TYPHOID ENTERIC PERFORATION The features of the case now reported are in conformity with other reported descriptions of pseudomyxoma peritonei. Two points need
emphasis. ( i ) I t is probably the first such case diagnosed by peritoneoscopy, and confirmed as such by biopsy carried out in the course of this examination. With some hindsight, the diagnosis could have been thought of on the basis of the history, when a story of gradual abdominal distension and increasing size of the nodular hernia was obtained, but we were misled by the change in the patient’s bowel habits. (ii) There is good evidence (Long et alii, 1969; Santoro rt alii, 1961 ; editorial, Brit. mcd. J.. 1973: Little c t alii. 1969) that in the management of pseudomyxoma peritonei, treatment on the basis that the condition is hopeless shouId be abandoned in favour of a more radical policy. It is well known that its presence is compatible with long survival, even if it is untreated. Obviously, because of the rarity of the condition, it would be difficult to assess the value of the merits of different modes of treatment in a series of any con-
SINGHA N D SINGH sequence. There is, however, ample evidence that a radical operative approach, combined with either intraperitoneal or systemic chemotherapy, offers the best prospects (Long et alii, 1969).
ACKNOWLEDGEMENT I should like to express my sincere thanks to Professor G. B. Ong, Head of the Department of Surgery, University of Hong Kong, for his kind permission to use the record of his patient for publication. REFERENCES Editorial (I973), Brit. nzed. J., 3 : 603. FRAENKEL, E. (I~oI), Munch. nzed. Wschr., 48: 965. LITTLE, J. M., HALLIDAY,J, P. and GLENN, D. C. (i&g), Lamet, 2 : 659. LONG,R., SPRATT, J. and DOWLING,E. (1969), Amer. I . Surg., 117: 162. MCCRAE,T. and COPLIN (1916), Amer. J . nted. ScL, 151: 475. PETERS,C. (1899), Mschr. Geburtsch. Gyniik, 10: 749. WERTH (1884), Arch. Gymak., 24: 100. WILLIS,R. A. (I952), “The spread of tumors in the human body”, second edition, C. V. Mosby Co., St Louis: 54. WOODRUFF, R. 2nd MCDONALD, 3. R. (1950). S w g . Ggnec. Obstet., 71: 750.
Enteric Perforation in Typhoid Fever : A Study of 1 5 Cases JOGINDER S I N G HA~ N D BHOLLASINCH* Medical College and Rajindra Hospital, Patiala, India I i f f r c i i patierits sztfferinq froiti typhoid perforatton are reported and discussctl Coniroz’rrsy \till persf-\tc. regarding the best f o r m of treatment. One Gaia still oid3~ ctnte that e a c h pntzeiat should br trented on his or her merits.
WITH the advent of chloramphenicol, the mortality in typhoid fever has seen a remarkable decline. However, the incidence of the much-dreaded complications of perforation and hzmorrhage has not changed significantly (Woodward rt alii, 1954). The pathological changes in the intestine appear to he little ?’rofessor of Surgery.
’ Registrar
of Surgery.
AUSI. N.Z. J SLJRG., VOL.45 -KO 3, Awcusr, 1975
influenced by the antibiotic. El Ramli (1950) in his series of 200 patients treated with chloramphenicol observed a perforation rate of 3.5%. Stuart and Pullen (1946), before the chloramphenicol era, reported a 1.9% incidence of perforation in 360 cases. During the period January, 1971 to December, 1973, 899 patients with typhoid fever were admitted to the Medical College Hospital, Patiala. Out of these 15 sustained the complication of
279
TYPHOID ENTERIC PERFORATION enteric perforation, giving an incidence of 1.66%. Scott (1973) states that the incidence of' typhoid perforation varies between 1 % and
5%.
The authors report their present experience of 15 cases of enteric perforation, seen over a three-year period. Only confirmed cases are included, those who reacted to the Widal test, or who had free air under the dome of the diaphragm, with or without peritoneal spill as demonstrated by paracentesis. A g e and sex.-There were four chiidren in the series, while the oldest patient was aged 55 years. The remaining ten patients were young adults in their second or third decade of life. There was a male preponderance, there being only four females in the series. Duration of perforation.-Only one patient reported within six to eight hours of the perforation. Six reported within 24 to 48 hours, and four reported between 72 and 96 hours of the perforation. Duration of illness preceding the onset of perforation.-Perforation occurred in the first week of the illness in four patients and in another four in the second week. Out of the total of I j. perforation with associated hzmorrhage occurred in two patients. Reperforation occurred in two.
SINGHA N D STNGH therapy. Thirteen patients received irregular treatment for their illness before the onset of perforation. T h e usual pattern was treatment of a common cold, followed by antimalarial therapy and finally administration of broad-spectrum antibiotics, often including chloramphenicol on a somewhat haphazard basis.
MANAGEMENT This can be summarized as follows: I. 2.
