1078 TABLE I-AGE AND SEX DISTRIBUTION OF
Occasional
50 CASES OF TYPHOID
PERFORATION
Survey
SURGICAL TREATMENT OF TYPHOID PERFORATION
NIMIT C. MARTIN
THEODORE P. WELCH
Department of Surgery, Faculty of Medicine, University of Chiang Mai, Chiang Mai, Thailand The treatment of perforation of the ileum in 50 cases of typhoid fever is reviewed. Because of the risk of reperforation after surgical closure of a perforation, wedge excision of the ulcer if there is a single area of diseased bowel or segmental resection of the ileum if the ileum is more extensively affected are recommended.
Sum ary
INTRODUCTION
PERFORATION of the terminal ileum is a fairly comsurgical emergency in the tropics. It has many causes, such as trauma, ascariasis, amoebiasis, and tuberculosis, but one of the most common causes, apart from trauma, is typhoid perforation. Typhoid fever is still endemic in many areas, and typhoid perforation of the ileum is a very serious complication. Its frequency has been estimated to be between 05 %1 and 17’9%2 of cases. This wide variation may be related in part to factors such as pattern of referral, criteria for hospital admission, and type of chemotherapy. Nonoperative treatment of typhoid perforation with chloramphenicol and the Oschner-Sherren regimen was recommended at one time,3 but lately surgery has been strongly advocated and the mortality figures have
mon
improved considerably from 80%4 to 10%.5 While many authorities recommend operative treatment for typhoid perforation, there is no uniformity of opinion of surgery that should be undertaken. At our hospital, where patients with typhoid perforation are seen frequently, various types of procedures from simple closure to more extensive resection have been used. While patients in our series were not randomly allocated to the various forms of surgical therapy, enough patients were treated with each type of surgery during the 14 years of our study for us to draw some tentative conclusions. as to
the
extent
PATIENTS AND METHODS
This is a retrospective study of 50 patients with typhoid perforation. We have analysed all the records we could obtain of patients seen between the years 1961 and 1974 at the Chiang Mai City Hospital who were treated surgically for typhoid perforation. The only patients excluded were a few treated medically and a few whose records were not available for analysis. Although there were several variations of operative procedure, the operations could be grouped in four categories: simple surgical closure of the perforation, wedge excision of the ulcer and closure of the ileum, resection of a length of ileum, and ileal resection pluus partial colectomy. The results of these four forms of surgical therapy are compared. RESULTS
The ages of the
patients
admitted with
typhoid
per-
foration during this 14-year period ranged from 6 to 67 years. Table i shows the age distribution. The mortality-rate did not vary significantly by age.
Clinical Presentation The preoperative diagnosis was made primarily on the clinical picture. The clinical diagnosis can often be difficult, and several patients were operated on with a provisional diagnosis of acute appendicitis or perforated peptic ulcer. Fever was a common symptom and had been present for from 1 to 30 days with an average duration of 8-7 days, confirming that perforation usually occurs during the second week of the disease. All cases had abdominal pain lasting 1-10 days with an average duration of 6 days. 21 patients (42%) had diarrhoea and 14 cases (28%) had a history of melsena. 5 patients were shocked on admission (all with a 6-7 day history of pain): 2 of these patients died. All the patients had abdominal tenderness, but only 15 were noted to have a distended abdomen.
