Abstract

ENTERIC PERFORATION: A CONSENSUS APPROACH OF MANAGEMENT

Dr. Purujit Choudhury and Dr. Pranab Boro*

ABSTRACT

Introduction and Aim: Intestine perforation is one of the most dreaded and common complication of typhoid fever remarkably so in developing world; it usually leads to diffuse peritonitis, requiring early surgical intervention. Despite various measures such as safe drinking water supply and safe disposal of waste, intestinal perforation from salmonellosis remains the most common emergency surgery performed. The incidence continues to rise, so also the mortality, despite new antibiotics and improvement in surgical technique. More disturbing is that we now see increasing number of ileal perforations and colonic involvement. Typhoid fever is a systemic and severe febrile illness caused primarily by the gram negative bacillus Salmonella enteritidis serovar Typhi: Hence it is an infective disorder with fatal outcome if the disease is not treated properly. The most lethal complication of it are bleeding and ileal perforation, both arising from necrosis of Peyer’s patches in the terminal ileum. Complications are to be controlled as and when infection is cured. The aim of this study: to know the best treatment protocol for this emergency disease after a thorough genesis. Also to show whether simple repair of perforation is the justified surgical procedure in terms of morbidity, mortality and cost effectiveness. Materials and Methods: The present study was conducted in 195 adult patients of Typhoid perforation admitted during 2014 to 2018 and treated surgically at Gauhati Medical College. Double layer simple closure of perforation done in majority. In this study enteric perforation was more common in males than in females with a ratio of 6.8:1.Their ages ranges from 14 to 65 years. Duration of perforation, number of perforation and development of faecal fistula are the factors which significantly affect mortality. Primary proximal temporary ileostomy and ileo transverse anastomosis were performed in some patients with multiple perforations and/or with perforation situated near/on the ileocaecal junction having greater risk of “repair leak”. Resection and anastomosis is considered in some cases of multiple perforations and unhealthy gut with or without defunctioning ileostomy. Results: Common post-operative complications include wound infection (21%), bleeding (1.02%-2 cases out of 195), faecal fistula (1.9%)-4 cases out of 195 and skin excoriation around ileostomy (9.4%).Primary closure (two layer) of perforation satisfactory result in terms of complications and resection is preferred in selected patients. Conclusions: Ileal perforation following typhoid fever is not unusual. Resuscitation followed by emergency surgery is the appropriate to manage. Quinolone is the drug of choice. Usually two layer primary closure is the procedure of choice though resection and anastomosis is reserved for special situation.Prognosis is much better if appropriately managed.

Keywords: Typhoid perforation, repair of perforation, ileostomy, repair with ileo transverse anastomosis.