Nature Number Deaths Closure of perforation with drainage . . . . . . . . . . 7 2 (i) Conservative . . 5 3 (ii) Supplementary drainage 3 2 "
8 -
5 -
Treatrnenf Prior to Perforation Only two patients were receiving regular chloramphenicol therapy before perforation. Out of these two. one was also receiving steroid
I. Closure of perforation. - Operative intervention was carried out in seven cases. Laparotoniy was done through a right paramedian incision under general anaesthesia. The perforation was closed by unabsorbable Lembert sutures. No effort was made to cover it with omentum. A corrugated rubber drain was brought out through the lower end of the incision and another drain was brought through the right flank. Occasionally the left flank was also drained. 2. ( i ) Conservative treatment.-This consisted of the Ochsner-Sherren regimen plus parenteral chloramphenicol therapy. Chloramphenicol was given in dosage of one gramme every four or six hours for one week, followed by half this amount every four or six hours in the second week. Oral administration of the drug was not started till the abdominal condition permitted. In addition, either tetracycline 2 jo nig six-hourly, or a combination of crystalline penicillin and streptomycin, was given for ten days. (ii) Supplementary drainage. - This was carried out as a desperate measure when there was gross soiling of the peritoneal cavity, and the general condition of the patient was too poor for any surgical intervention. Through a small incision under local anaesthesia a corrugated rubber drain was introduced into the peritoneal cavity through the right flank. This was done as a bedside procedure. Eight patients were treated by a conservative approach, including three who had supplementary drainage.
280
AUST.N.Z. J.
Presenting Features of Perforation In six of the I j patients, in whom the perforation occurred in the first week or the early part of the second week of the illness, the onset of perforation was marked by acute abdominal pain and spreading rigidity. T n the remaining nine, in whom the perforation was observed i n the latter part of the second week o r in the third week of the illness, acute abdominal pain was absent. Prominent features were increasing abdominal discomfort and progressive distension. There was little rigidity. Tachycardia and tachypncza were marked. Free fluid of seropurulent foul character was recovered by paracentesis in all cases. Culture of the aspirated material showed E . coli, or Streptococcus fEralis, or both organisms. in all cases.
SUHC,.. VOI..
35
- NO.
3.
.~LJGllSl.
1975
SINCHAND SINCH
TYPHOID ENTERIC PERFORATION rAuLE I
Analysis of ihe Saics of Paficnts Rcfiporfcd
No.
(Years)
Sex
Duration of perforation (hours)
I
17
M.
24-48
2
12
3
13 13
M. M. F.
Serial
4
Age
Time of onset of perforation
Treatment prior to perforation
Associated hiemorrhage
2nd week (late)
Irregular
No
72-96 72-96
3rd week 3rd week
24-48 24-48 6-8 24-48 24-48 48-72
1st week
Irregular Irregular Irregular Irregular Irregular Irregular Irregular Regular Irregular Regular steroid Irregular
No Yes No No No
5 6 7
20
a 9
55 30
10
25
i c
~
I1
22
F.
48-72
12
25
F.
48-72
2nd week (early) 1st week 2nd week (early) 1st week and week (late) 1st ~ week a 3rd week 3rd week
13
15
M.
4a-7~
3rd week
Irregular
No
14
IR
M.
72-96
3rd week
Irregular
Yes
15
28
M.
72-96
3rd week
Irregular
No
15 25
M. M. M. M. F.
~
-
+
Opctpative Findings In all seven patients subjected to surgery, there was a single perforation within the last 12 inches of the terminal ileum. T h e perforation was typically in the long axis of the g u t ; it generally measured 5 mm to 10 mm in length, and was situated on the antimesenteric border of the gut. The mesenteric glands showed moderate enlargement in all cases. The margins of the perforation were cedematous, but no undue friability of the gut was observed. The seromusciilar coat of the gut was tough enough to take the stitches well. The peritoneal cavity generally contained three to four litres of seropurulent. purulent, or fzecal material. .4fter removal of the pus by suction and mopping up of the peritoneal cavity, intestinal fluid of hilious type could be seen welling out of the perforation. There was no attempt at spontaneous sealing of the perforation. No adhesion formation was seen between the loops of gut and the parietal peritoneum or the greater omentum. I n the three patients in whom a simple drainage procedure had been employed, there was copious soakage of the dressings with purulent or facal discharge, which ultimately assumed a bilious character and persisted as a fzcal fistula, which proved fatal on two occasions. and took 48 days to close in the sole survivor.
No No
No NO No No
Treatment
(i) Closure (ii) Drainaie for re-perforation Conservative Conservative Closure Closure
Closure Closure Closure Conservative Conservative Conservative (i) Closure (ii) Closure' for re-perforation Drainage (conservative) Drainage (conservative) Drainage (conservative)
Result
Cure Death Death Death Cure Cure Death Cure Cure Cure Death Death
Cure Death Death
Re-perforation.-Re-perforation occurred in two of the seven patients subjected to surgery. The first patient survived a simple drainage procedure following a re-perforation which had occurred during convalescence. The second patient developed re-perforation and abdominal wound dehiscence twice and died. Mortality.-Of the seven patients treated by operation, two died, whereas of the eight patients treated conservatively five died.