Investigations The white-blood-cell count was raised above 10,000 per c.mm. in 29 patients (58%), but in only 4 of these was it above 20,000 per c.mm. X-rays of the abdomen were taken in the upright position in 21 patients, and 15 of these showed free air under the
diaphragm. Typhoid fever
confirmed in all cases. Widal tests were taken to be positive if the H titre was more than 1/50 or the 0 titre more than 1/100.6 They were positive in 27 patients. The other patients were diagnosed by positive cultures of blood, stool, or ascitic fluid or examination of the resected ileum. The site of the perforation in the ileum ranged between 2-5 cm. and 160 cm. from the ileocaecal valve (average 50 cm.). The size ranged from 2 to 22 mm. in diameter (average 5 mm.). In 9 cases the perforations were multiple with two, three, or four perforations. In 2 other cases there was, in addition to a perforation, an area of necrotic ileum which had not yet perforated. The choice of operation did not seem to have any correlation with the site or number of was
perforations. Treatment Because the diagnosis was usually made only at operation, specific antibiotic therapy for typhoid was started after operation. All were treated with chloramphenicol, and in a few cases this was supplemented with ampicillin or co-trimoxazole. None of the strains were known to be resistant to chloramphenicol. 1 in for had been the medical ward 14 on days patient chloramphenicol before perforation. All the others were admitted as surgical emergencies.
1079
The patients were operated on by many different surgeons and no guidelines had been given as to the best procedure. The distribution of the type of surgical procedure used over the years covered in this series is fairly even. The availability of better postoperative care (an intensive-care unit) in recent years would apply to patients treated by all the surgical
procedures. The surgical categories:
fell
treatment
(1) Simple closure (2) Wedge excision
of the
into
perforation
four in two
main
layers.
of the ulcer and closure of the ileal
defect. (3) Resection offlength of ileum which included the site of the perforation or perforations and anastomosis in two
layers. of the terminal ileum (including the site of with a partial colectomy and ileotransverse anastomosis or a colostomy and ileostomy. The results are summarised in table n.
(4) Resection
perforation)
Of the 11patients treated by foration 1 had perforations at
simple closure of the two
persites. 4 died. In the
TREATED FOR TYPHOID PERFORATION BY FOUR DIFFERENT SURGICAL PROCEDURES
TABLE II-RESULTS OF PATIENTS
Figures in parentheses indicate deaths.
’
fatal cases there was leakage from the site of the perforation. 2 died of peritonitis, and no further operation was performed; 1 had a length of ileum, including the leaking perforation, resected, but he died later; the fourth developed a fistula from the leak, an ileostomy was done, but he died 63 days after the first operation.
Wedge excision of the penoration was performed on 12 patients. All survived, except 1 who had two perforations, both treated by wedge excision and closure of the ileum. He leaked from the sites of the closures and had 60 cm. of ileum, including the sites of perforation, resected. There was subsequent leakage from the anastomosis and he died from peritonitis. Resection of a length of ileum with end-to-end anastomosis was performed on 20 patients. 17 survived. 1 died from septicaemia. Another had resection of the ileum with ileotransverse anastomosis. He died of septicaemia, and necropsy confirmed that there was no leakage from the anastomosis or the closed end of ileum. The third who died leaked from the anastomosis, and although a defunctioning ileostomy was done, he died of pneumonia and
peritonitis. 7 patients were treated by resection of a length of terminal ileum combined with a partial colectomy (usually a right hemicolectomy). 4 had a right hemicolectomy with no associated colostomy. 2 made uneventful recoveries. Of the other 2, 1 had a burst abdomen resutured and was able to go home after a long and stormy convalescence. The other patient had a subphrenic abscess and died after
an operation to drain this. There was no leakage from the bowel anastomosis. All the 3 who had a hemicolectomy with ileostomy and colostomy subsequently had the ileostomy closed and anastomosis of the ileum and transverse colon. 1 of these died after the second operation. Another had to undergo laparotomy because of obstruction from adhesions, but he survived to return home.
