甲状旁腺全切除术加前臂移植治疗尿毒症难治性继发性甲状旁腺功能亢进

【目的】研究甲状旁腺全切除术加自体前臂移植对于尿毒症引起的难治性继发性甲状旁腺功能亢进的效果。【方法】总结分析本院12例因慢性肾脏疾病长期接受规律性血液透析的患者发生继发性甲状旁腺功能亢进（SHPT），因持续性高血钙及高甲状旁腺素（parathyroid hormone，PTH），药物治疗无效，予行甲状旁腺全切除术加前臂移植术的疗效。比较手术前及手术后血PTH值，血钙值以及相关临床症状的变化情况。【结果】手术后12例病患无一例死亡，其中8例血PTH降至正常水平，血钙值一度低于正常水平，经补充钙剂之后恢复正常水平并维持，4例患者术后血PTH及血清钙数值明显降低，但仍高于正常值，故术后再次切除部分移植于前臂的甲状旁腺组织，术后血PTH及血清钙数值均降至正常。全组术后低血钙症发生率达66．7％（8／12）。血清钙术后三周内下降明显，至术后6个月逐渐恢复至正常水平。病患全身骨痛，皮肤瘙痒，乏力，纳差等症状改善明显。骨密度测定，骨量上升明显。【结论】甲状旁腺全切除术加前臂自体移植对于治疗尿毒症难治性继发性甲状旁腺功能亢进症疗效明确，是一种安全可靠的治疗手段。

Inactivated Bone Replantation with Preservation of the Epiphysis in Children with Osteosarcoma:Clinical Report of Two Cases

Objective: To evaluate the value of inactivated bone replantation with preservation of the epiphysis following the effective chemotherapy in avoiding postoperative discrepancy of the affected limb in children with osteosarcoma. Methods: Two children (aged 5 and 10 years, 1 male and 1 female) with osteosarcoma underwent inactivated bone replantation with preserving epiphysis following chemotherapy (MMIA protocol, including high-dose methotrexate, adriamycin and ifosfamide). After two cycles of preop-erative chemotherapy, pain vanished, the local mass shrank and there was no pain on pressing the affected parts. Sera AKP and LDH were reduced to normal levels; marked shrinkage and sclerotic changes and good margin of lesions were seen on plain radiographs and MR images. Two courses of the same protocol as preoperative chemotherapy were administered postoperatively. Results: Postoperative histological examination of the specimens demonstrated absence of vital tumor cells. Incisions healed well and no complications occurred. The replanted inactivated bone healed with host at 6 months after operation. In the two patients, no evidence was seen of metastasis and recurrence and discrepancy of the affected limbs in postoperative 36 and 48 months. Functions of the affected limbs were satisfactory. Conclusion: Inactivated bone replantation with preserving epiphysis was a viable option for osteosarcoma in children. The long-term outcomes remain to be further proven.

Endoscopic therapy of benign biliary strictures

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post- liver transplant anastomotic strictures and distal （Bismuth ! and I） post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.

Postoperative complications in patients with portal vein thrombosis after liver transplantation:Evaluation with Doppler ultrasonography

