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Surgical Complications of Typhoid Fever 107

anastomosis or simple closure. The perforation (if single) or the
proximal and distal ends (following segmental resection) of the
intestine are exteriorised as stoma, to be closed at a later date when
oedema has subsided and the patient is fit. In very ill patients, a T-tube
placed in the lumen after closing all distal perforations has been found
to be effective. 12
Note: Be sure to clean the peritoneal cavity with copious amounts
of normal saline.
The fascia and skin are closed; however, if the anterior abdominal
wall is oedematous, the skin is left open (delayed primary closure is
done after 3 days if there is no wound infection). If the skin is closed
in the presence of abdominal wall oedema, surgical site infection
frequently occurs.
Where there is severe contamination of the peritoneal cavity with
faeculent peritoneal fluid and/or pus, the alternative is to pack the
peritoneal cavity with abdominal packs soaked in normal saline and
return to close the wound in 48 to 72 hours. This delayed primary wound
closure allows a second look to inspect the peritoneal cavity for fluid/
pus collection, inspect the suture line or anastomosis for leakage, and
repair perforations missed during the first surgery or even reperforations.
Cholecystitis
Cholecystitis and perforation of the gallbladder are important com-
plications 13–15 that occur with increasing frequency. If the diagnosis is
certain and no evidence of perforation or gangrene exists, the antibiot-
ics described earlier under “Management” (#7, Antibiotic therapy) are
administered and the patient is monitored. If the fever subsides and
the child improves, the antibiotics are continued for 7 to 10 days. A
cholecystectomy is performed after 6 to 12 weeks. Figure 17.6: Closure of a single ileal perforation after excising the necrotic edges
If the above treatment fails or there is evidence of general peritonitis together with the inflamed surrounding area (see Figure 17.5).
(perforation or gangrene), treatment is operative. A laparotomy
is performed and the specimen of gallbladder contents is sent for
culture. A tube cholecystostomy, using a Foley or Malecot catheter, is
performed. When all evidence of inflammation has subsided, the tube
is removed (note that a tube cholangiogram may be necessary before
removal of the tube).
Intestinal Bleeding
After resuscitation, the antibiotics described earlier under
“Management” (#7, Antibiotic therapy) are started. The antibiotics
are continued for 10 to 14 days after cessation of bleeding. Blood loss
may need to be replaced by blood transfusion. The patient is kept in Figure 17.7: Diagrammatic illustration of an enterostomy.
hospital for 5 to 7 days after the bleeding has completely stopped—this
is necessary because the bleeding may recur. Postoperative Complications
Osteomyelitis Complications are frequently encountered, particularly in patients
Some of the affected patients may have sickle cell disease, which is who have had intestinal perforation. The more common complications
treated accordingly. Administer chloramphenicol (50–75 mg/kg/24 include:
hr in 6-hour dosing); ampiclox (100 mg/kg/24 hr in 6-hour dosing); 1. Prolonged ileus may last for several days and manifest as
or third-generation cephalosporin, initially by intravenous route until increasing or persistent nasogastric drainage. Adequate fluid and
temperature returns to normal, then orally for 4–6 weeks. Caution is electrolyte balance, nasogastric drainage, and parenteral nutrition are
advised if chloramphenicol is going to be used for a long time. maintained, and the condition usually resolves on this treatment.
Any associated abscesses are drained. The affected limb may need 2. Surgical site infection is one of the most common complications
to be splinted and elevated until the pain and oedema subside. occurring in 49–59% of patients with TIP. Infection is usually
3–5
Abscesses superficial in the wound but may be deep. If the infection is deep,
Abscesses can occur in any part of the body; they can be superficial or anastomotic leakage is suspected. A swab from the wound is cultured to
deeply located. The abscess is drained and the patient is given appro- ascertain the microorganisms and their antibiotic sensitivity. Treatment
priate antibiotics. is by local wound care (native honey is quite effective). If the skin was
previously sutured, some of the stitches may need to be removed to
Malnutrition allow drainage. After the infection is under control, secondary suturing
Some of the patients are malnourished or nutritionally depleted. of the wound is performed; if the wound contracts, and the residual
Parenteral nutrition, if available, is given during the acute phase of wound is small, it is allowed to heal by secondary intention.
the illness. When the patient is able to tolerate oral intake, a diet rich 3. Abdominal wound dehiscence may be partial or complete. This
in proteins and carbohydrates is given—small, frequent feedings are has been reported in 3–14% of children with TIP, and is frequently the
3–5
better tolerated than a large amount at one time.
result of surgical site infection, anastomotic leakage, or intraperitoneal