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106 Surgical Complications of Typhoid Fever

operatively). Ciprofloxacin (8–16 mg/kg/24 hours in 2 divided
doses IV) and metronidazole as above. Oral ciprofloxacin is given
as 10–30 mg/kg in 2 divided doses (this drug combination may be
given with or without gentamicin).
The chosen antibiotic regime is continued postoperatively until
the temperature returns to normal. Thereafter, the drugs are continued
orally (if an oral form is available) for 7–14 days.
Definitive Treatment
Intestinal Perforation
The definitive treatment for intestinal perforation is operative—to
evacuate faecal contamination and prevent further contamination.
Surgery is done only when the child is adequately resuscitated. Blood
transfusions may need to be continued intraoperatively or even post-
operatively. If the child is too sick, nonparalysing anaesthesia and
hypotension-producing anaesthetic agents (e.g., ketamine hydrochlo-
ride) are considered.
For the abdominal incision in small children, a transverse upper or
lower abdominal incision is used. If perforated appendicitis is a strong
differential diagnosis, a lower transverse incision is more appropriate;
if complicated cholecystitis or perforated duodenal ulcer is a strong
differential diagnosis, an upper transverse incision is more appropriate.
In bigger children (>8 years of age), a long midline incision centred on
Figure 17.4: Segmental resection of ileum with perforations and end-to-end the umbilicus may provide better exposure.
anastomosis: (A) preparation of bowel with multiple perforations for resection;
(B) demonstration of picking only the seromuscular layer; (C) insertion of the Once the peritoneal cavity is opened, a specimen of any peritoneal
posterior seromuscular layer of sutures; (D) posterior seromuscular layer of fluid or pus is taken. All peritoneal collections are evacuated. The
sutures tied. intestines are thoroughly examined, beginning at the ileocaecal junction
until the duodenojejunal junction is reached. The perforation(s) are
usually located on the antimesenteric border, and near perforation(s)
may also be identified. Leakage from any identified perforation is
controlled by a Babcock’s forceps clamped lightly over a piece of
gauze. Alternatively, the bowel with the piece of gauze over the
perforation is handed over to the assistant to put light pressure over it
to prevent leakage of intestinal contents while the surgeon continues
inspecting the rest of the intestine.
After identifying the perforation(s), the stomach, duodenum, large
intestine, liver, and spleen are inspected. Most perforations are located
in the last 80 cm of the terminal ileum, 3,5,7 but, rarely, the jejunum and
colon (caecum to sigmoid colon) may also be involved. The definitive
9
surgical procedure is decided only after completing the examination
of the entire small and large intestines because the sites and number
of perforations may dictate the procedure of choice, and there may be
areas of impending perforation, which would appear paper-thin on the
serosal surface.
Currently, the surgical options are:
1. Segmental resection of affected intestine (Figure 17.4): The
resected segment should include all perforations and near perforations.
The resection margin should be healthy and free of evidence of
inflammation such as oedema. Segmental resection is a good choice
even for a single perforation. A limited right hemicolectomy may be
necessary if the most distal perforation is too close to the ileocaecal
Figure 17.5: Closure of a single ileal perforation in one layer: (A) the perforation junction for safe anastomosis (i.e., <3 cm). The resected length
on the antimesenteric border of the ileum; (B) after the necrotic edges of the of intestine is always measured and documented. Then intestinal
perforation have been excised and stay sutures placed in readiness for a single- continuity is restored by end-to-end anastomosis. The resected
layer interrupted seromuscular closure of the perforation; (C) the perforation segment is sent to the lab for histopathology.
being closed; (D) the final result of single-layer closure of a typhoid perforation.
2. Simple closure of perforations (Figures 17.5 and 17.6): This
procedure may be used for a single perforation, if perforations are
far apart, or if the number of perforations are so numerous that
resection may result in a short gut. The edge of the perforation is
excised circumferentially (the excised edge is sent to the lab for
histopathology). Then simple closure is achieved by a single layer of
interrupted, seromuscular stitches.
3. Enterostomy (Figure 17.7): An enterostomy is performed if
the child is too sick or intestinal oedema is too extensive for safe