AIM： To study the postoperative complications in patients with preoperative portal vein thrombosis （PVT） undergoing liver transplantation （LT） and to evaluate the complications with Doppler ultrasonography.METHODS： Retrospective studies were performed on 284 patients undergoing LT （286 LT） with respect to pre- and postoperative clinical data and Doppler ultrasonography. According to the presence and grade of preoperative PVT, 286 LTs were divided into three groups： complete PVT （c-PVT）, partial PVT （p-PVT） and non-PVT, with 22, 30 and 234 LTs, respectively. Analyses were carried out to compare the incidence of early postoperative complications.RESULTS： PVT, inferior vena cava （IVC） thrombosis, hepatic artery thrombosis （HAT） and biliary complications were found postoperatively. All complications were detected by routine Doppler ultrasonography and diagnoses made by ultrasound were confirmed by clinical data or/and other imaging studies. Nine out of 286 LTs had postoperative PVT. The incidence of the c-Pv-r group was 22.7%, which was higher than that of the p-Pv-r group （3.3%, P 〈 0.05） and non- PVT group （1.3%, P 〈 0.005）. No difference was found between the p-PVT and non-PVT groups （P 〉 0.25）. Of the 9 cases with postoperative PVT, recanalizations were achieved in 7 cases after anticoagulation under the guidance of ultrasound, 1 case received portal vein thrombectomy and 1 case died of acute injection. Ten LTs had postoperative 1VC thrombosis. The c-PVT group had a higher incidence of IVC thrombosis than the non- PVT group （9.1% vs 2.6%, P 〈 0.05）; no significant difference was found between either the c-PV-T and p-PVT groups （9.1% vs 6.7%, P 〉 0.5） or between the p-PVT and non-PVT groups （P 〉 0.25）. Nine cases with IVC thrombosis were cured by anticoagulation under the guidance of ultrasound, and 1 case gained natural cure without any medical treatment after 2 mo. HAT was found in 2 non-PVT cases, giving a rate of 0.7% among 286 LTs. Biliary complications were seen in 12 LTs. The incidence of biliary complications in the c-PVT, p-PVT and non-PVT groups was 9.1%, 3.3% and 4.3%, respectively （P 〉 0.25 for all）, among which 2 stenosis led retransplantations and others were controlled by relative therapy.CONCLUSION： C-PVT patients tend to have a higher incidence of PVT and IVC thrombosis than non- PVT patients after LT. The incidence of postoperative complications in p-PVT patients does not differ from that of non-PVT patients, A relatively low incidence of HAT was seen in our study, Doppler ultrasonography is a convenient and efficient method for detecting posttransplant complications and plays an important role in guiding treatment.

Autologous transplantation of bone marrow mesenchymal stem cells on diabetic patients with lower limb ischemia

Objective： To study the efficacy and safety of autologous transplantation of bone marrow mesenchymal stem cells on diabetic patients with lower limb ischemia. Methods： Fifty Type 2 diabetic patients with lower limb ischemia were enrolled and randomized to either transplanted group or control group. Patients in both group received the same conventional treatment. Meanwhile, 20 ml bone marrow from each transplanted patient were collected, and the mesenchymal stem cells were separated by density gradient centrifugation and cultured in the medium with autologous serum. After three-weeks adherent culture in vitro, 7.32×10^8-5.61×10^9 mesenchymal stem cells were harvested and transplanted by multiple intramuscular and hypodermic injections into the impaired lower limbs. Results： At the end of 12-week follow-up, 5 patients were excluded from this study because of clinical worsening or failure of cell culture. Main ischemic symptoms, including rest pain and intermittent claudication, were improved significantly in transplanted patients. The ulcer healing rate of the transplanted group （1 5 of 18, 83.33%） was significantly higher than that of the control group （9 of 20, 45.00%, P=0.012）.The mean of resting ankle-brachial index （ABI） in transplanted group significantly was increased from 0.61±0.09 to 0.74±0.11 （P〈0.001）. Magnetic resonance angiography （MRA） demonstrated that there were more patients whose score of new vessels exceeded or equaled to 2 in the transplant patients （11 of 15） than in control patients （2 of 14, P=0.001）. Lower limb amputation rate was significantly lower in transplanted group than in the control group （P=0.040）. No adverse effects was observed in transplanted group. Conclusion： These results indicate that the autologous transplantation of bone marrow mesenchymal stem cells relieves critical lower limb ischemia and promotes ulcers healing in Type 2 diabetic patients.

Multi-disciplinary treatment for cholangiocellular carcinoma

Cholangiocarcinoma(CC)is rare malignant tumors composed of cells that resemble those of the biliary tract.It is notoriously difficult to diagnose,and is associated with a high mortality.Traditionally,CC is divided into intrahepatic and extraheaptic disease according to its location within the biliary tree.Intrahepatic cholangiocellular carcinoma(IH-CCC)or peripheral cholangiocellular carcinoma(CCC)appears within the second bifurcation of hepatic bile duct,and is the second most common primary liver cancer following hepatocellular carcinoma(HCC),IH-CCC or peripheral CCC often presents with advanced clinical features,and the cause for this cancer rise is still unclear.MRI,CT and PET provide useful diagnostic information in those patients.Surgical resection is the only chance for cure,with results depending on selected patients and careful surgical technique.Liver transplantation could offer long-term survival in selected patients when combined with chemotherapy.Chemotherapy,radiation therapy or combination therapies remain as the only treatment for inoperable patients.However,these are uniformly ineffective in patients' survival.