DISCUSSION The mortality could not be related to either age or sex per se in the present study. It could, however, be directly related to the time lapse between perforation and treatment. When the duration of the perforation was less than 48 hours, the mortality was 14'25%, and it rose progressively thereafter. When the time lapse between perforation and treatment was 48 to 72 hours, the rnortaIity rose to 75%. and was 100% if the time interval was more than 72 hours. Mehta (1953) found a 29% mortality if the patient reported for treatment within 24 hours, as compared with a 90% mortality when treatment was carried out after this period. Sephaha et alii (1970) found that the mortality was 100% when the interval between perforation and treatment exceeded 24 hours. I n the present study there was a significant correlation between the mortality
28 I
Tur.rroin ENTERIC PERFORATION and the duration of the illness before the perforation occurred. Of the four patients who sustained a perforation in the first week of the illness, none died. Of a further four patients, whose perforation occurred in the second week, one died; of the other seven patients whose perforation occurred in the third week. none survived. Dickson and Cole (1964) also found that in those who died, there had been a longer period of illness than in those who survived. With early perforation in t h e illness, when the general condition of the patient is comparatively better, the chances of recovery are increased with institution of proper therapy. I n the third week, following prolonged toxemia, perforation is catastrophic. The condition of two patients in the series was complicated with hmnorrhage and neither survived. The association of h a n o r r h a g e worsens the outlook. Tw o patients in the series who were operated on developed re-perforation ,. I his worsens the prognosis, but it does not necessarily make it hopeless Scott and Ortner (1944) report successful closure of three re-perforations. A study of the availahle literature reveals that there is no finality concerning the preferable method of treatment for typhoid enteric perforation. There are strong advocates of conservative therapy (Huckstep, 1960 ; Woodward and Sniadel, 1964). Huckstep has presented the most convincing series treated by chloramphenicol and supportive therapy. I n his 15 patients so treated, only four died, while LVoodward and Smadel (1964) reported six patients treated conservatively with only one death. They regard the antibiotic line of treatment as depeadahle. T h e supporters of conservative therapy report that in chloramphenicol-treated patients, the peritoneal spill is sterile, the peritonits produced is localized hy adhesion formation, and there is a natural tendency for the perforation to heal. O n the other hand, the small intestine in typhoid fever is too fragile and almost like wet Idotting-paper. The inflamed Peyer patches are, i n fact, all potential perforations, and a \urgical attempt to suture a manifest perforation is hut a futile quest. Moreover, surgery for enteric perforation in a typhoid patient who is in a state of toxzinia has always been 282
SINGIIA N D SINCH associated with a staggering mortality of 80% to 1007~ (Wilcocks and Manson Bahr, 1972). There are equally strong advocates of surgical treatment of enteric perforation in typhoid (Dicksm and Cole, 1964 ; Shah, 1967 : Sephaha et alii, 1970). The association of a prohibitive mortality with surgical intervention is, in fact, related to the pre-chloramphenicol era. Shah (1967 j has reported a large series of 40 patients treated by operative closure with only a 22.5% mortality. Dickson and Cole (1964) treated 23 patients by operative closure, with 11 deaths, while of the seven patients treated conservatively all died. They even carried out resectional surgery in seven patients of whom only two survived: however, this was consistent with the type of the patients operated upon. Sephaha ct alii (1970) reported 50 patients treated conservatively, with 39 deaths, whereas ten were operated upon with four deaths. Shepherd (1960) states that in enteric typhoid perforation there is little tendency to spontaneous sealing. Even in patients operated upon late, there is lack of adhesion formation. Similar observations were made by us in six of the seven patients operated upon in our series. T h e peritoneal cavity contained an average of three t o four litres of pus, yielding a florid growth of E . coli or Streptococcus fcccalis or both. Chloramphenicol therapy alone could neither be relied upon to sterilize such large accumulations of pus nor to seal the perforation. Under such conditions surgical intervention is mandatory in order to close the source of leakage and to evacuate large collections of pus. Moreover, the exceptional friability of the gut associated with typhoid was not encoimtered. Of our 15 patients in the present series, 13 did not receive regular chloramphenicol therapy before perforation. Leakage under such conditions is followed by a purulent form of peritonitis. Huckstep ( 1960) has observed that his own patients, who at the time of perforation tvere already covered hy proper chloramphenicol therapy. developed as the result of the leak only a localized form of peritonitis which was usually sterile. Of the seven patients operated on in our series, two were lost. One died after re-perforation and ahdomiml wound dehisAUST. N Z. J S U I K VOL , 45 - N o
3. .AUGUST, r975
TYPIIOII)ESTERTC PERFORATION cence. The second, who reported 24 t o 48 hours after the perforation, presented with only lower abdominal rigidity and was fit for surgery. There was little soiling of the peritoneal cavity. This patient died suddenly 48 hours after the operation. Autopsy was not carried out. and the cause of death could not be determined. However, for this patient, the operative treatment was felt to be quite appropriate. The patients treated on conservative lines fa11 into three groups.