81
The duration of hospital admission varied from 8 days with an average of 26 days.
to
Mortality-rates varied from 43 % in those treated right hemicolectomy with or without colostomy or ileostomy, 36 % in cases with simple closure, 15 % in those treated with ileal resection, to 8 % of those treated with wedge excision (table 11). The differences between the mortality-rates for wedge excision and local ileal resection were significantly lower than those for simple closure of the perforation or with right hemiThe frequency of colectomy (x2=327, p
Occasional
50 CASES OF TYPHOID
PERFORATION
Survey
SURGICAL TREATMENT OF TYPHOID PERFORATION
NIMIT C. MARTIN
THEODORE P. WELCH
Department of Surgery, Faculty of Medicine, University of Chiang Mai, Chiang Mai, Thailand The treatment of perforation of the ileum in 50 cases of typhoid fever is reviewed. Because of the risk of reperforation after surgical closure of a perforation, wedge excision of the ulcer if there is a single area of diseased bowel or segmental resection of the ileum if the ileum is more extensively affected are recommended.
Sum ary
INTRODUCTION
PERFORATION of the terminal ileum is a fairly comsurgical emergency in the tropics. It has many causes, such as trauma, ascariasis, amoebiasis, and tuberculosis, but one of the most common causes, apart from trauma, is typhoid perforation. Typhoid fever is still endemic in many areas, and typhoid perforation of the ileum is a very serious complication. Its frequency has been estimated to be between 05 %1 and 17’9%2 of cases. This wide variation may be related in part to factors such as pattern of referral, criteria for hospital admission, and type of chemotherapy. Nonoperative treatment of typhoid perforation with chloramphenicol and the Oschner-Sherren regimen was recommended at one time,3 but lately surgery has been strongly advocated and the mortality figures have
mon
improved considerably from 80%4 to 10%.5 While many authorities recommend operative treatment for typhoid perforation, there is no uniformity of opinion of surgery that should be undertaken. At our hospital, where patients with typhoid perforation are seen frequently, various types of procedures from simple closure to more extensive resection have been used. While patients in our series were not randomly allocated to the various forms of surgical therapy, enough patients were treated with each type of surgery during the 14 years of our study for us to draw some tentative conclusions. as to
the
extent
PATIENTS AND METHODS
This is a retrospective study of 50 patients with typhoid perforation. We have analysed all the records we could obtain of patients seen between the years 1961 and 1974 at the Chiang Mai City Hospital who were treated surgically for typhoid perforation. The only patients excluded were a few treated medically and a few whose records were not available for analysis. Although there were several variations of operative procedure, the operations could be grouped in four categories: simple surgical closure of the perforation, wedge excision of the ulcer and closure of the ileum, resection of a length of ileum, and ileal resection pluus partial colectomy. The results of these four forms of surgical therapy are compared. RESULTS
The ages of the
patients
admitted with
typhoid
per-
foration during this 14-year period ranged from 6 to 67 years. Table i shows the age distribution. The mortality-rate did not vary significantly by age.
Clinical Presentation The preoperative diagnosis was made primarily on the clinical picture. The clinical diagnosis can often be difficult, and several patients were operated on with a provisional diagnosis of acute appendicitis or perforated peptic ulcer. Fever was a common symptom and had been present for from 1 to 30 days with an average duration of 8-7 days, confirming that perforation usually occurs during the second week of the disease. All cases had abdominal pain lasting 1-10 days with an average duration of 6 days. 21 patients (42%) had diarrhoea and 14 cases (28%) had a history of melsena. 5 patients were shocked on admission (all with a 6-7 day history of pain): 2 of these patients died. All the patients had abdominal tenderness, but only 15 were noted to have a distended abdomen.
