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Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 172-177 Comparative study of operative procedures in typhoid perforation Udai Singh Beniwal, Dinesh Jindal, Jagdish Sharma, Sumita Jain, Ghan Shyam Upgraded Department of General Surgery, S.M.S. Medical College and Hospital,
Jaipur, Rajasthan Paper Received: May 2002, Paper Accepted: November 2002. Source of Support: Nil Code Number: is03030 ABSTRACT The present study was conducted in 200 patients of typhoid perforation treated surgically. The aim of the study was to compare the results of different operative procedures done in enteric perforation in terms of morbidity, mortality, and cost effectiveness and to find out the ideal operative procedure. Observations were compared using statistical methods such as Chi-Square test and standard error of difference between proportions. The overall morbidity and mortality were 51% and 10.5% respectively. The morbidity and mortality were not affected by the type of operative procedure and the duration of perforation at presentation (P value >.05). Common postoperative complications included wound infection (23%), bleeding (5.5%), fecal fistula (16.5%) and skin excoriation around ileostomy (5.7%). The number of perforations and the development of fecal fistula were factors which significantly affected mortality (P value <. 025 and <. 001 respectively). Primary temporary ileostomy and ileo-transverse colostomy were performed in some patients with multiple perforations and\or with perforation situated near the ileocecal junction having greater risk of "repair leak". In conclusion, repair of the perforation is a better procedure than temporary ileostomy in enteric perforation due to its cost effectiveness and absence of complications related to ileostomy. Ileostomy and ileo-transverse bypass should be considered as treatment options in patients with an unhealthy gut. KEYWORDS: Typhoid perforations, repair of perforation, primary ileostomy, repair with ileo-transverse colostomy. How to cite this article: Beniwal US, Jindal D, Sharma J, Jain S, Shyam G. Comparative study of operative procedures in typhoid perforation. Indian J Surg 2003;65:172-7. INTRODUCTION Typhoid fever is an endemic disease in India and other tropical countries. Small intestinal perforations and gastrointestinal haemorrhage are the most common and dreadful complications of enteric fever. In the past, enteric perforation was considered almost fatal and up to 1960, most surgeons favoured conservative management.1 1970 onwards most surgeons have favoured surgical intervention in typhoid perforations.2,3 Various operative procedures were advocated by different authors, such as simple repair of perforation,4 repair of perforation with ileo-transverse colostomy,5 primary ileostomy,6,7 single layer repair with an omental patch,8 and resection and anastomosis.9 Even with such a variety of procedures, enteric perforation still has a high rate of morbidity and mortality. The aim of the present study was to evaluate the role of various operative procedures in cases of enteric perforation by comparing them in terms of morbidity, mortality and cost-effectiveness and to find out the ideal procedure. MATERIAL AND METHODS The study was carried out in 200 cases of enteric perforation admitted to the surgical units of the S.M.S. Medical College and Hospital Jaipur, during the period from May 2000 to Sept 2001. The study was not a controlled study as all the patients were subjected to different operative procedures depending on the condition of the small intestine. Paediatric patients were usually treated in another hospital at our institute so only one patient of age X10 years is reported in the study. Diagnosis of enteric perforation was based upon a history of fever followed by acute onset of pain in the abdomen, signs and symptoms of perforation peritonitis, a Widal test, usually supplemented by radiological findings of pneumoperitoneum and peroperative findings. All patients of typhoid perforation were treated as a surgical emergency. Preoperatively all the patients had had broad-spectrum antibiotic coverage, nasogastric suction and management of fluid and electrolyte imbalance. Anaemic patients required blood transfusion. Postoperatively parenteral antibiotics were continued and after that oral quinolones were given for 10 to 14 days in every patient. Double layer closure of the enteric perforation(s) was done in 107 patients, inner layer with chromic catgut 2/0 and outer layer with silk 2/0. In 70 patients primary ileostomy was done. Repair of perforation(s) with proximal side-to-side ileotransverse colostomy, closure of perforation with an omental patch and resection and anastomosis were done in 14, 6 and 3 patients respectively. In almost all the cases, the abdomen was explored through the right paramedian or midline incision. The abdomen was closed in a single layer and in addition to interrupted skin stitches, one or two intraabdominal drains were put in the pelvis and/or in the right subhepatic space. Defunctioning ileostomy and ileo transverse bypass were usually performed in patients with an unhealthy gut having multiple perforations and/or perforation(s) situated near the ileocecal junction