Laparoscopic Surgical Management of Perforative Peritonitis in Enteric Fever

Mortality in typhoid intestinal perforation-a declining trend

BACKGROUND

Typhoid fever is an important public health problem in developing countries. Intestinal perforation is one of the leading fatal complications of typhoid fever. Typhoid perforation occurs more commonly in terminal ileum. Morbidity and Mortality associated with typhoid perforation are high (9-22%). However this study aims to know whether there are any changes of the same.

AIM

To analyse the clinical presentation, management, complications, morbidity and mortality associated with typhoid intestinal perforation and assess changing trends in mortality in typhoid intestinal perforation.

MATERIAL & METHODS

This is a retrospective observational study. Cases regarding the study have been analyzed by reviewing the patient records. It includes 40 patients who were diagnosed with typhoid intestinal perforation, admitted and treated in the Department of General Surgery from February 2011 to January 2012.

RESULTS

A total of 40 patients were considered for the study and their mean age was 35.75 years. 80% of patients were male. Pain abdomen was their main symptom which lasted for an average of 2.95 days. Leukocytosis (11,000 cells/cumm) was present in 57.5% patients. Single perforation was present in 31(77.5%) patients and primary closure was done in 30 of them. Culture sensitivity showed E coli as the main organism. Complications were seen in 42.5% of patients in post-operative period.

CONCLUSION

Early recognition, timely surgical intervention with appropriate surgery and antibiotics, and effective peri-operative care reduces the mortality in typhoid intestinal perforation.

Spectrum of perforation peritonitis in delhi: 77 cases experience

Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.

Feasibility of emergency laparoscopic colectomy for children with acute colonic perforations and fibropurulent peritonitis

BACKGROUND

Several studies have demonstrated that laparoscopic surgery is safe and effective for urgent and emergent colectomy in adulthood. The aim of the present study was to evaluate the feasibility of laparoscopic colectomy for children in emergent settings.

METHODS

Between March 2008 and August 2011, 10 consecutive children with acute colonic perforations and fibropurulent peritonitis secondary to infectious colitis underwent emergency laparoscopic colectomy. Simultaneously, we reviewed and recorded the same data from another consecutive 10 patients who underwent standard laparotomy between November 2004 and February 2008. The two groups were compared with regard to operative time, length of hospital stay (LOS), and complications.

RESULTS

The gender, age, body weight, serum C-reactive protein, number of involved bowel segments, operative time, and LOS were not significantly different (P = 0.36, 0.50, 0.33, 0.62, 0.81, 0.14 and 0.23, respectively). In the laparoscopy group, one patient required conversion to open surgery because of extensive bowel involvement, and another patient with solitary colonic perforation required reoperation for anastomostic leakage. However, patients who underwent laparotomy had a higher incidence of later complications, including wound infection, incisional hernia, and adhesion ileus (P = 0.03, 0.06, and 0.03, respectively) and thus required more additional unplanned operations (P = 0.05).

CONCLUSIONS

Emergency laparoscopic surgery is technically feasible in most children with acute colonic perforations and fibropurulent peritonitis. However, extensive intestinal involvement with multiple perforations should be an indication for converting to open surgery.

An audit of secondary peritonitis at a tertiary care university hospital of Sindh, Pakistan

Objective

Peritonitis is the most common life threatening surgical emergency, which requires urgent surgical intervention and is a significant cause of morbidity and mortality. The objective of this study was to highlight the frequency of secondary peritonitis and to analyze the site and causes of perforation, in our tertiary care setup.

Methods

A retrospective analysis of 311 patients of secondary peritonitis was done from July 2008 to June 2010 at Liaquat University Hospital Jamshoro, Hyderabad, Sindh, Pakistan. All cases found to have peritonitis as a result of perforation of any part of gastrointestinal tract at the time of surgery were included in the study. All cases with either primary peritonitis or that due to anastomotic dehiscence were excluded.