SINCHA N D SINCH
(.ii) Three patients with evidence of gross soiling of the peritoneal cavity reported for treatment between 48 and 96 hours of the perforation. They were then in the third week of their illness. None had prior chloramphenicol therapy. One had associated hiemorrhage. They had profound toxiemia and were not fit for any type of surgery. The condition of each deteriorated rapidly, and all died within three to five days of admission to hospital. (iii) This group of three patients was identical in clinical status with the preceding group. In view of the fulminating course of these three. supplementary drainage was carried out as a bedside procedure. Their further course was quite different from that of the preceding group, as they showed marked clinical improvement within three to four days of the drainage procedure. However, the condition of two of them deteriorated subsequently, and these two died after 10 to 15 days as a result of fluid loss from a facal fistula. The third patient survived. the facal fistula gradually closed and the patient left the hospital 48 days after the drainage procedure. Of the eight patients treated on conservative lines, five died. It is quite apparent that the six patients of the conservatively treated group presented late and were profoundly ill. The outcome would have been the same regardless
of any form of treatment adopted, rendering useless the adoption of any particular therapy. However, the clinical improvement observed following the institution of the drainage procedure in three patients lends support to the view that a more aggressive approach, though phased, is needed in an attempt to salvage the seemingly hopeless cases. I n the phase of recovery within a week of the drainage procedure, operative intervention should be considered in order to effect closure of the perforation or to even exteriorize the gut. The restriction of such patients to conservative therapy alone amounts to reconciliation to a state of abject despair. The results of a particular form of therapy for a condition like typhoid enteric perforation would depend on a number of factors, as the disease becomes manifest in its various gradations of toxzmia. It would depend on the time lapse between perforation and the institution of therapy, the duration of the illness before the onset of perforation, the occurrence of re-perforation, the association of perforation and hiemorrhage, and the question whether or not the patient had received proper and regular chloramphenicol therapy. In the light of the observations made in the present series, and the evidence available in the literature, neither surgery nor conservative therapy can be considered as the sole method of treatment for an enteric typhoid perforation. Each has its place, and they should be meted out as a judicious blend according to the requirements of the indivdual patient. W e feel that the following line of approach emerges as a result of the present study. I. If the patient reports within 48 hours of the perforation and shows minimal evidence of peritoneal soiling, conservative therapy should be given a trial in the first instance, because a typhoid patient is always an operative risk. 2. If the patient has obvious evidence of peritoneal soiling and reports within 48 hours of the perforation operative intervention should be carried out to close the perforation and to remove large collections of pus. Patients in whom perforation occurs in the first or second week of the illness stand the operation well, as they are not worn out by the effects of toxaemia.
T. SUKG., VOL.45 -NO. 3, AUGUST, 1975
283
(i) There were two patients who had minimal evidence of peritoneal soiling and were treated solely on conservative lines ; both survived. One is noteworthy ; although there was little evidence of peritoneal contamination, the patient was very toxic and was considered a grave surgical risk. However, antibiotic therapy brought about a surprising recovery.
.%UST.
N.Z.
PORTAL PYZMIA WITH COLONIC CARCINOMA 3 . When the patient reports late, generally after tilore than $3 hours of the perforation, and is profoundly ill, a preliminary drainage procedure should be carried out to permit the escape of the purulent collection. I n the phase of recovery, timely operative intervention may help some of these desperately ill patients to recover.
REFER I- N ( ,F.$ F)ICKSON, J. A . S. and COLE, G. J. (1964), Brit. 1.
Sco.r.~,R. I3. (19731, “Price’s T r x t Rook of the Practice of Medicine”, Oxford University Press, London, 11th ed.: SO. SEPHAHA, G. C., KHANDEKAK, I. I). and CHA1iR.Z. M. L. (1970). .I. Indiatz i i w d . Ass., 54: 558. SHAH,J. S. (1967), J. Ass. Phycns India, 15: 537. SHI:PHEKD, J. A. (1960), “Surgery of the Acute Abdomen”, E. and S. Livingstone Ltd., EdinIiurgli antl London: 368. STUAW, R. M. and PULLEN. I?. I.. (1946), .4vrh. i ~ i t e r ~.M’cd.. ~. 78 : 629. M‘ILCOCKS,C . and MANSONl3.4riiq 1’. E. C. (I972), “Manson’s Tropical Diseases”, T h e English language book iociety and l3ailIii.re-Tindal1, London, 17th etl.: 538. \~’ooIJLv.~H~), T. E. antl SMMADI:L. 1. E. (1964), Atin. iuteriz. Med., 60 : 144. WI)OI~\V.AKD, T. E.. SMADEI.. 1. F,. and T’AIIXER, R . T. (1954). .lfrrl. Cliii. N . .4rrirr., 38 : 577.
