Interest in typhoid peritonitis is justified by its high incidence in developing countries, its high mortality, and its prevalence in children and young people [9, 21–25]. In fact, in our experience approximately 30% of the patients were under 7 years old.
Most of our patients presented a state of severe malnutrition, although for this retrospective study we have no relevant data. Nor was the presence of leukocytosis seen to be a useful indicator of the immune response, as neutropenia was encountered in only 10% of cases; however, we did encounter microcytic anaemia (Hb < 10 g/dl) in 43.6% of the patients.
In spite of the scarcity of diagnostic tools, in our patients with acute peritonitic abdomen the indication for laparotomy was made correctly in 91.8% of cases, solely on the basis of clinical examination. Leukocytosis was not useful for diagnosis, being present in only 40% of these typhoid peritonitis patients. On the other hand, it was useful to spend adequate time to resuscitate and stabilise the patient before undertaking surgery, as suggested by others [3, 15–17].
In such patients the number of typhoid perforations is widely variable (range 1–7) in literature [15, 16, 26] and in our experience we observed one case with 11 perforations (Figure 3). It is well known that the number and size of perforations have no relationship with the severity of symptoms [16], but it is nevertheless important to carry out a careful intestinal exploration at laparotomy [25]. In our experience, we found 2 or more perforations in 47.1% of our patients, and a number of these had more than 6. None of our cases showed signs of synchronous intestinal haemorrhage, which has been reported by others [16].
Regardless of the number of perforations, the finding of severe peritonitis is very frequent, and is often related to delayed access to the hospital (in our experience 81.4% of patients presented enteric content in the peritoneal cavity at first laparotomy).
Thus the first issue is to choose the surgical treatment because there are many factors to be considered. In fact, the choice of surgical treatment for ileal perforation remains controversial [15, 16]. The types of surgical treatment recommended in literature include primary repair; simple excision of the edges of the perforation and closure; wedge resection and closure; segmental resection with primary end-to-end anastomosis; and right hemicolectomy with ileocolic or ileotransverse anastomosis [10, 16]. In summary, we can say that there are two prevalent surgical procedures: primary repair and intestinal resection with anastomosis. Rahman and Atamanalp [10, 21] found no correlation between the surgical procedures adopted and mortality. On the other hand, some others [27, 28] found the rates of mortality and morbidity in resection-and-anastomosis patients lower than in primary repair patients. Beniwal has suggested primary repair as the first choice of treatment [7], as have others who reported a reduction in mortality [9, 10, 13, 18, 26, 29–32]. Ileostomy might also be proposed among the options but we believe that it should be reserved for selected, very serious cases in which the macroscopic condition of the intestine, due both to typhoid disease and to peritonitis often neglected for hours or days, make any kind of repair impossible [10, 25].
The choice between primary repair of the perforation (or perforations) and resection of the tract involved can be conditioned by various factors, some objective (macroscopic intestinal condition, number and site of perforations, severity of peritonitis, etc.) and others subjective, depending on the surgeon's experience.
In principle we can affirm that a single perforation should be sutured and the peritoneal cavity should be irrigated [11]. On the other hand, in a case of multiple perforations, close together, segmental resection with anastomosis is to be preferred [9, 25].
As we have said, however, perforations can be highly variable in number, and they are often not close together. In our experience primary repair was the most widely used technique (72.1% of cases), and the choice was certainly influenced by the number of perforations if we consider that 72% of the primary repair patients had only one, with an average of 1.4 perforations in Group A and 3.26 in Group B (see Figure 5). However, primary repair was also adopted in cases of multiple perforations, which was the case for approximately 30% of our Group A patients. Primary repair is certainly the simplest and quickest technique, and can therefore in theory be performed by any surgeon.
Another factor believed by some to be relevant in the choice of surgical treatment is the distance of the perforation from the ileocaecal valve. In fact the valve can develop a condition of hypertension above it, that is, precisely in correspondence to the area perforated and repaired (by suture or resection and anastomosis), which could be considered a risk factor for dehiscence.
In our experience, almost 90% of perforations were sited within 30 cm of the ileocaecal valve, a situation confirmed in literature [33]. If we correlate the distance of the perforations from the ileocaecal valve with the type of surgery performed (see Figure 4), we see that primary repair was the most frequently adopted technique, regardless of the distance of the perforations from the valve, while resection with anastomosis was mostly performed for perforations less than 20 cm from the valve. However there was no statistical significance (p = 0.35).
The surgical choice probably depends on both parameters: number of perforations and site, taken together. In fact, 90% (9 out of 10) of patients with perforations less than 20 cm from the valve and subjected to resection had, in effect, multiple perforations, with an average of 2.8, while for the primary repair patients the perforations were multiple in only 25% of cases, and never more than 2 (average 1.35), regardless of the site. Thus, as it is logical to think, the tract of ileum < 20 cm from the valve, with multiple perforations – which corresponds to the most frequent site of typhoid perforations – was resected more often than repaired. However, there was no primary repair dehiscence, and only one dehiscence of an ileo-ileal anastomosis, at < 20 cm. Therefore the distance of the perforations from the valve seems to have little effect on the surgical choice and its results, while the presence of multiple perforations in this tract, close together, tends to influence the surgeon towards resection. This is confirmed by Mock’s study, in which the principle of adopting primary repair in all cases, in single or double plane, resulted in a mortality of 88% in cases of multiple perforations treated without resection [11].