Results

A total of 311 patients were studied. Most of the patients were males (77%) and (89%) were in the third and fourth decades of life. Majority of the patients presented with pain (97%) associated with bowel symptoms. Most common site of perforation was small bowel (ileal 59%, jujenal 2%). In this series, most common risk factor of perforation was typhoid (43%). Ileostomy was the most commonly performed procedure. Overall morbidity was 48.5% and mortality was 17%.

Conclusion

Considering the relatively higher rate of typhoid perforation quoted in this study, it is vital that typhoid fever ought to be eliminated by improved sanitation and immunizing programmes, otherwise surgeons will be confronted with its complications.

Outcome of surgical treatment of intestinal perforation in typhoid fever

AIM: To represent our clinical experience in the treatment of intestinal perforation arising from typhoid fever.

METHODS: The records of 22 surgically-treated patients with typhoid intestinal perforation were evaluated retrospectively.

RESULTS: There were 18 males and 4 females, mean age 37 years (range, 8-64 years). Presenting symptoms were fever, abdominal pain, diarrhea or constipation. Sixteen cases were subjected to segmental resection and end-to-end anastomosis, while 3 cases received 2-layered primary repair following debridement, one case with multiple perforations received 2-layered primary repair and end ileostomy, one case received segmental resection and end-to-end anastomosis followed by an end ileostomy, and one case received segmental resection and end ileostomy with mucous fistula operation. Postoperative morbidity was seen in 5 cases and mortality was found in one case.

CONCLUSION: Intestinal perforation resulting from Salmonella typhi is an important health problem in Eastern and Southeastern Turkey. In management of this illness, early and appropriate surgical intervention is vital.

Laparoscopic closure of small bowel perforation: Technique of small bowel anchoring to the abdominal wall

INTRODUCTION

More and more complicated laparoscopic abdominal surgeries are now being performed across the world. Laparoscopic suturing of the bowel perforations is being performed by experienced surgeons. We have developed our own technique of small bowel anchoring to the abdominal wall before suturing the perforation.

OUR MODIFICATION

A single stitch is taken at the corner of the perforation. The long end of the suture is retrieved by a suture retrieval needle and the small bowel is anchored to the abdominal wall. Rest of the bowel perforation is suture by the intracorporeal knot-tying technique.

ADVANTAGES

Anchoring the bowel to the abdominal wall helps in fixation of the bowel to be sutured. This helps specifically for large perforation. Suturing and knot tying is relatively easy by this technique.

Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience

Background

Perforation peritonitis is the most common surgical emergency encountered by the surgeons all over the world as well in Pakistan. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counter part. This study was conducted at Dow University of health sciences and Civil Hospital Karachi (DUHS & CHK) Pakistan, designed to highlight the spectrum of perforation peritonitis in the East and to improve its outcome.

Methods

A prospective study includes three hundred consecutive patients of perforation peritonitis studied in terms of clinical presentations, Causes, site of perforation, surgical treatment, post operative complications and mortality, at (DUHS&CHK) Pakistan, from 1st September 2005 – 1st March 2008, over a period of two and half years. All patients were resuscitated underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled.

Results

The most common cause of perforation peritonitis noticed in our series was acid peptic disease 45%, perforated duodenal ulcer (43.6%) and gastric ulcer 1.3%. followed by small bowel tuberculosis (21%) and typhoid (17%). large bowel perforation due to tuberculosis 5%, malignancy 2.6% and volvulus 0.3%. Perforation due to acute appendicitis (5%). Highest number of perforations has seen in the duodenum 43.6%, ileum37.6%, and colon 8%, appendix 5%, jejunum 3.3%, and stomach 2.3%. Overall mortality was (10.6%).

Conclusion

The spectrum of perforation peritonitis in Pakistan continuously differs from western country. Highest number of perforations noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. Most common cause of perforation peritonitis is perforated duodenal ulcer, followed by small bowel tuberculosis and typhoid perforation. Majority of the large bowel perforations are also tubercular. Malignant perforations are least common in our setup.