Portal Pyzmia Secondary to Carcinoma of the Rectum
emphasis. ( i ) I t is probably the first such case diagnosed by peritoneoscopy, and confirmed as such by biopsy carried out in the course of this examination. With some hindsight, the diagnosis could have been thought of on the basis of the history, when a story of gradual abdominal distension and increasing size of the nodular hernia was obtained, but we were misled by the change in the patient’s bowel habits. (ii) There is good evidence (Long et alii, 1969; Santoro rt alii, 1961 ; editorial, Brit. mcd. J.. 1973: Little c t alii. 1969) that in the management of pseudomyxoma peritonei, treatment on the basis that the condition is hopeless shouId be abandoned in favour of a more radical policy. It is well known that its presence is compatible with long survival, even if it is untreated. Obviously, because of the rarity of the condition, it would be difficult to assess the value of the merits of different modes of treatment in a series of any con-
SINGHA N D SINGH sequence. There is, however, ample evidence that a radical operative approach, combined with either intraperitoneal or systemic chemotherapy, offers the best prospects (Long et alii, 1969).
ACKNOWLEDGEMENT I should like to express my sincere thanks to Professor G. B. Ong, Head of the Department of Surgery, University of Hong Kong, for his kind permission to use the record of his patient for publication. REFERENCES Editorial (I973), Brit. nzed. J., 3 : 603. FRAENKEL, E. (I~oI), Munch. nzed. Wschr., 48: 965. LITTLE, J. M., HALLIDAY,J, P. and GLENN, D. C. (i&g), Lamet, 2 : 659. LONG,R., SPRATT, J. and DOWLING,E. (1969), Amer. I . Surg., 117: 162. MCCRAE,T. and COPLIN (1916), Amer. J . nted. ScL, 151: 475. PETERS,C. (1899), Mschr. Geburtsch. Gyniik, 10: 749. WERTH (1884), Arch. Gymak., 24: 100. WILLIS,R. A. (I952), “The spread of tumors in the human body”, second edition, C. V. Mosby Co., St Louis: 54. WOODRUFF, R. 2nd MCDONALD, 3. R. (1950). S w g . Ggnec. Obstet., 71: 750.
Enteric Perforation in Typhoid Fever : A Study of 1 5 Cases JOGINDER S I N G HA~ N D BHOLLASINCH* Medical College and Rajindra Hospital, Patiala, India I i f f r c i i patierits sztfferinq froiti typhoid perforatton are reported and discussctl Coniroz’rrsy \till persf-\tc. regarding the best f o r m of treatment. One Gaia still oid3~ ctnte that e a c h pntzeiat should br trented on his or her merits.
WITH the advent of chloramphenicol, the mortality in typhoid fever has seen a remarkable decline. However, the incidence of the much-dreaded complications of perforation and hzmorrhage has not changed significantly (Woodward rt alii, 1954). The pathological changes in the intestine appear to he little ?’rofessor of Surgery.
’ Registrar
of Surgery.
AUSI. N.Z. J SLJRG., VOL.45 -KO 3, Awcusr, 1975
influenced by the antibiotic. El Ramli (1950) in his series of 200 patients treated with chloramphenicol observed a perforation rate of 3.5%. Stuart and Pullen (1946), before the chloramphenicol era, reported a 1.9% incidence of perforation in 360 cases. During the period January, 1971 to December, 1973, 899 patients with typhoid fever were admitted to the Medical College Hospital, Patiala. Out of these 15 sustained the complication of
279
TYPHOID ENTERIC PERFORATION enteric perforation, giving an incidence of 1.66%. Scott (1973) states that the incidence of' typhoid perforation varies between 1 % and
5%.
The authors report their present experience of 15 cases of enteric perforation, seen over a three-year period. Only confirmed cases are included, those who reacted to the Widal test, or who had free air under the dome of the diaphragm, with or without peritoneal spill as demonstrated by paracentesis. A g e and sex.-There were four chiidren in the series, while the oldest patient was aged 55 years. The remaining ten patients were young adults in their second or third decade of life. There was a male preponderance, there being only four females in the series. Duration of perforation.-Only one patient reported within six to eight hours of the perforation. Six reported within 24 to 48 hours, and four reported between 72 and 96 hours of the perforation. Duration of illness preceding the onset of perforation.-Perforation occurred in the first week of the illness in four patients and in another four in the second week. Out of the total of I j. perforation with associated hzmorrhage occurred in two patients. Reperforation occurred in two.
SINGHA N D STNGH therapy. Thirteen patients received irregular treatment for their illness before the onset of perforation. T h e usual pattern was treatment of a common cold, followed by antimalarial therapy and finally administration of broad-spectrum antibiotics, often including chloramphenicol on a somewhat haphazard basis.
MANAGEMENT This can be summarized as follows: I. 2.