Acanthus ilicifolius plant extract prevents DNA alterations in a transplantable Ehrlich ascites carcinoma-bearing murine model

AIM： To investigate the chemopreventive efficacy of the Indian medicinal plant Acanthus ilicifolius L Acanthaceae in a transplantable Ehrlich ascites carcinoma （EAC）- bearing murine model.METHODS： Male Swiss albino mice were divided into four groups： Group A was the untreated normal control; Group B was the EAC control mice group that received serial, intraperitoneal （ip） inoculations of rapidly proliferating 2 × 10^5 viable EAC cells in 0.2 mL of sterile phosphate buffered saline; Group C was the plant extract-treated group that received the aqueous leaf extract （ALE） of the plant at a dose of 2.5 mg/kg body weight by single ip injections, once daily for 10, 20 and 30 consecutive days following tumour inoculation （ALE control）; and Group D was the EAC ＋ ALE- treatment group. The chemopreventive potential of the ALE was evaluated in a murine model by studying various biological parameters and genotoxic markers, such as tumour cell count, mean survival of the animals, haematological indices, hepatocellular histology, immunohistochemical expression of liver metallothionein （MT） protein, sister-chromatid exchanges （SCEs）, and DNA alterations.RESULTS： Treatment of the EAC-bearing mice with the ALE significantly （P 〈 0.001） reduced viable tumour cell count by 68.34% （228.7 × 10^6 ± 0.53） when compared to EAC control mice （72.4 × 10^6 ± 0.49）, and restored body and organ weights almost to the normal values. ALE administration also increased （P 〈 0.001） mean survival of the hosts from 35 ± 3.46 d in EAC control mice to 83 ± 2.69 d in EAC ＋ ALE-treated mice. Haematological indices also showed marked improvement with administration of ALE in EAC-bearing animals. There was a significant increase in RBC count （P 〈 0.001）, hemoglobin percent （P 〈 0.001）, and haematocrit value （P 〈 0.001） from 4.3 ± 0.12, 6.4 ± 0.93, and 17.63 ± 0.72 respectively in EAC control mice to 7.1 ± 0.13, 12.1 ± 0.77, and 30.23 ± 0.57 respectively in EAC ＋ ALE-treated group, along with concurrent decrement （P 〈 0.001） in WBC count from 18.8 ± 0.54 in EAC control to 8.4 ± 0.71 in EAC ＋ ALE. Furthermore, treatment with ALE substantially improved hepatocellular architecture and no noticeable neoplastic lesions or foci of cellular alteration were observed. Daily administration of the ALE was found to limit liver MT expression, an important marker of cell proliferation with concomitant reduction in MT immunoreactivity （62.25 ± 2.58 vs 86.24 ± 5.69, P 〈 0.01）. ALE was also potentially effective in reducing （P 〈 0.001） the frequency of SCEs from 14.94 ± 2.14 in EAC control to 5.12 ± 1.16 in EAC ＋ ALE-treated group. Finally, in comparison to the EAC control, ALE was able to suppress in vivo DNA damage by abating the generations of＇tailed＇ DNA by 53.59% （98.65 ± 2.31 vs 45.06 ± 1.14, P 〈 0.001）, and DNA single-strand breaks （SSBs） by 38.53% （3.14 ± 0.31 vs 1.93 ± 0.23, P 〈 0.01） in EAC-bearing murine liver.CONCLUSION： Our data indicate that, ALE is beneficial in restoring haematological and hepatic histological profiles and in lengthening the survival of the animals against the proliferation of ascites tumour in vivo. Finally, the chemopreventive efficacy of the ALE is manifested in limiting MT expression and in preventing DNA alterations in murine liver. The promising results of this study suggest further investigation into the chemopreventive mechanisms of the medicinal plant A. ilicifolius in vivo and in vitro.

