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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 59-63

Typhoid intestinal perforation: Analysis of the outcome of surgical treatment in Kano, Nigeria


1 Department of Surgery, General Surgery Unit, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
2 Department of Surgery, Paediatric Surgery Unit, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria; Division of Pediatrics Infectious Disease, University of Nebraska Medical Center, Omaha, USA

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Lofty-John Chukwuemeka Anyanwu
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_119_17

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  Abstract 


Background: Intestinal perforation is a serious complication of typhoid fever with high case fatality rates in developing countries. This study aims to determine the factors associated with an adverse clinical outcome among patients managed for typhoid intestinal perforation (TIP) in our hospital. Materials and Methods: We retrospectively reviewed the records of all patients presenting to our general surgery unit with TIP between January 2012 and December 2015. The patients were categorized based on postoperative outcome status and the patient-related variables were compared and analyzed for determinants of outcome, using the Chi-square test. A statistical significance was assigned to a P < 0.05. Results: There were fifty patients who had surgery for TIP during the study period, but only the records of 47 patients could be retrieved for analysis. Of these, 32 (68.1%) were males and 15 (31.9%) were females. The male/female ratio was 2.13:1. Their ages ranged from 13 to 55 years with a median of 17 years. A single intestinal perforation was seen in 87.2% (41/47), while 12.8% (6/47) had two or more. The mortality rate was 8.5% (4/47). The occurrence of a postoperative fecal fistula was significantly (P = 0.016) associated with a postoperative mortality. A peritoneal aspirate volume >1000 ml was significantly associated with having a postoperative fecal fistula (P = 0.011) and postoperative mortality (P = 0.002). A number of intestinal perforations were not significantly associated with an adverse outcome (P > 0.05). Conclusion: Postoperative fecal fistula adversely affected the outcome of the patients in our series. Multiple intestinal perforations did not seem to affect the outcome in our patients.

Keywords: Typhoid fever, intestinal perforation, fecal fistula, mortality, clinical outcome


How to cite this article:
Sheshe AA, Anyanwu LJC, Mohammad AM, Muhammad AB, Obaro SK. Typhoid intestinal perforation: Analysis of the outcome of surgical treatment in Kano, Nigeria. Arch Med Health Sci 2018;6:59-63

How to cite this URL:
Sheshe AA, Anyanwu LJC, Mohammad AM, Muhammad AB, Obaro SK. Typhoid intestinal perforation: Analysis of the outcome of surgical treatment in Kano, Nigeria. Arch Med Health Sci [serial online] 2018 [cited 2018 Dec 15];6:59-63. Available from: http://www.amhsjournal.org/text.asp?2018/6/1/59/234090




  Introduction Top


Typhoid fever (TF) is caused by the bacterium  Salmonella More Details enterica serovar Typhi, although a similar but less severe illness is caused by S. enterica serovar Paratyphi A and also by serovar Paratyphi B.[1],[2],[3] In developed countries, this disease has been largely controlled by effective public health measures; however, developing countries continue to bear the burden of the disease because of poor standards for drinking water, sanitation, and hygiene.[3],[4] TF causes at least 5% of all deaths in sub-Saharan Africa, with markedly significant mortality in endemic areas.[5] A recent study from Kano, Nigeria, shows that Salmonellae accounted for 364 of the 609 (59.8%) cases of clinically significant bacteremia in children.[6]

Intestinal perforation, a dreaded complication of TF, has maintained a double-digit mortality figure in the West African subregion over the last quarter of a century, as against single-digit mortality rates reported from more developed regions.[7] Nigeria records one of the highest rates of typhoid intestinal perforation (TIP) globally.[8] Perforation results in superinfection of the peritoneal cavity with gut flora leading to a full-blown peritonitis, with severe peritoneal contamination being associated with a poor prognosis and high mortality.[2] The reasons for the high mortality are multifactorial.[9],[10],[11] This study aims to determine the factors associated with an adverse clinical outcome among patients managed for TIP in our hospital.


  Materials and Methods Top


This is a retrospective review of all patients who had surgery for TIP in the general surgery unit (adult surgical unit) of our hospital, between January 2012 and December 2015. The study was approved by the hospital's Ethics Committee.

The diagnosis was based on clinical features, which were supplemented by intraoperative findings. Preoperatively, all patients were adequately resuscitated and optimized, with intravenous infusion of crystalloids before surgery. A nasogastric tube was passed for gastric decompression, and a urethral catheter was put in place to monitor urine output as a measure of the adequacy of fluid resuscitation. Blood was transfused as indicated, that is, when the packed cell volume fell below 30% or in those with hemoglobin concentration of <10 g/dL. All patients had intravenous broad-spectrum antibiotics which included ceftriaxone and metronidazole.

Resuscitation was followed by an exploratory laparotomy through a midline incision under general anesthesia with endotracheal intubation. The surgical treatment of the identified intestinal perforation was at the discretion of the operating surgeon. All intraperitoneal collections were aspirated and quantified. The abdominal cavity was lavaged with copious amounts of warm normal saline solution, and nylon-1 sutures were used to achieve mass closure of the abdomen over an intraperitoneal drain. Delayed primary closure of the skin was done with interrupted stitches of nylon-2/0.