Nature Number Deaths Closure of perforation with drainage . . . . . . . . . . 7 2 (i) Conservative . . 5 3 (ii) Supplementary drainage 3 2 "
8 -
5 -
Treatrnenf Prior to Perforation Only two patients were receiving regular chloramphenicol therapy before perforation. Out of these two. one was also receiving steroid
I. Closure of perforation. - Operative intervention was carried out in seven cases. Laparotoniy was done through a right paramedian incision under general anaesthesia. The perforation was closed by unabsorbable Lembert sutures. No effort was made to cover it with omentum. A corrugated rubber drain was brought out through the lower end of the incision and another drain was brought through the right flank. Occasionally the left flank was also drained. 2. ( i ) Conservative treatment.-This consisted of the Ochsner-Sherren regimen plus parenteral chloramphenicol therapy. Chloramphenicol was given in dosage of one gramme every four or six hours for one week, followed by half this amount every four or six hours in the second week. Oral administration of the drug was not started till the abdominal condition permitted. In addition, either tetracycline 2 jo nig six-hourly, or a combination of crystalline penicillin and streptomycin, was given for ten days. (ii) Supplementary drainage. - This was carried out as a desperate measure when there was gross soiling of the peritoneal cavity, and the general condition of the patient was too poor for any surgical intervention. Through a small incision under local anaesthesia a corrugated rubber drain was introduced into the peritoneal cavity through the right flank. This was done as a bedside procedure. Eight patients were treated by a conservative approach, including three who had supplementary drainage.
280
AUST.N.Z. J.
Presenting Features of Perforation In six of the I j patients, in whom the perforation occurred in the first week or the early part of the second week of the illness, the onset of perforation was marked by acute abdominal pain and spreading rigidity. T n the remaining nine, in whom the perforation was observed i n the latter part of the second week o r in the third week of the illness, acute abdominal pain was absent. Prominent features were increasing abdominal discomfort and progressive distension. There was little rigidity. Tachycardia and tachypncza were marked. Free fluid of seropurulent foul character was recovered by paracentesis in all cases. Culture of the aspirated material showed E . coli, or Streptococcus fEralis, or both organisms. in all cases.
SUHC,.. VOI..
35
- NO.
3.
.~LJGllSl.
1975
SINCHAND SINCH
TYPHOID ENTERIC PERFORATION rAuLE I
Analysis of ihe Saics of Paficnts Rcfiporfcd
No.
(Years)
Sex
Duration of perforation (hours)
I
17
M.
24-48
2
12
3
13 13
M. M. F.
Serial
4
Age
Time of onset of perforation
Treatment prior to perforation
Associated hiemorrhage
2nd week (late)
Irregular
No
72-96 72-96
3rd week 3rd week
24-48 24-48 6-8 24-48 24-48 48-72
1st week
Irregular Irregular Irregular Irregular Irregular Irregular Irregular Regular Irregular Regular steroid Irregular
No Yes No No No
5 6 7
20
a 9
55 30
10
25
i c
~
I1
22
F.
48-72
12
25
F.
48-72
2nd week (early) 1st week 2nd week (early) 1st week and week (late) 1st ~ week a 3rd week 3rd week
13
15
M.
4a-7~
3rd week
Irregular
No
14
IR
M.
72-96
3rd week
Irregular
Yes
15
28
M.
72-96
3rd week
Irregular
No
15 25
M. M. M. M. F.
~
-
+
Opctpative Findings In all seven patients subjected to surgery, there was a single perforation within the last 12 inches of the terminal ileum. T h e perforation was typically in the long axis of the g u t ; it generally measured 5 mm to 10 mm in length, and was situated on the antimesenteric border of the gut. The mesenteric glands showed moderate enlargement in all cases. The margins of the perforation were cedematous, but no undue friability of the gut was observed. The seromusciilar coat of the gut was tough enough to take the stitches well. The peritoneal cavity generally contained three to four litres of seropurulent. purulent, or fzecal material. .4fter removal of the pus by suction and mopping up of the peritoneal cavity, intestinal fluid of hilious type could be seen welling out of the perforation. There was no attempt at spontaneous sealing of the perforation. No adhesion formation was seen between the loops of gut and the parietal peritoneum or the greater omentum. I n the three patients in whom a simple drainage procedure had been employed, there was copious soakage of the dressings with purulent or facal discharge, which ultimately assumed a bilious character and persisted as a fzcal fistula, which proved fatal on two occasions. and took 48 days to close in the sole survivor.
No No
No NO No No
Treatment
(i) Closure (ii) Drainaie for re-perforation Conservative Conservative Closure Closure
Closure Closure Closure Conservative Conservative Conservative (i) Closure (ii) Closure' for re-perforation Drainage (conservative) Drainage (conservative) Drainage (conservative)
Result
Cure Death Death Death Cure Cure Death Cure Cure Cure Death Death
Cure Death Death
Re-perforation.-Re-perforation occurred in two of the seven patients subjected to surgery. The first patient survived a simple drainage procedure following a re-perforation which had occurred during convalescence. The second patient developed re-perforation and abdominal wound dehiscence twice and died. Mortality.-Of the seven patients treated by operation, two died, whereas of the eight patients treated conservatively five died.