and a greater risk of repair leak. Huckstepl advocated conservative management of typhoid perforation. Bhansali4 treated 96 cases of enteric perforation with double layer closure of perforation, Prasad et a15 treated 15 cases of typhoid perforation with repair of perforation and ileotransverse bypass. B.K. Kau16 and K.P. Singh, K. Singh and Kohli7 advocated that ileostomy was a safe and simple operation. Purohit8 reported a series of 41 patients, out of these 31 were treated by double layer closure and 10 by single layer closure and an omental patch. Eggleston and Santoshil0 reported a series of 78 cases of enteric perforation in which repair of perforation was done in 43 patients, 29 patients were treated by repair of perforation with bypass, and 3 patients underwent resection anastomosis. A.R.K. Adesunkanmi and O.G. Ajao11 treated 50 cases of enteric perforation with edge excision and double layer closure. Athie, Guizar and Alcantara9 recommend that resection anastomosis with a10 cm margin from the site of perforation should be the choice of treatment in enteric perforation cases. Statistics were worked out mainly to test the significance of the difference between different observations. Methods used were Chi-square test and standard error of difference between proportions. A. Chi-square test is done in the following steps:
Matching in probability tables test is significant only if the P value is less than 0.05. B.S.E. of difference between proportion test is considered significant when the observed difference is more than twice the S.E. of difference. The values of both the tests are given in the text at appropriate places. RESULTS Enteric perforation was more common in males than in females with a ratio of 6.41:1. Their ages ranged from 8-65 years, the maximum number of patients (40.5%) were in their 3rd decade followed by 32% of patients in their 2nd decade. Patients of enteric perforation were admitted throughout the year with the highest number in the months of August and September. Majority (95.5%) of patients presented with a history of fever followed by sudden onset of pain in the abdomen. Other common findings were of abdominal distension (95%), constipation, diarrhoea and vomiting. Clinically generalized guarding, rigidity and tenderness were found in all the patients. 98 patients (49%) presented within 48 hours of perforation, 68 patients (34%) presented with a 3-4 days old perforation while 17% patients had more than a 4 days old perforation with a mortality rate of 6.1%, 11.8% and 20.5% respectively. Mortality was unaffected by the duration of perforation as revealed by null hypothesis (x2(chi square) = 5.796, d.f = 2, P value> 0.05) and S.E. (standard error) of difference between proportions (8.06) (Table 1). In the present series, perforation occurred in the first week of fever in 40.8% cases and in the second week of fever in 48% patients (Table 2). Pneumoperitonium was present in 91.7% of patients who had an x-ray abdomen standing. The Widal test was useful with a "diagnosis positivity of 80.5%". Out of 138 patients in whom TLC (total leucocyte count) was done, leucopenia was present in 84 patients and leucocytosis in 41 patients. Peritoneal contamination with intestinal fluid was found in all the cases. In about 87% of patients perforation(s) was/were located in the terminal ileum within 2 feet of the ileocaecal junction. 81.4% of all the patients had a single perforation and the rest had more than one perforation (Table 3). Various complications were recorded in 102 patients, thus accounting for a total morbidity of 51%. Major complications were wound infection (23%), fecal fistula (16%), wound dehiscence (6%), bleeding diathesis (5.5%), and skin excoriation around ileostomy (5.7%) (Table 4). Mortality rates of repair of perforation, primary ileostomy, repair with I-T (bypass Ileo-transverse bypass), omental patch repair and resection anastomosis were 6.5%, 12.8%, 21.4%, 16.6% and 33% respectively (Table 5). We analyzed the significance of the difference between mortality of repair of perforation, ileostomy and of other procedures with the help of the Chi-square test (x2 =5.28, d.f.(degree of freedom) = 2, P value > 0.05) which revealed that mortality was not affected by the type of operative procedure. Similarly, there was no significant difference in the development of faecal fistula ( x2 =2.407, d.f.=1, P value > 0.I) and other complications ( x 2 = 0.78, d.f. =1, P value > 0.1) in relation to the operative procedure performed. The average hospital stay of the patients was slightly longer in case of ileostomy (16.5 days) in comparison with other procedures (15 days). There were 21 deaths accounting for a mortality rate of 10.5%. Mortality was more in patients with multiple perforations as compared to single perforation cases ( x 2= 5.955, d.f. =1, P value < 0.025). Development of fecal fistula was unrelated to the number of perforations. It developed in 15.3% of "single perforation cases" and in 21.6% of patients with multiple perforations (x2 = .874, df.=1, P value>0.1). S.E. (Standard error) of difference between proportion for fecal fistula is 7.32 while observed difference (6.3) was less than twice of S.E., thus it was not significant. There were 10 deaths in 33 patients with fecal fistula and the development of fecal fistual significantly affected the mortality (x2=15.23, d.f.