Atypical Spontaneous Cecal Perforation During Redo Kidney Transplant Post Heart-Kidney Transplantation

Colonic perforation postrenal transplantation is rare (0.5%-2.3% incidence) and often associated with sigmoid diverticulitis, with reported mortality rates of 25%-50%. Right-sided spontaneous colonic perforation is particularly uncommon. We describe a 44-year-old male with a history of combined heart-kidney transplantation who developed rapid-onset cecal perforation following repeat deceased donor kidney transplantation. Despite early return of bowel function, an aggressive bowel regimen, and minimal opioid exposure, he developed acute abdominal distention, nausea, and obstipation on postoperative Day 5. Although he remained afebrile without leukocytosis or peritoneal signs, imaging demonstrated marked colonic dilatation and pneumoperitoneum, prompting emergent surgical exploration. Isolated cecal perforation was identified and successfully managed with right hemicolectomy, primary anastomosis, and diverting ileostomy. The patient recovered with preserved allograft function. This case underscores the potential for atypical and insidious gastrointestinal complications in patients with prolonged and intensified immunosuppression and highlights the importance of early imaging and prompt surgical intervention. Heightened clinical suspicion is essential as retransplantation and multiorgan transplant populations continue to expand.