As regards the strategy of creating a laparostomy and proceeding to revisions, we hypothesised its usefulness in malnourished patients with septic shock, for whom the risk of dehiscence and new perforations is very great, and the associated mortality is very high (67% according to Mock) [11]. It therefore seemed logical, in contrast with the opinion of some authors [13], to re-explore the abdomen rather than wait for clinical evidence of complications, evidence that can often be difficult to identify due to the scarcity of diagnostic tools and the consequent prolonging of a septic state.
In fact laparostomy revisions showed 16 patients with complications that were not yet clinically evident. There were 6 new perforations and 2 primary suture dehiscences in Group A patients (8/54, morbility 14.8%) while there were 3 new perforations and 5 anastomotic dehiscences in Group B (8/16, morbility 50%) (p = 0.003).
Contrary to what might be expected, resection does not seem to reduce the risk of new perforations. In our experience, the incidence of new perforations was more statistically significant in the Group B patients than in Group A (p = 0.01), but we have not found any data in literature concerning incidence of new perforations.
The incidence of new perforations decreases noticeably after the third revision, but the number of anastomotic dehiscences remains high (see Figure 6), although these often occur in the same patients; it can be supposed that the persistence of malnutrition, peritoneal phlogosis, and the septic state hinder the healing of the intestinal wall. In other words the resection patients (Group B) show greater morbidity than the primary repair patients, and therefore require a greater number of laparostomy revisions (see Table 1). In this connection, the risk of recurrency of anastomotic dehiscence is so high in the same patient as to lead us to create an ileostomy once the first dehiscence is encountered. Indeed, Meier, Adensukamni and Onen suggest an ileostomy in cases with multiple perforations and severe peritoneal contamination [14, 20, 34]. Atamanalp is of the same opinion, especially in cases of intestinal ischemia, inflammation, and edema, but nevertheless reports greater mortality in ileostomy patients, probably not due to the ileostomy itself but rather to the extreme severity of clinical conditions in these patients [10]. Unfortunately we could not consider ileostomy as a valid option for our patients, because in a rural area it is virtually impossible to find the necessary devices.
The high incidence of anastomotic dehiscence in our experience differs from that reported in literature, where it seems to be on average less than 10% [15, 21]. This might be explained by the early identification of dehiscences through systematic laparostomy revision. Mortality, as we have mentioned before, was high (30-40%) for our patients, not statistically different between Groups A and B (see Table 2). We must consider, however, that more than half of the patients who died, died after the initial laparotomy, probably due to the severity of their general condition. Unfortunately, we did not find, retrospectively, sufficient data to quantify preoperative patient malnutrition and severity of sepsis. High mortality in the first 24 hours (30%) was also observed in the experience of Mock [11]. Thus, if we exclude these patients, overall mortality is noticeably lower (21.2%), according with others [12, 25].
We confirm that mortality is not higher in patients with a greater number of perforations at initial laparotomy, as reported by some authors [7, 10, 21, 35] but not confirmed by others [7, 11, 20, 25]. We did not, however, observe increased mortality for male patients, although this is reported by others [10, 13, 14, 18, 20] and attributed perhaps to the fact that males spend more time than females in outdoor activities.
As regards perforation site, few studies in literature correlate this datum to mortality [16]. In our experience mortality was not related to perforation site. On the other hand factors that correlate with greater mortality, are neutropenia and severe peritoneal contamination (84.6% of the patients who presented pus in the peritoneum initially, died) as is confirmed by data in literature [9, 11, 14, 18, 20, 25, 29, 34].
This last datum can be interpreted as a result of late access of the patient to a hospital, which many authors also consider to be a relevant factor for increased mortality [9, 10, 13, 17, 18, 20, 21, 25],[34, 36–38]. This delay is generally due to the distance from village to hospital, and by sociocultural factors (recourse to traditional medicine and healers).
Mortality is not, however, related to the number of operations performed (see Table 2). For example there is no significant difference in mortality between patients who had 2 revisions and patients who had more than 4 (29.4% vs 21.4%). Moreover, the surviving patients in both groups underwent, on average, a greater number of operations (Group A: 3.41, Group B: 4.83) than those who died (Group A: 1.81, Group B: 3.12) even though this is not statistically significant (p = 0.11 and 0.19, respectively). This could support our hypothesis that an apparently aggressive surgical strategy that provides for the adoption in principle of laparostomy with successive revisions may have, in these patients, a positive impact on survival.
Mortality is certainly strongly influenced also by the absence of intensive therapy (clinical monitoring, total parenteral nutrition, control of hydroelectrolytic balance, etc.), [15, 18] which would surely reduce mortality in the immediate postoperative period. In fact, where postoperative recovery care is available, mortality is less than 5% [8, 10, 11, 39].
