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 × 109/L in five patients (neutrophilic leukocytes were above 90%) and 1.5 × 109/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.