Investigations The white-blood-cell count was raised above 10,000 per c.mm. in 29 patients (58%), but in only 4 of these was it above 20,000 per c.mm. X-rays of the abdomen were taken in the upright position in 21 patients, and 15 of these showed free air under the
diaphragm. Typhoid fever
confirmed in all cases. Widal tests were taken to be positive if the H titre was more than 1/50 or the 0 titre more than 1/100.6 They were positive in 27 patients. The other patients were diagnosed by positive cultures of blood, stool, or ascitic fluid or examination of the resected ileum. The site of the perforation in the ileum ranged between 2-5 cm. and 160 cm. from the ileocaecal valve (average 50 cm.). The size ranged from 2 to 22 mm. in diameter (average 5 mm.). In 9 cases the perforations were multiple with two, three, or four perforations. In 2 other cases there was, in addition to a perforation, an area of necrotic ileum which had not yet perforated. The choice of operation did not seem to have any correlation with the site or number of was
perforations. Treatment Because the diagnosis was usually made only at operation, specific antibiotic therapy for typhoid was started after operation. All were treated with chloramphenicol, and in a few cases this was supplemented with ampicillin or co-trimoxazole. None of the strains were known to be resistant to chloramphenicol. 1 in for had been the medical ward 14 on days patient chloramphenicol before perforation. All the others were admitted as surgical emergencies.
1079
The patients were operated on by many different surgeons and no guidelines had been given as to the best procedure. The distribution of the type of surgical procedure used over the years covered in this series is fairly even. The availability of better postoperative care (an intensive-care unit) in recent years would apply to patients treated by all the surgical
procedures. The surgical categories:
fell
treatment
(1) Simple closure (2) Wedge excision
of the
into
perforation
four in two
main
layers.
of the ulcer and closure of the ileal
defect. (3) Resection offlength of ileum which included the site of the perforation or perforations and anastomosis in two
layers. of the terminal ileum (including the site of with a partial colectomy and ileotransverse anastomosis or a colostomy and ileostomy. The results are summarised in table n.
(4) Resection
perforation)
Of the 11patients treated by foration 1 had perforations at
simple closure of the two
persites. 4 died. In the
TREATED FOR TYPHOID PERFORATION BY FOUR DIFFERENT SURGICAL PROCEDURES
TABLE II-RESULTS OF PATIENTS
Figures in parentheses indicate deaths.
’
fatal cases there was leakage from the site of the perforation. 2 died of peritonitis, and no further operation was performed; 1 had a length of ileum, including the leaking perforation, resected, but he died later; the fourth developed a fistula from the leak, an ileostomy was done, but he died 63 days after the first operation.
Wedge excision of the penoration was performed on 12 patients. All survived, except 1 who had two perforations, both treated by wedge excision and closure of the ileum. He leaked from the sites of the closures and had 60 cm. of ileum, including the sites of perforation, resected. There was subsequent leakage from the anastomosis and he died from peritonitis. Resection of a length of ileum with end-to-end anastomosis was performed on 20 patients. 17 survived. 1 died from septicaemia. Another had resection of the ileum with ileotransverse anastomosis. He died of septicaemia, and necropsy confirmed that there was no leakage from the anastomosis or the closed end of ileum. The third who died leaked from the anastomosis, and although a defunctioning ileostomy was done, he died of pneumonia and
peritonitis. 7 patients were treated by resection of a length of terminal ileum combined with a partial colectomy (usually a right hemicolectomy). 4 had a right hemicolectomy with no associated colostomy. 2 made uneventful recoveries. Of the other 2, 1 had a burst abdomen resutured and was able to go home after a long and stormy convalescence. The other patient had a subphrenic abscess and died after
an operation to drain this. There was no leakage from the bowel anastomosis. All the 3 who had a hemicolectomy with ileostomy and colostomy subsequently had the ileostomy closed and anastomosis of the ileum and transverse colon. 1 of these died after the second operation. Another had to undergo laparotomy because of obstruction from adhesions, but he survived to return home.
81
The duration of hospital admission varied from 8 days with an average of 26 days.
to
Mortality-rates varied from 43 % in those treated right hemicolectomy with or without colostomy or ileostomy, 36 % in cases with simple closure, 15 % in those treated with ileal resection, to 8 % of those treated with wedge excision (table 11). The differences between the mortality-rates for wedge excision and local ileal resection were significantly lower than those for simple closure of the perforation or with right hemiThe frequency of colectomy (x2=327, p