Pure red cell aplasia due to parvovirus B19 infection after liver transplantation:A case report and review of the literature

Pure red cell aplasia （PRCA） due to parvovirus B19 （PVB19） infectiori after solid organ transplantation has been rarely reported and most of the cases were renal transplant recipients, Few have been described after liver transplantation. Moreover, little information on the management of this easily recurring disease is available at present. We describe the first case of a Chinese liver transplant recipient with PVB19-induced PRCA during immunosuppressive therapy. The patient suffered from progressive anemia with the lowest hemoglobin level of 21 g/L. Bone marrow biopsy showed selectively inhibited erythropoiesis with giant pronormoblasts. Detection of PVB19-DNA in serum with quantitative polymerase chain reaction （PCR） revealed a high level of viral load. After 2 courses of intravenous immunoglobulin （IVIG） therapy, bone marrow erythropoiesis recovered with his hemoglobin level increased to 123 g/L. He had a lowlevel PVB19 load for a 5-too follow-up period without recurrence of PRCA, and finally the virus was cleared. Our case indicates that clearance of PVB19 by IVIG in transplant recipients might be delayed after recovery of anemia.

Liver transplantation for polycystic liver with massive hepatomegaly: A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease. Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008. The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack). Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and fi nally, right hepatectomy was performed. OLT was performed successfully. The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed fi rst during OLT if the liver is over enlarged.

Amniotic membrane transplantation for porous sphere orbital implant exposure

Objective: This study is aimed at describing the clinical outcome of amniotic membrane transplantation for exposure of porous sphere implants. Methods: A retrospective review of consecutive cases of porous sphere orbital implant exposure was carried out. Eight cases were presented between May 2004 and Oct. 2006 (5 males, 3 females; mean age 44.5 years). Six had enucleation and two had evisceration. Exposure occurred in two primary and six secondary. Orbital implant diameter was 22 mm in seven cases and 20 mm in one case. Six patients are with hydroxyapatite and two with high-density porous polyethylene (Medpor) orbital implants. The mean time from implantation to exposure was 1.1 months (range 0.8~2 months). All patients required surgical intervention. Results: The time of follow-up ranged from 3.0 to 28.0 months (mean 16.5 months). Amniotic membrane grafting successfully closed the defect without re-exposure in all of these patients. The grafts were left bare with a mean time to conjunctiva of about 1 month (range 0.8~1.5 months). Conclusion: Exposed porous sphere implants were treated suc-cessfully with amniotic membrane graft in all of patients. The graft is easy to harvest. This technique is useful, dose not lead to prolonged socket inflammation and infection, and it is valuable application extensively.

Massive allograft replacement in management of bone tumors

Objective： To evaluate the functional outcome and complications of allograft replacement in management of bone tumors. Methods： Between March 1992 and September 2002, 164 patients underwent bone tumor resection and massive allograft reconstruction of bone defects. The length of the resected part ranged from 5-35 cm. The resections were classified as marginal or wide resections of the tumor on the basis of the Musculoskeletal Tumor Society staging system. Fresh-frozen allografts were employed as osteoarticular grafts （n = 95）, hemi-condylar （n = 15）, massive （n = 23）, allograft-prosthesis composite （n = 12）, intercalary grafts （n = 15） or hemi-pelvic grafts （n = 4）. Most of the lesions were osteosarcoma and giant cell tumor of bone and located in proximal and distal femur, proximal tibia and humerus. Results： At a median follow-up of 47 months （range, 12 to 168 months） after the operation, 154 of the patients in the study were free of disease and 10 died of disease. Twenty-one （12.8%） patients had local recurrence and 38 （23.2%） nonunion. Late complications included 11 （6.7%） fractures of the allograft and 18 （11.0%） infections of the graft, instability of the joint in the form of subluxation was noted in 13 （7.9%） patients. Ten extremities were amputated due to local recurrence or severe infection. Conclusion： AIIografts can be used for reconstruction of bony defects after tumor resection. AIIograft has nearly similar shape, strength, osteo-inductivity and osteo-conductivity with host bone. AIIograft implantation is a high complication reconstruction method, and the dsk of recurrence increases when less surgical margin achieves.

