Ileostomy in the Treatment of Typhoid Enteric Perforation Among Patients Presenting Late in The Hospital

Introduction: Typhoid enteric perforation is a communal acute emergency of abdomen in our hospital settings. Maximum patients in Pakistan come from rural zones and have a serious illness when presented in the laten final stages. Objective: To govern the importance of an ileostomy in cases of late presentation with enteric perforation. Study Design: A retrospective study. Place and Duration: In the surgical Department of Islam Medical College and Teaching Hospital Sialkot for one year duration from July 2020 to July 2021. Methods: 52 total patients of typhoid enteric perforation were included in our department. 5 to 32 years was the age range of patients with an average age of 16 years. Most of these patients have complaints of fever, abdominal pain, abdominal distension and vomiting Results: 52 patients with late presentation of typhoid perforation were alienated into 2 groups. All cases of group A underwent laparotomy and perforation exteriorization was done as loop ileostomy. In group A, when exteriorization was performed as the first procedure, fecal fistula was later developed in 12 cases. Ten of these cases had to be re-examined and the second perforation was found to be close to the original one. The mortality was observed in three cases. Conclusion: In a relatively normal-looking intestine, restoration of the margin, closure of the two layers of perforation, and ileostomy near the perforation are safer in the case of late onset of typhoid fever enteric perforation. Keywords: typhoid perforation, double-layer closure and ileostomy

A study of non-traumatic gastrointestinal perforations in a tropical country

Background: Gastrointestinal perforations constitute one of the commonest surgical emergencies encountered by surgeons all over the world. However, non traumatic gastrointestinal perforations are more commonly seen in tropical countries. They cause considerable mortality and usually require emergency surgery. This study was designed to study the clinical spectrum of non traumatic gastrointestinal perforation in a tropical country and thereby assessing the surgical outcome.Methods: An observational study was conducted in the department of general surgery, Mamata medical college, Khammam to analyse the clinical spectrum and their management protocol with outcome of the patients presenting with non traumatic gastrointestinal perforation. A total number of 140 patients of various etiologies of non traumating gastrointestinal perforations were found to be treated over a period of six years. Detailed demographic profile, clinical presentations and etiological factors were studied along with various management protocols offered to them with the outcome.Results: Most common age of presentation was 41-60 years with 72%being males. Most common site of perforation was duodenum (28.57%) followed by stomach (25%). Peptic ulcer (53.57%) was the predominant etiology followed by appendicular perforation (15.71%), enteric perforation (12.85%), tubercular (4.28%), malignancy (1.42%) and diverticula (0.71%). Most common post-operative complication was wound infection (37.14%) followed by dyselectrolytaemia (31.42%). Mortality was 7.14%.Conclusions: Gastrointestinal perforations constitute one of the commonest surgical emergencies. Non traumatic gastrointestinal perforations are quite common in a tropical country like India. The high rates of mortality among those, who present late, prompt an early diagnosis and active management protocol in order to reduce mortality and morbidity in such patients.

East surgical ward enteric perforation score: a new statistically valid scoring criteria for decision between repair or ileostomy in patients with peritonitis due to enteric perforation

Background: Enteric fever leading to enteric perforation is very common surgical emergency in the developing nations. The two surgical solutions used worldwide are to repair or exteriorize the perforation as ileostomy. The aim of the study was to setup and validate a statistically reliable scoring system for decision between repair and ileostomy in patients with peritonitis due to enteric perforation.Methods: It was an observational cross-sectional study done at East Surgical Ward of Mayo Hospital, Lahore. 256 patients were selected by consecutive non-probability sampling after ethical approval. The duration of study was 2 years from 1st August to 2018 to 30th July 2020. Patients with age more than 13 years presented in emergency department with diagnosis of peritonitis due to enteric perforation were included. A preformed scoring criterion named as East surgical ward enteric perforation (ESWEP) score was set by giving each variable a score of 1 to 3. Cut-off value between repair and ileostomy was observed.Results: 142 (55.4%) patients were male and 114 (44.5%) were female. Male to female ratio was 1: 1.24. The average age of patients is about 37 years with SD of ±9.67 years. ROC curve showed cut-off of pre-operative ESWEP score of 4 (sensitivity78%, specificity of 88%), per operative score of 7 (sensitivity 96%, specificity of 85%) and total ESWEP score of 11 (sensitivity 94%, specificity of 88%).Conclusions: ESWEP score is new score which helps in standardization of operative procedure done for the patients with peritonitis due to enteric perforation.

Study of antibiotic resistance in patients of enteric perforation in a tertiary care hospital.