Postoperatively, the patients were maintained on nil per os until bowel sounds returned, following which their nasogastric tubes were removed. For patients who have passed flatus or stools, graded oral feeds were commenced usually on the 5th day postoperation. It was delayed if flatus was not passed. The abdominal wound was inspected on the 2nd day after surgery, and daily wound care was done afterward till the patient was discharged from the hospital.

Data from each patient were entered into the study questionnaire. Data were analyzed using SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). The patients were categorized based on postoperative outcome status, and the patient-related variables were compared and analyzed for determinants of outcome. Descriptive statistics were computed for continuous variables, while proportions were used for categorical characteristics of the study participants. Chi-square and t-test statistics were used to test for associations. Fisher's exact test (two tailed) was employed where appropriate. Level of statistical significance was set at P < 0.05 for all analyses.


  Results Top


Demographic characteristics

There were fifty patients who had surgery for TIP during the study period, but only the records of 47 patients could be retrieved for analysis. Of these, 32 (68.1%) were males and 15 were (31.9%) females. The male/female ratio was 2.13:1. Their ages ranged from 13 to 55 years with a median of 17 years. For the eight patients for whom data were available, the median perforation–operation interval was 6.5 days (range 2–28 days). [Figure 1] depicts the distribution of their age groups.
Figure 1: Age groups of typhoid intestinal perforation patients (1: ≤15; 2: >15–≤25; 3: >25–≤40; 4: >40)

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Intraoperative findings

All the patients had an exploratory laparotomy for the management of their intestinal perforations and peritonitis. A total of 55 perforations were seen in the study, all of which were in the small intestine. Single perforation occurred in 87.2% (41/47) of the patients, while 12.8% (6/47) of them had multiple perforations. The number of perforations ranged from 1 to 3, with a mean of 1.17 (standard deviation = 0.48). The median distance of the perforations from the ileocecal junction was 24 cm (range 5–48 cm). There was no statistically significant difference between the mean ages of those with a single perforation and those with multiple perforations (t = −1.43; P = 0.21). The median volume of the intraperitoneal aspirate drained was 750 ml (range 300–4500 ml). In 76.09% (35/46) of the patients, the volume of the aspirate was 1000 ml or less, while in 23.91% (11/46) it was more than 1000 ml. There was a statistically significant difference in mortality in both groups (P = 0.002) [Table 1].
Table 1: Association between “postoperative death” and selected variables of the patients

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Surgical intervention

Intestinal perforations in this study were all treated operatively. A wedge excision of the necrotic edge and simple closure of the perforation in two layers was done in 95.7% (45/47) of the patients, while 4.3% (2/47) had segmental resection with end-to-end anastomosis of the bowel. None of the patients had a right hemicolectomy. The median volume of blood transfused was 1000 ml (range 500–1500 ml).

Clinical outcome

Among the patients, surgical site infection (SSI) (wound infection) occurred in 55.3% (26/47) (superficial 19.1%; deep 12.8%; and organ/space 23.4%). [Table 2] depicts the relationship between wound infection and selected patient variables. The median interval between surgery and the documentation of an evidence of wound infection (i.e., a purulent wound exudate) was 6 days (range 4–12 days). Wound dehiscence occurred in 14.9% (7/47) (superficial 2.1%; total 12.8%) of the patients. Among the study participants, 27.7% (13/47) had a residual intra-abdominal abscess, while 6.4% (3/37) had a postoperative fecal fistula. A peritoneal aspirate volume >1000 ml was significantly associated with having a postoperative fecal fistula (P = 0.011). The median duration of hospital stay was 16 days (range 4–101 days). The mortality rate was 8.5% (4/47) (3 males and 1 female). The median interval between surgery and death was 19.5 days (range 3–26 days). All the deaths were attributable to septic shock. The occurrence of a postoperative fecal fistula and having a peritoneal aspirate volume >1000 ml were significantly associated (P< 0.05) with a postoperative mortality [Table 1].
Table 2: Association between “wound infection” and selected variables of the patients

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  Discussion Top


For most of the population in Africa, the burden of TF has not been well characterized.[12] To make a definitive diagnosis of TF, S. typhi has to be isolated from blood, bone marrow, or a specific anatomical lesion, with the mainstay of diagnosis being the blood culture.[13],[14] Due to financial constraints, late presentation is common with TIP patients in the subregion. Only a few health facilities in sub-Saharan Africa have the laboratory capacity to identify invasive bacterial infections.[12],[15],[16] The diagnosis of TF in much of the developing world is commonly made on clinical criteria.[3]

It is believed that the incidence of TIP is an indicator of the endemicity of TF in any locality.[4] It may appear that multiple exposures to S. typhi may be required for the activation of the enhanced immune system, producing ileal perforation.[17] In the present study, a high incidence of TIP was noticed in the first and second decades of life. Other workers and an earlier report from our hospital have documented similar findings.[4],[18],[19] Chalya et al., working in Tanzania, had earlier reported that the median age of the patients with a single perforation in their study was significantly higher than that with multiple perforations.[4] Our data are, however, at variance with their findings. Although the presence of multiple intestinal perforations was not a significant contributor to adverse outcome in this study, other workers had earlier documented its significant contribution to mortality in patients with TIP.[4] The small sample size of this present study may explain the observation.

