Ileostomy for Non-Traumatic Ileal Perforations: Is this the Beginning of the End?

Clinical Presentations, Treatments, and Complications of Ileal Perforation at a Tertiary Center: A Cross-Sectional Study

Background Ileal perforations represent one of the most common surgical emergencies in India, associated with significant morbidity and mortality rates. The causes of these perforations include infections such as tuberculosis and enteric fever, as well as malignancy and trauma. Management options encompass ileostomy, resection with anastomosis, and primary closure. Objective The objective of this study is to evaluate the clinical profile, etiology, management strategies, and complications associated with ileal perforation. Methodology A total of 70 patients with ileal perforation were included in the study. The proportions of various etiological factors, surgical interventions, and their associated complications were analyzed. The study aimed to determine whether ileostomy leads to fewer complications compared to primary repair. Results Ileal perforation is more prevalent in males than in females, with an incidence ratio of 2.68:1, predominantly affecting individuals in their 30s. Antituberculosis treatment does not consistently protect against perforation. Delays in presentation are linked to a higher likelihood of developing pyoperitoneum, increased chances of stoma creation (with a mean delay of 2.50 days in the closure group compared to 4.98 days in the ileostomy group), and greater mortality. Closure was performed in 18 patients (25.7%), while 52 patients (74.3%) underwent stoma creation. The duration of surgery was longer in the closure group (2.889 hours) than in the ileostomy group (2.635 hours) and also greater in the mortality group (three hours) compared to the non-mortality group (2.64 hours). The mean number of perforations was 1.59 ± 0.970, with 1.33 ± 0.840 in the closure group and 1.67 ± 1.004 in the ileostomy group. A higher number of perforations is associated with an increased likelihood of stoma creation. The most common cause of perforation was nonspecific, accounting for 40% of cases. The most frequently encountered complication was wound infection, occurring in 42.9% of patients. The mean duration of hospital stay was shorter in the ileostomy group (9.50 ± 5.500 days) than in the closure group (17.22 ± 19.219 days). Death occurred in 18.6% of cases, with higher rates observed in males (8:5), patients with delayed presentation, and elderly patients. A significant p-value was found in relation to leaks and fecal fistulas. Conclusions No significant difference was observed in complications associated with the various surgical procedures performed. However, a delay in presentation is linked to a higher rate of complications and increased mortality.

A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study

BACKGROUND

Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis.

METHODS

Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy).

RESULTS

The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group.

CONCLUSION

The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).