Objective: To study the clinical outcomes and determine the antibiotic resistance in patients of enteric perforation in a tertiary care hospital. Study Design: Cross Sectional study. Setting: Department of General Surgery at Nishtar Hospital, Multan. Period: May 2017 to December 2019. Material & Methods: Sample size was calculated to be 97 with a confidence level of 95% and margin of error of 10%. We collected data from 100 patients. All the surgeries were done by the same team of consultant surgeons. The abdomen was closed by the same surgical team using the same surgical technique to avoid any bias. All the continuous variables were reported as mean ± standard deviation. The antibiotic resistance was compared with the number of patients with wound infections, burst abdomen, ICU admissions and number of in-hospital stay days. Categorical variables were compared using Chi square test for Independence. The number of in-hospital stay days were compared using Student t-test. The results were compiled using SPSS version 20. Results: Our result indicated that a patient had a greater chance of having a burst abdomen and wound infection if there was resistance to ciprofloxacin or ceftriaxone. Similar results were obtained for ICU admissions. There was a significantly longer in-hospital stay observed for patients who were resistant to the standard regimen of Ceftriaxone. Conclusion: It seems only rationale that the patients susceptible should be treated with Imipinem for 2 weeks as the empirical therapy rather than the standard empirical therapy of ceftriaxone and ciprofloxacin. The blood cultures can be sent before starting Imipinem and treatment management plan changed if the culture results are sensitive for the empiric antibiotics.

A STUDY OF SURGICALAPPROACH TO TYPHOID ILEAL PERFORATION

Introduction: Even with variety of procedures, typhoid (enteric) perforation still has a high rate of morbidity and mortality. The aim ofthe present study is to study clinical presentations, to evaluate management pattern of typhoid ileal perforation, to determine mortality and morbidity of perforation and to study the re-exploration rate and causes of re-exploration and its effect on mortality and morbidity. Methods: This prospective observational study was conducted in the Department of Surgery at Nalanda Medical College and Hospital, Patna, Bihar during May 2019toApril 2020. A total 45 patients with typhoid ileal perforation were included in the study. Among them, 32 cases (71%) undergone the simple primary closure of the perforation and peritoneal lavage after refreshing the edge, 7 cases (16%) undergone exploratory laparotomy with proximal loop ileostomy with primary closure and 6 (13%) were operated by exploratory laparotomy with resection anastomosis. Results: Mean duration of the stay for patient undergone PC+PL was 10.20 days and for ileostomy it was 18.4 days and for RA + PL it was18.6 days. Total 37 incidences of complications were found in 45 cases. Among them wound infection was presented in 16 (43%) and burst abdomen presented in 2 (5%) cases. Fecal fistulae, post-operative collection and pneumonitis were present in 4 (11%) cases each. Conclusion: The overall mortality was found nearly 4 percent in our study. The typhoid ileal perforation should be always treatedsurgically. There are many operative techniques to deal with but no one is full proof.

Enteric Fever Complicated by Intestinal Perforation in Children: A Persistent Health Problem Requiring Surgical Management

Objective: To evaluate clinical presentation and surgical outcome in children with enteric perforation. Methods: A descriptive retrospective study was conducted in Department of Paediatric Surgery at National Institute of Child Health, Karachi from August 2016 and September 2019, in children 12 years of age and under with diagnosis of enteric perforation. Data about age, gender, duration of illness, hemodynamic status and baseline investigation on admission was reviewed. Details about patients operated early and those who required prolong resuscitation and were operated after 24 hours of admission, need for tube laparostomy, operative findings, type of surgical procedure performed and post-operative outcome were reviewed. Data was analyzed using SPSS version 22. Results: Ninety-seven patients, 60(61.85%) males and 37(38.14%) females were managed during the study period with age ranged from 3-12 years (mean 7.82, ± 2.94 years).and duration of symptoms ranged from 7-30 days (mean 15.56, ± 9.39days). High grade fever and abdominal pain were seen in all patients (100%). Pneumoperitoneum was noted in 71(73.19%) cases on X-ray abdomen. Fifty-one (52.57%) children were anemic and required blood transfusion before surgery. Seventy-one (73.19) patients were optimized and operated within 24 hours while 28(28.86%) cases required more resuscitation so tube laparostomy was done initially and operated after 24 hours. Seventy nine (81.44%) cases had single perforation, 14(14.43%) cases had multiple and four had sealed perforation. Primary repair of perforation was done in 37(38.14%) cases, while ileostomy in 65(76.01%) cases. Postoperatively wound infection was seen in 71(73.19%) cases, intra-abdominal collections in 31(31.95%) and burst abdomen in nine (9.27%) cases. Overall mortality was 12.37%. Till date in 47 patients (72.30%) reversal of stoma has been done. Conclusions: Enteric perforation in children presents usually with hemodynamic instability and sepsis due to prolong period of illness. Therefore, regardless of surgical procedure performed it is associated with high morbidity and mortality. doi: https://doi.org/10.12669/pjms.36.5.2270 How to cite this:Azhar M, Zamir N, Shaikh M, Inayat ullah4. Enteric Fever Complicated by Intestinal Perforation in Children: A Persistent Health Problem Requiring Surgical Management. Pak J Med Sci. 2020;36(5):---------. doi: https://doi.org/10.12669/pjms.36.5.2270 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Incidence and management of intestinal perforation in typhoid: a prospective, observational study