DISCUSSION The mortality could not be related to either age or sex per se in the present study. It could, however, be directly related to the time lapse between perforation and treatment. When the duration of the perforation was less than 48 hours, the mortality was 14'25%, and it rose progressively thereafter. When the time lapse between perforation and treatment was 48 to 72 hours, the rnortaIity rose to 75%. and was 100% if the time interval was more than 72 hours. Mehta (1953) found a 29% mortality if the patient reported for treatment within 24 hours, as compared with a 90% mortality when treatment was carried out after this period. Sephaha et alii (1970) found that the mortality was 100% when the interval between perforation and treatment exceeded 24 hours. I n the present study there was a significant correlation between the mortality
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Tur.rroin ENTERIC PERFORATION and the duration of the illness before the perforation occurred. Of the four patients who sustained a perforation in the first week of the illness, none died. Of a further four patients, whose perforation occurred in the second week, one died; of the other seven patients whose perforation occurred in the third week. none survived. Dickson and Cole (1964) also found that in those who died, there had been a longer period of illness than in those who survived. With early perforation in t h e illness, when the general condition of the patient is comparatively better, the chances of recovery are increased with institution of proper therapy. I n the third week, following prolonged toxemia, perforation is catastrophic. The condition of two patients in the series was complicated with hmnorrhage and neither survived. The association of h a n o r r h a g e worsens the outlook. Tw o patients in the series who were operated on developed re-perforation ,. I his worsens the prognosis, but it does not necessarily make it hopeless Scott and Ortner (1944) report successful closure of three re-perforations. A study of the availahle literature reveals that there is no finality concerning the preferable method of treatment for typhoid enteric perforation. There are strong advocates of conservative therapy (Huckstep, 1960 ; Woodward and Sniadel, 1964). Huckstep has presented the most convincing series treated by chloramphenicol and supportive therapy. I n his 15 patients so treated, only four died, while LVoodward and Smadel (1964) reported six patients treated conservatively with only one death. They regard the antibiotic line of treatment as depeadahle. T h e supporters of conservative therapy report that in chloramphenicol-treated patients, the peritoneal spill is sterile, the peritonits produced is localized hy adhesion formation, and there is a natural tendency for the perforation to heal. O n the other hand, the small intestine in typhoid fever is too fragile and almost like wet Idotting-paper. The inflamed Peyer patches are, i n fact, all potential perforations, and a \urgical attempt to suture a manifest perforation is hut a futile quest. Moreover, surgery for enteric perforation in a typhoid patient who is in a state of toxzinia has always been 282
SINGIIA N D SINCH associated with a staggering mortality of 80% to 1007~ (Wilcocks and Manson Bahr, 1972). There are equally strong advocates of surgical treatment of enteric perforation in typhoid (Dicksm and Cole, 1964 ; Shah, 1967 : Sephaha et alii, 1970). The association of a prohibitive mortality with surgical intervention is, in fact, related to the pre-chloramphenicol era. Shah (1967 j has reported a large series of 40 patients treated by operative closure with only a 22.5% mortality. Dickson and Cole (1964) treated 23 patients by operative closure, with 11 deaths, while of the seven patients treated conservatively all died. They even carried out resectional surgery in seven patients of whom only two survived: however, this was consistent with the type of the patients operated upon. Sephaha ct alii (1970) reported 50 patients treated conservatively, with 39 deaths, whereas ten were operated upon with four deaths. Shepherd (1960) states that in enteric typhoid perforation there is little tendency to spontaneous sealing. Even in patients operated upon late, there is lack of adhesion formation. Similar observations were made by us in six of the seven patients operated upon in our series. T h e peritoneal cavity contained an average of three t o four litres of pus, yielding a florid growth of E . coli or Streptococcus fcccalis or both. Chloramphenicol therapy alone could neither be relied upon to sterilize such large accumulations of pus nor to seal the perforation. Under such conditions surgical intervention is mandatory in order to close the source of leakage and to evacuate large collections of pus. Moreover, the exceptional friability of the gut associated with typhoid was not encoimtered. Of our 15 patients in the present series, 13 did not receive regular chloramphenicol therapy before perforation. Leakage under such conditions is followed by a purulent form of peritonitis. Huckstep ( 1960) has observed that his own patients, who at the time of perforation tvere already covered hy proper chloramphenicol therapy. developed as the result of the leak only a localized form of peritonitis which was usually sterile. Of the seven patients operated on in our series, two were lost. One died after re-perforation and ahdomiml wound dehisAUST. N Z. J S U I K VOL , 45 - N o
3. .AUGUST, r975
TYPIIOII)ESTERTC PERFORATION cence. The second, who reported 24 t o 48 hours after the perforation, presented with only lower abdominal rigidity and was fit for surgery. There was little soiling of the peritoneal cavity. This patient died suddenly 48 hours after the operation. Autopsy was not carried out. and the cause of death could not be determined. However, for this patient, the operative treatment was felt to be quite appropriate. The patients treated on conservative lines fa11 into three groups.