Dose requirements of continuous infusion of rocuronium and atracurium throughout orthotopic liver transplantation in humans

Objective： To compare the dose requirements of continuous infusion of rocuronium and atracurium throughout orthotopic liver transplantation （OLT） in humans. Methods： Twenty male patients undergoing liver transplantation were randomly assigned to two comparable groups of 10 patients each to receive a continuous infusion of rocuronium or atracurium under intravenous balanced anesthesia. The response of adductor pollicis to train-of-four （TOF） stimulation of unlar nerve was monitored. The infusion rates of rocuronium and atracurium were adjusted to maintain Tl/Tc ratio of 2%-10%. The total dose of each drug given during each of the three phases of OLT was recorded. Results： Rocuronium requirement, which were （0.468±0.167）mg/（kg·h） during the paleohepatic phase, decreased significantly during the anhepatic phase to （0.303±0.134）mg/（kg·h） and returned to the initial values at the neohepatic period （（0.429±0.130） mg/（kg·h））; whereas atracuruim requirements remained unchanged during orthotopic liver transplantation. Conclusions： This study showed that the exclusion of the liver from the circulation results in the significantly reduced requirement of rocuronium while the requirement of atracurium was not changed, which suggests that the liver is of major importance in the clearance of rocuronium. A continuous infusion of atracurium with constant rate can provide stable neuromuscular blockade during the three stages of OLT.

Pediatric liver transplantation

In previous decades,pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality.Graft and patient survival have continued to improve as a result of improvements in medical,surgical and anesthetic management,organ availability,immunosuppression,and identification and treatment of postoperative complications.The utilization of split-liver grafts and living-related donors has provided more organs for pediatric patients.Newer immunosuppression regimens,including induction therapy,have had a significant impact on graft and patient survival.Future developments of pediatric liver transplantation will deal with long-term followup,with prevention of immunosuppression-related complications and promotion of as normal growth as possible.This review describes the state-of-the-art in pediatric liver transplantation.

Jejunoileal bypass:A surgery of the past and a review of its complications

Jejunoileal bypass(JIB),popular in the 1960s and 1970s,had remarkable success in achieving weight loss by creating a surgical short bowel syndrome.Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery.Later,it was recognized that he had a JIB in the 1970s,which was also responsible for the gamut of his illnesses.Patients with JIB are often not recognized,as they died of complications,or underwent reversal of their surgery or a liver-kidney transplant.Early identification with prompt reversal,and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.

Results of Treating Vertebral Metastases by Percutaneous Vertebroplasty Combined with Interventional Chemotherapy

OBJECTIVE Vertebral metastases are a common manifestation in patients with advanced cancer and treatment is often ineffective. This study was conducted to explore the efficacy of treating vertebral metastases by percutaneous vertebroplasty （PVP） combined with interventional chemotherapy. METHODS Seventy-five patients with vertebral metastases （42 men, 33 women; ages 31-76 years） were divided into 2 groups： 39 cases were treated by PVP combined with chemotherapy （VPCC group）, and 36 cases were treated by PVP alone （VP group）. All procedures were guided by computed tomography （CT） scanning. The results and complications were evaluated by a questionnaire regarding pain and routine follow-up. RESULTS The response rate was significantly higher in the VPCC group than in the VP group （93.0% vs 74.4%, P〈0.05）; total response rates for the VPCC and VP groups were 25.6% and 10.3% respectively. A common complication related to VPCC was transient aggravating pain. CONCLUSION PVP may ameliorate pain, and consolidate the vertebrae of patients with vertebral metastases. Its short-term effect may be enhanced by adding drugs into the bone cement.