Background: Intestinal perforation is a common surgical problem, which need proper attention. Typhoid is the most common cause of bowel perforation. With the concept of a correct diagnosis of perforation in reference to its etiology and further study of etiological factor (typhoid) in relation to epidemiology, surgical treatment and outcome, the present study has been undertaken.Methods: It is a prospective, observational study in which 50 cases of enteric perforation admitting in SMS Hospital at JAIPUR were observed. All patients of enteric perforation peritonitis were evaluated by detailed history, clinical examination and radiological as well as laboratory investigations. After initial resuscitation patient were treated by operative procedures. Postoperatively progress report, morbidity and mortality data were observed.Results: Mean age of patients was 26.38 years. Male to female ratio was 4:1. Enteric perforation is more common in patients with poor nutritional status and rural area. Primary repair of perforation was done in patient with small perforation with relatively healthy bowel, while ileostomy was done in patients with large perforation of longer duration, multiple perforations and edematous bowel with necrotic patches. Mortality was highest in patients who underwent primary repair and proximal loop ileostomy (33.3%) and lowest in patients in which exteriorization of the perforation as loop ileostomy was done (10.3%).Conclusions: The time interval between occurrence of perforation and starting of specific therapy is the most important factor in deciding the ultimate outcome of the typhoid perforation patient and operative procedure is another important factor in deciding the outcome.

Intestinal stomas: A clinical study in a Teaching Hospital, our experience

Background: An intestinal stoma is an opening of the intestine on anterior abdominal wall made with an intention of either decompression of an obstructed colon or diversion of stool. Intestinal stomas may be temporary or permanent, depending on their role. Objectives: The objective of this study was to determine the common indications and types of intestinal stomas, and outcomes of patients operated at Manipal Teaching Hospital, Pokhara, Nepal. Methodology: A retrospective cross-sectional study was conducted in 105 patients of intestinal stomas from February 2017 to March 2020 in a teaching hospital after approval from institutional review committee. Data were derived from medical records of patients and operation logbooks with the consecutive sampling method. Data were analyzed with the help of the Statistical Package for Social Sciences (SPSS) version20 and p value < 0.05 was considered significant. Results: Total of 105 patients with intestinal stomas was included for the study of which 82.9% (n=63) were emergency operations and 17.1% (n=13) were elective. There were 46 (43.80%) cases of ileostomy, 9(8.5%) jejunostomy and 50(47.6%) colostomy patients. Major indications of stoma formation were trauma 33.3% (n=35) and intestinal obstruction 22.8% (n=24). Complications were observed in 39 (37.14%) of the patients, with wound infection 11.8% (n=9) and peristomal dermatitis 11.8% (n=9) for ostomates being the commonest. Higher complications were seen with ileostomy as compared to colostomy (p=0.02) and loop ileostomy still higher than end ileostomy (p=0.00). Conclusion: Common indications for intestinal stomas were abdominal trauma, enteric perforation, intestinal obstruction and colorectal carcinoma. Main complications included local skin problems, wound infection and retraction.

Outcome of various surgical procedures and their outcome following enteric perforation at Dr. Ruth K.M.Pfau, Civil Hospital, Karachi.

Objectives: To observe the outcome of various surgical procedures opted in patients presenting with peritonitis, following typhoid perforation. Study Design: Prospective observational study. Setting: Single surgical unit, Dr. Ruth K.M.Pfau, Civil Hospital, Karachi. Period: 37 months from December 2014 to December 2017. Material and Methods: 25 patients who were admitted from emergency department with the clinical diagnosis of peritonitis following typhoid perforation. The diagnosis of typhoid peritonitis was confirmed on histopathology with the finding of chronic inflammation not associated with granuloma/ giant cell and malignant cells. Results: Out of 25 patients there were 19(76%) male and 6(24%) female patients. The mean age± standard deviation (SD) was 29.52±15 years. Fever and abdominal pain was present in all patient. Generalized peritonitis was present in 23(92%), single perforation at terminal ileum was found in 23(92%). Whereas, loop ileostomy was the commonest procedure performed 14(56%) of patients. En masse abdominal wall closure was performed in 22(88%), however, skin closure was only possible in 11(44%) of the patients. Wound infection was common complication noted 21(84%), whereas 2(8%) patients died during treatment. Conclusion: With reference to morbidities and mortality loop ileostomy seems to be have a good outcome.