Surgical intervention for intestinal typhoid perforation

AIM

Typhoid perforation is the most fatal complication of typhoid fever in developing countries and is most often caused by the bacteria Salmonella Typhi. There are conflicting views as to which type of surgical intervention gives the best outcome. The aim of this study was to determine the mortality associated with the different types of surgical interventions employed in patients with typhoid perforation.

METHOD

This was a retrospective review of the medical records of adult and paediatric surgical patients treated in the general and paediatric surgical units of the Korle Bu Teaching Hospital. Information was obtained from medical records at the Korle Bu Teaching Hospital in Accra, Ghana, between January 2009 and April 2012. The data was analysed using IBM SPSS Statistics version 20 and 22.

RESULTS

133 patients (median age of 21 years, 72.2% males) with typhoid perforation were included in the study. The typhoid perforation specific mortality rate was 12.8%. Males had a significantly lower mortality rate (7.3%) compared to females (27%). Simple bowel closure (85.7% of total) was the most common surgical intervention performed and patients operated upon with this method had a significantly lower mortality rate (9.6%) compared to patients with bowel resection (31.6%).

CONCLUSIONS

In this study, patients treated with intestinal resection were more likely to die from typhoid perforation and female gender was a risk factor for death. Simple bowel closure was the predominant surgical procedure.

Early intraperitoneal metabolic changes and protease activation as indicators of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Ischaemia and local protease activation close to the pancreaticojejunal anastomosis (PJA) are potential mechanisms of postoperative pancreatic fistula (POPF) formation. To provide information on the pathophysiology of POPF, intraperitoneal microdialysis was used to monitor metabolic changes and protease activation close to the PJA after pancreaticoduodenectomy (PD).

METHODS

In patients who underwent PD, intraperitoneal metabolites (glycerol, lactate, pyruvate and glucose) were measured by microdialysis, and lactate and glucose in blood were monitored, every 4 h for 5 days, starting at 12.00 hours on the day after surgery. Trypsinogen activation peptide (TAP) was measured in microdialysates as a marker of protease activation.

RESULTS

Intraperitoneal glycerol levels and the ratio of lactate to pyruvate were higher after PD and glucose levels were lower in seven patients who later developed symptomatic POPF than in eight patients with other surgical complications (OSC) and 33 with no surgical complications (NSC) (all P < 0·050). TAP was detected at a concentration greater than 0·1 µg/l in six of seven patients with POPF, two of eight with OSC and two of 33 with NSC. Intraperitoneal lactate concentrations were higher than systemic levels in all patients on days 1 to 5 after surgery (P < 0·001). In patients with POPF, high intraperitoneal lactate concentrations were observed without systemic hyperlactataemia.

CONCLUSION

Early in the postoperative phase, patients who later developed clinically significant POPF had higher intraperitoneal glycerol concentrations and lactate/pyruvate ratios, and lower glucose concentrations in combination with a TAP level exceeding 0·1 µg/l close to the PJA, than patients who did not develop POPF.