Revascularization for Iliac-femoral Artery Pseudoaneurysm with Greater Saphenous Vein

Objective To investigate the role of revascularization procedures with autologous greater saphenous vein in surgical management of iliac-femoral artery pseudoaneurysm in parenteral drug abusers. Methods Twenty-one patients with iliac-femoral artery pseudoaneurysm caused by parenteral drug abuse from 2004 to 2007 were enrolled. Among them,15 patients were male and 6 were female; their average age was 31.3 years. The size of pseudoaneurysms ranged from 3.0 cm to 7.5 cm. Common femoral artery and distal external iliac artery were often involved. We performed arterial reconstruction on these patients with autologous greater saphenous vein as a graft after excising iliac-femoral artery pseudoaneurysm through a single curved inguinal incision. All patients were followed up,and the complications were recorded. Results The surgical procedures were finished without intraoperative mortality or perioperative complications. All patients were free of claudication symptoms after the surgery except one case with preoperative popliteal artery stenosis. One case of infection and wound tissue fistula was found later. One case had inguinal incisional hematoma and another complained of numbness in thigh skin. Conclusions The use of autologous greater saphenous venous grafts for arterial reconstruction after pseudoaneurysm excision in drug abusers is safe and effective. This technique offers more advantages than arterial ligation alone without revascularization. An optimal greater saphenous venous graft is a prerequisite for revascularization.

Therapeutic effectiveness of pediatric renal transplantation in 63 cases

Objective： To explore the characteristic of operation, intra-operation treatment and the application of immunosuppressant in pediatric renal transplantation in order to improve therapeutic effectiveness. Methods： From March 1986 to October 2006, the clinical data of 63 children who underwent renal transplantation in our hospital were retrospectively analyzed. Results： The 1-, 3-, 5-, 10-year graft survival rates were 98.4%, 90.5%, 88.9% and 68.3%, respectively. And the corresponding patient survival rates were 100%, 95.2%, 92.1%, 71.4%. The body weight increased 4 to 12 kg and the body height grew up 2 to 6 cm during the first year post-transplantation. The main complications in the first year post-transplantation were hypertension （26/63, 41.3%）, crinosity （14/63, 22.2%）, drug-induced hepatic injury（11/63, 17.5%）, gingival hyperplasia （10/63, 15.8%）, pulmonary infection（9/63, 14.3%）, bone marrow suppression（5/63, 7.9%）, herpes （4/63, 6.3%） and diabetes （3/63, 4.8%）. Conclusion： Renal transplantation is a preferred method for the treatment of children in end-stage renal disease （ESRD）. Good tissue matching, proper operative time and pattern, peri-operactive care were essential to success, as well as appropriate immuno-suppressant strategy and good compliance.

Gut perforation after orthotopic liver transplantation in adults

AIM： To describe cases of gut perforation after orthotopic liver transplantation.METHODS： Data were colleted from our center database and medical records. Six of 187 patients （3.2%）who underwent orthotopic liver transplantation from January to December 2005 developed gut perforation.All patients were male with an average age of 46 years.Modified piggyback liver transplantation was performed at the Organ Transplantation Center, First Affiliated Hospital, Sun Yat-Sen University.RESULTS： Previous operation, steroid therapy, and prolonged portal venous cross clamp time, poor nutritional status and iatrogenic injury were found to be its ecological factors. The patients with gut perforation were found to have fever, increased leukocytes, mild abdominal pain and tenderness. The median portal venous clamp time was 63 min （range 45-72 min）,median cold ischaemia time was 11.3 h （range 7-15 h）.Median intraoperative blood loss was 500 mL （range 100-1200 mL） and median operation time was 8.8 h （range 6-12 h）. None of the six patients developed acute cellular rejection. White cell count was above 18 × 10^9/L in five patients （neutrophilic leukocytes were above 90%） and 1.5 × 10^9/L in one patient. Bacterial culture in drainage liquid revealed enterococci in five patients. Of the 6 patients undergoing orthotopic liver transplantation, 3 survived and 3 died after modified piggyback liver transplantation.CONCLUSION： Gut perforation occurs after orthotopic liver transplantation in adults. A careful and minimal dissection during OLT, longer retention of the stomach tube, and reducing the portal clamp time and steroid dose should be taken into consideration. If gut perforation is not prevented, then early diagnosis,preferably through detection of enterococci may ensure better survival.