Laparoscopic reintervention for anastomotic leakage after primary laparoscopic colorectal surgery

BACKGROUND

Anastomotic leakage is associated with high morbidity and mortality rates. The aim of this study was to assess the potential benefits of a laparoscopic reintervention for anastomotic leakage after primary laparoscopic surgery.

METHODS

Between January 2003 and January 2006, ten patients who had laparoscopic colorectal resection and later developed anastomotic leakage had a laparoscopic reintervention. A second group included 15 patients who had relaparotomy after primary open surgery.

RESULTS

Patient characteristics were comparable in the two groups. The median time from first operation to reintervention was 6 days in both groups. There were no conversions. The intensive care stay was shorter in the laparoscopic group (1 versus 3 days; P = 0.002). Resumption of a normal diet (median 3 versus 6 days; P = 0.031) and first stoma output (2 versus 3 days; P = 0.041) occurred earlier in the laparoscopic group. The postoperative 30-day morbidity rate was lower (four of ten patients versus 12 of 15; P = 0.087) and hospital stay was shorter (median 9 versus 13 days; P = 0.058) in the laparoscopic group. No patient developed incisional hernia in the laparoscopic group compared with five of 15 in the open group (P = 0.061).

CONCLUSION

These data suggest that laparoscopic reintervention for anastomotic leakage after primary laparoscopic surgery is associated with less morbidity, faster recovery and fewer abdominal wall complications than relaparotomy.

Typhoid Intestinal Perforations: Twenty-six Year Experience

BACKGROUND

Typhoid fever (TF) is a severe febrile illness caused by Salmonella typhi. One of the most lethal complications of TF is ileal perforation (TIP). Although the mortality of associated with TIP has decreased slightly over the past decade, it is still high.

METHODS AND RESULTS

The records of the 82 surgically treated patients with TIP were evaluated retrospectively. There were 64 men with the mean age of 36.3 years (range: 7-68 years). In surgical treatment, debridement with primary closure was performed in 32 patients (39.0%), and wedge resection with primary closure was performed in 9 (11. 0%), resection with primary anastomosis in 9 (11.0%), and resection with ileostomy in 32 (39.0%). The most common postoperative complication was wound infection, which occurred in 24 patients (29.3%). The overall morbidity was highest in the ileostomy group. The overall mortality was 11.0% (9 patients). Age, gender, number, and localization of the perforations (p > 0.05) were not found to affect mortality, but prolonged preoperative period (p < 0.001), extended peritoneal contamination (p < 0.01), and ileostomy procedure (p < 0.001) were found to influence the increase in mortality.

CONCLUSIONS

Early and appropriate surgical intervention with effective preoperative and postoperative care may improve survival in TIP.

Peritonitis: laparoscopic approach

Background

Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment – exploration to identify the causative pathology and performance of an appropriate operation – can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution.

Methods

From January 1992 and January 2002 a total of 935 patients (mean age 42.3 ± 17.2 years) underwent emergent and/or urgent surgery. Among them, 602 (64.3%) were operated on laparoscopically (of whom 112 -18.7% – with peritonitis), according to the presence of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than two previous major abdominal surgeries or massive bowel distension were not treated Laparoscopically. Peritonitis was not considered contraindication to Laparoscopy.

Results

The conversion rate was 23.2% in patients with peritonitis and was mainly due to the presence of dense intra-abdominal adhesions. Major complications ranged as high as 5.3% with a postoperative mortality of 1.7%. A definitive diagnosis was accomplished in 85.7% (96 pat.) of cases, and 90.6% (87) of these patients were treated successfully by Laparoscopy.

Conclusion

Even if limited by its retrospective feature, the present experience let us to consider the Laparoscopic approach to abdominal peritonitis emergencies a safe and effective as conventional surgery, with a higher diagnostic yield and allows for lesser trauma and a more rapid postoperative recovery. Such features make Laparoscopy a challenging alternative to open surgery in the management algorithm for abdominal peritonitis emergencies.