Successful therapy, patic transplantation, they do not bleed in the discovered at autopsy. There were individual absence of portal-vein thrombosis. All four cases of bleeding from operative trauma to patients with variceal bleeding demonstrated the small bowel. small bowel ulcers, disrup­ either thrombosis or cavernous transforma­ tion of a duodenostomy closure, and cystic tion of the portal vein. The Sengstaken­ artery bleeding at the gallbladder anastomo­ Blakemore tube was used in all four patients SIS. with temporary success. One patient went on Lower gastrointestinal bleeding was some­ to sclerotherapy of his varices, but again bled times difficult to distinguish clinically from several days later, requiring ligation of duodenal bleeding (Table 3). Three patients varices. This operative ligation appeared had ulcerations in the right colon and under­ unduly treacherous because of the recent went either right or subtotal colectomy. None sclerotherapy, the esophagus being edema­ survived. Two patients had massive colonic tous and friable. bleeds from pneumatosis cystoides intestinalis The enteroentrostomy of the Roux-en-Y involving the colon. Both survived following jejunostomy was the site of bleeding in two subtotal colectomies. patients. In neither patient was it identified Gastrointestinal bleeding has arisen at clinically. One patient underwent pyloro­ intervals of several days to over a year post­ plasty before the enteroenterostomy was transplant. Frequently, small enteric bleeds opened and the bleeding site ligated. The occur during this interval. and because these other patient had both an abscess and bleed­ bleeds may be the prelude to a later hemody­ ing from the enteroenterostomy, which was namically significant bleed, vigorous diagnos- Table 2. Upper Gastrointestinal Bleeding: Nonpeptic Disease Etiology Therapy Number Esophageal varicies 4 Sengstaken· Blakemore 4 Sclerotherapy 1 Oversew 1 (s) Enteroenterostomy 2 (Roux·en-Y) Repair 2 (5) Small bowel 2 Operative trauma Resection Small bowel ulcers Pyloroplasty Disrupted duodenal closure Repair Gallbladder (cystic artery bleed) Repair (5). Successful therapy, - GASTROINTESTINAL COMPLICATIONS OF HEPATIC lRANSPLANTATION 259 Table 3. Lower Gastrointestinal Bleeding Table 4. Enteric Leaks Secondary to Biliary Drainage EtIology Therapy Number No Leaks EtIology (No. Procedures) Cecal ulceration 3 5 (65) Right celectomy 2 Cholecystoduodenostomy 6 (14) lIeoprectostomy Choledochoduodenostomy Roux-en-Y jejunostomy Pneumatosis (at new enteroenterostomy) 8 (48) Cystoides 2 Roux·en-Y jejunostomy Intestinales lIeoproctostomy 2 (5) (at choledochoJejunostomy) 1 (26) (s). Successful therapy. tic maneuvers are indicated. Vital signs, alternative biliary drainage and either drain­ hemoglobulin levels, and overt and occult ing or closing the duodenum. enteric blood loss are carefully monitored. Currently, when choledochocholedochos­ Panendoscopy has been crucial in all bleeding tomy is not feasible, Roux-en-Y jejunostomy episodes regardless of how minor they appear. to either gallbladder or common duct is Colonoscopy has been used but has not had a preferred. Enteric leaks have arisen at the direct therapeutic benefit. Proctoscopy is enteroenterostomy in 17% of the newly useful. as anal disease is quite frequent, and constructed Roux-en-Y jejunostomies. Leak­ the bleeding site sometimes is obscure even at ing enteroenterostomies have been corrected surgery. Radiographic studies have been help­ by reinforcing small leaks or reconstructing ful in minor bleeding, but in the major bleeds the anastomosis. Of these eight repairs, two included here. hemodynamic instability pre­ needed revision. One reinforced leak dis­ cluded this delay. rupted, requiring reconstruction of the entero­ enterostomy. The other, also a reinforced Perforation leak, developed a second leak a t a separate Gastrointestinal perforations and fistulas site that had not appeared compromised at were less frequent but even more lethal the previous laparotomy. This site was complications than bleeding. The preponder­ successfully reinforced. While leaks at the ance of leaks were secondary to the establish­ enteroenterostomy may occur at any time up ment of biliary drainage. In the 150 patients to 4 weeks, once this anastomosis has healed, in this series, 198 biliary procedures have the raux limb biliary drainage may be safely been performed. ChoIedcichocholedochostomy revised at the free end if necessary. The obviates the need for entry into the gastroin­ existence of a preexisting Roux-en-Y jejunos­ testinal t.ract and thus eliminates enteric leaks tomy is thus regarded as an asset among from biliary drainage. This has been used in potential transplant recipients. Like the duo­ 33 patients and is our preference for adults denal fistulas. these enteroenterostomy leaks with suitable ducts. Cholecystoduodenostomy have been highly lethal with only one survivor was the earliest drainage technique and has a among eight leaks. low incidence of leakage (8%). but was aban­ Unfortunately. the existence of a previous doned for other reasons (Table 4). The ma­ Roux-en-Y jejunostomy implies previous he­ jority of the 14 choledochoduodenostomies patic surgery. Previous Roux-en-Ys have were conversions from previous cholecysto­ been injured three times during particularly duodenostomies. The incidence of leakage in difficult hepatectomies resulting in fistulas choledochoduodenostomies