=1, P value<0.001). Fecal peritonitis, septicaemia and bleeding were the main causes of death accounting for 17 out of 21 deaths. Other causes were broncho-pneumonitis, aspiration pneumonitis, D.V.T. and uraemia. DISCUSSION Enteric perforation is more common in males than in females. In the present series M:F (Male-female ratio) ratio was 6.4:1, that is consistent with the ratio of 3.8:1 reported by Baliga,12 5.25:1 reported by N.M. Swadia13 and 4:1 reported by A.R.K. Adesunkanmill. This is due to the fact that enteric fever is more common in males, possibly because of more exposure to infection. Typhoid perforation is common in the 2nd and 3rd decades of life. The high percentage of cases (40.5%) amongst the age group of 21-30 years in the present series is similar to that reported by Vyas,14 Olurin et al, Eggleston and Santoshilo and K.P. Singh and Kohli.7 Typhoid perforation usually occurs in the second and third week of fever. In the present series the maximum incidence of perforation was in the second week of fever followed by those in the first week. Dickson and Cole,16 Olurin et al15and Purohit8 reported that majority of perforations occurred in the first week of fever and Eggleston and Santoshilo reported 33% incidence in the second week of fever. Gas under diaphragm in x-ray abdomen standing is an important finding, and helpful in diagnosis. In typhoid perforation cases, lecucopenia (<4000/cu.mm.) was present in the majority (61%) of cases in spite of peritonitis. It may be due to bone marrow depression by enteric toxaemia. Enteric perforation is best managed surgically as it prevents further peritoneal contamination by intestinal contents. After a proper peritoneal toilet, correct management of perforation should be done. A wide variety of operative procedures are tried in enteric perforation cases but all have a high morbidity and mortality. Development of fecal fistula due to reperforation or perforation from another ulcer is a significant factor affecting mortality and every effort should be done to avoid this. Repair of perforation should be the choice of treatment in enteric perforation because this is a simple, quick and cost-effective procedure. Ileostomy is more expensive as all the patients have to undergo re-operation for closure of ileostomy and it further needs specialized care prior to closure. Ileostomy should be considered as a secondary procedure in patients who have developed fecal fistula. Overall mortality was 10.5%. The mortality was unrelated to the duration of perforation and type of operation performed (P value > 0.05). Factors significantly affecting mortality were number of perforations and the development of fecal fistula (f. P value < 0.025 and < 0.001 respectively). In previously published studies mortality reported with repair of perforation was 48% by Bhansali,4 14.6% by Purohitg and 28% by A.R.K. Adesunkanmill. K.P. Singh and Kohli7 reported no mortality in 8 patients of enteric perforation treated with temporary ileostomy while overall mortality was 14.2%. Prasad et al reported 20% mortality with repair of perforation and ileo-transverse bypass. Shah A.A., Wani and Wazir17 reported 37.5% mortality with resection anastomosis. Thus in comparison with previous studies our mortality rates were lower, especially in patients treated with a repair of the perforation. Postoperative fecal fistula formation due to repair leak or new perforation was recorded in 16.5% of the total cases. Incidence of fecal fistula was reported as 16.6% by Olurin et al, 10% by Talwar S. and Sharma R.K.I8 and 8% by A.R.K. Adesunkanmi". Fecal fistula is a very sinister complication as it increases the morbidity and mortality. Development of fecal fistula was unrelated to the operative procedure performed ( x2 =2.407, d.f.=1, P value > 0.1). The best possible way to decrease the morbidity and mortality of typhoid perforation is to prevent typhoid fever by improved sanitation and immunization programmes. CONCLUSION Typhoid perforations continue to have high morbidity and mortality rates irrespective of the type of operative procedure performed. Mortality is significantly affected by the number of perforations and the development of postoperative fecal fistula. Morbidity and mortality are unrelated to the type of operation done. Simple repair of perforation in two layers is the choice of treatment for typhoid perforation. Primary ileostomy and repair of perforation with ileotransverse colostomy should be considered selectively in patients with multiple perforations, matted bowel loops and an unhealthy gut due to oedema and inflammation. Extensive procedures such as resection anastomosis and right hemicolectomy should be avoided in patients with poor general condition and toxaemia. Ileostomy as a secondary procedure should be considered once fecal fistula develops in order to avoid peritoneal contamination. REFERENCES
Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com The following images related to this document are available:Photo images[is03030t5.jpg] [is03030t1.jpg] [is03030t4.jpg] [is03030t3.jpg] [is03030t2.jpg] |
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