SINCHA N D SINCH
(.ii) Three patients with evidence of gross soiling of the peritoneal cavity reported for treatment between 48 and 96 hours of the perforation. They were then in the third week of their illness. None had prior chloramphenicol therapy. One had associated hiemorrhage. They had profound toxiemia and were not fit for any type of surgery. The condition of each deteriorated rapidly, and all died within three to five days of admission to hospital. (iii) This group of three patients was identical in clinical status with the preceding group. In view of the fulminating course of these three. supplementary drainage was carried out as a bedside procedure. Their further course was quite different from that of the preceding group, as they showed marked clinical improvement within three to four days of the drainage procedure. However, the condition of two of them deteriorated subsequently, and these two died after 10 to 15 days as a result of fluid loss from a facal fistula. The third patient survived. the facal fistula gradually closed and the patient left the hospital 48 days after the drainage procedure. Of the eight patients treated on conservative lines, five died. It is quite apparent that the six patients of the conservatively treated group presented late and were profoundly ill. The outcome would have been the same regardless
of any form of treatment adopted, rendering useless the adoption of any particular therapy. However, the clinical improvement observed following the institution of the drainage procedure in three patients lends support to the view that a more aggressive approach, though phased, is needed in an attempt to salvage the seemingly hopeless cases. I n the phase of recovery within a week of the drainage procedure, operative intervention should be considered in order to effect closure of the perforation or to even exteriorize the gut. The restriction of such patients to conservative therapy alone amounts to reconciliation to a state of abject despair. The results of a particular form of therapy for a condition like typhoid enteric perforation would depend on a number of factors, as the disease becomes manifest in its various gradations of toxzmia. It would depend on the time lapse between perforation and the institution of therapy, the duration of the illness before the onset of perforation, the occurrence of re-perforation, the association of perforation and hiemorrhage, and the question whether or not the patient had received proper and regular chloramphenicol therapy. In the light of the observations made in the present series, and the evidence available in the literature, neither surgery nor conservative therapy can be considered as the sole method of treatment for an enteric typhoid perforation. Each has its place, and they should be meted out as a judicious blend according to the requirements of the indivdual patient. W e feel that the following line of approach emerges as a result of the present study. I. If the patient reports within 48 hours of the perforation and shows minimal evidence of peritoneal soiling, conservative therapy should be given a trial in the first instance, because a typhoid patient is always an operative risk. 2. If the patient has obvious evidence of peritoneal soiling and reports within 48 hours of the perforation operative intervention should be carried out to close the perforation and to remove large collections of pus. Patients in whom perforation occurs in the first or second week of the illness stand the operation well, as they are not worn out by the effects of toxaemia.
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(i) There were two patients who had minimal evidence of peritoneal soiling and were treated solely on conservative lines ; both survived. One is noteworthy ; although there was little evidence of peritoneal contamination, the patient was very toxic and was considered a grave surgical risk. However, antibiotic therapy brought about a surprising recovery.
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PORTAL PYZMIA WITH COLONIC CARCINOMA 3 . When the patient reports late, generally after tilore than $3 hours of the perforation, and is profoundly ill, a preliminary drainage procedure should be carried out to permit the escape of the purulent collection. I n the phase of recovery, timely operative intervention may help some of these desperately ill patients to recover.
REFER I- N ( ,F.$ F)ICKSON, J. A . S. and COLE, G. J. (1964), Brit. 1.
Sco.r.~,R. I3. (19731, “Price’s T r x t Rook of the Practice of Medicine”, Oxford University Press, London, 11th ed.: SO. SEPHAHA, G. C., KHANDEKAK, I. I). and CHA1iR.Z. M. L. (1970). .I. Indiatz i i w d . Ass., 54: 558. SHAH,J. S. (1967), J. Ass. Phycns India, 15: 537. SHI:PHEKD, J. A. (1960), “Surgery of the Acute Abdomen”, E. and S. Livingstone Ltd., EdinIiurgli antl London: 368. STUAW, R. M. and PULLEN. I?. I.. (1946), .4vrh. i ~ i t e r ~.M’cd.. ~. 78 : 629. M‘ILCOCKS,C . and MANSONl3.4riiq 1’. E. C. (I972), “Manson’s Tropical Diseases”, T h e English language book iociety and l3ailIii.re-Tindal1, London, 17th etl.: 538. \~’ooIJLv.~H~), T. E. antl SMMADI:L. 1. E. (1964), Atin. iuteriz. Med., 60 : 144. WI)OI~\V.AKD, T. E.. SMADEI.. 1. F,. and T’AIIXER, R . T. (1954). .lfrrl. Cliii. N . .4rrirr., 38 : 577.
Portal Pyzmia Secondary to Carcinoma of the Rectum