Following intestinal perforation, leakage of fecal matter from the intestine into the peritoneal cavity results in a superinfection with intestinal bacteria and peritonitis.[2],[20] It has been shown that the volume of purulent/feculent matter contained within the peritoneal cavity is an indication of the magnitude of peritoneal contamination.[2],[4] In this present study, a peritoneal aspirate volume >1000 ml was significantly associated with a postoperative mortality. Similar findings have been documented by earlier workers.[2],[9],[21] Other factors such as perforation–operation interval, end-organ damage, for example, kidney injury, and the patients' nutritional status may have contributed to the peritoneal aspirate volume. None of the patients in our study received parenteral nutrition as this is not readily available at our center. A high-protein high-calorie diet was given on commencement of oral feeds and was supplemented by intravenous infusions of crystalloids and dextrose.

Given the severe toxic state of these patients, management in an Intensive Care Unit (ICU) may be beneficial.[4] Only one patient in this series had an ICU admission postsurgery. Given the pressure on our few (four) ICU beds, we do not routinely admit TIP patients to the ICU. The rate of SSI was high in this study even though the wounds were closed by delayed primary suturing. We do not have data to suggest that delaying the abdominal wall closure would have reduced the SSI rate.

Perforation–operation interval is known to significantly affect the clinical outcome in TIP.[2],[4] Chalya et al. had shown in a hospital-based study in Tanzania that more than 85% of their patients had a perforation–operation interval of more than 72 h.[4] This is similar to the findings in this study. Given the retrospective nature of the present study, sufficient data were not available in the patients' records for the analysis of the contribution of these factors to clinical outcome. Of all the complications following surgery for TIP, it is believed that the development of a postoperative fecal fistula is the one mostly associated with a high incidence of postoperative mortality.[9],[10],[22] In the present study, the presence of a postoperative fecal fistula was significantly associated with postoperative mortality. For patients who develop a fecal fistula and have associated clinical signs of peritonitis, we usually do a salvage ileostomy. None of the patients in this series had an ileostomy.

Limitation

This is a retrospective study and relied only on available records in the patients' case files, which may be incomplete. Furthermore, being that the patients had no structured follow-up, late mortalities after discharge home were not captured in the available records.


  Conclusion Top


Severe peritoneal contamination and the occurrence of a postoperative fecal fistula were factors that adversely affected the outcome of the patients in this study. Given the economic burden of this disease in our subregion, there is a need to design a prospective multicentric study in the region, to investigate the host risk factors for TIP. Data from descriptive studies such as the present one may help in the development of a hypothesis for such studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaikh GS, Soomro Q, Bhutto AA, Bhatti Y, Alideenari R, Baloch I. Typhoid ileal perforation, experience of 62 cases at Chandka Medical College Hospital, Larkana. Med Channel 2009;15:187-90.  Back to cited text no. 1
    
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Chalya PL, Mabula JB, Koy M, Kataraihya JB, Jaka H, Mshana SE, et al. Typhoid intestinal perforations at a University teaching hospital in Northwestern Tanzania: A surgical experience of 104 cases in a resource limited setting. World J Emerg Surg 2012;7:4.  Back to cited text no. 4
    
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Massi MN, Shirakawa T, Gotoh A, Hatta M, Kawabata M. Identification and sequencing of Salmonella enterica serotype typhi isolates obtained from patients with perforation and non-perforation typhoid fever. Southeast Asian J Trop Med Public Health 2005;36:118-22.  Back to cited text no. 5
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Obaro SK, Hassan-Hanga F, Olateju EK, Umoru D, Lawson L, Olanipekun G, et al. Salmonella bacteremia among children in central and Northwest Nigeria, 2008-2015. Clin Infect Dis 2015;61 Suppl 4:S325-31.  Back to cited text no. 6
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Mogasale V, Desai SN, Mogasale VV, Park JK, Ochiai RL, Wierzba TF, et al. Case fatality rate and length of hospital stay among patients with typhoid intestinal perforation in developing countries: A systematic literature review. PLoS One 2014;9:e93784.  Back to cited text no. 8
    
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Adesunkanmi AR, Ajao OG. The prognostic factors in typhoid ileal perforation: A prospective study of 50 patients. J R Coll Surg Edinb 1997;42:395-9.  Back to cited text no. 9
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Neil KP, Sodha SV, Lukwago L, O-Tipo S, Mikoleit M, Simington SD, et al. Alarge outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese district, Uganda, 2008-2009. Clin Infect Dis 2012;54:1091-9.  Back to cited text no. 12
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