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108 Surgical Complications of Typhoid Fever

abscess. These causes are considered and excluded. A reoperation is Prevention
required: the anastomosis is inspected and handled accordingly if there Typhoid fever and its complications can be largely prevented by
is leakage; any abscess collection is evacuated and the peritoneal cavity simple public health measures. Current preventive measures include
cleaned; the fascia is closed with continuous suturing using appropriate improvements in sanitation and water supply and vaccination.
size nonabsorbable suture. Tension-relaxing sutures may need to be Improvements in Sanitation and Water Supply
applied for 7 to 10 days to take the tension off the fascial closure. As a faeco-oral infection, typhoid fever is controlled by improvements
4. Anastomotic leakage or complete breakdown of the anastomosis in sewage and waste disposal, as well as provision of safe potable
has been reported in about 7% of children with TIP and usually water. Where piped water is not feasible, provision of bore holes is
requires relaparotomy. The initial anastomosis is resected and another useful. Community health education regarding waste disposal and
anastomosis effected. Alternatively, the ends of the intestine are discouraging defaecation in the open is relevant.
exteriorised as stoma, to be closed at a later date when safe to do so.
5. Enterocutaneous fistula will usually close spontaneously with Vaccination
nonoperative management. If there is evidence that it is an end fistula, Although vaccination is not routine at this time, WHO has recom-
1,2
or if copious intestinal fluid (high output fistula) is discharging mended it as a short-term measure in high-risk areas. Two vaccines
through the wound, or if there is peritonitis, relaparotomy is required are considered safe and effective and are presently licenced interna-
2
and the situation is then handled as in the case of anastomotic leakage. tionally for those aged >2 years: the injectable Vi polysaccharide and
3,5
6. Intraperitoneal abscess (7–9%) usually manifests as a return the live attenuated oral Ty21a vaccine (available as a capsule and in
of fever in a patient who had started to improve. The abscess may suspension). The vaccines are recommended for control of typhoid
be due to a leaking anastomosis or inadequate toileting of the in high-risk groups and populations as well as for outbreak control.
peritoneal cavity with copious amounts of normal saline. Abdominal Vaccines may also be offered to travellers to endemic areas. These
ultrasonography should confirm the diagnosis. Relaparotomy is vaccines are not licensed for use in children aged <2 years. Other
required. The anastomosis is inspected to identify any leakage. The improved vaccines are presently being tested, including the Vi-protein
abscess is drained and the peritoneal cavity is thoroughly cleaned. conjugate vaccine, which could be useful for children below 2 years of
1
7. Adhesion intestinal obstruction may occur several days to years age if eventually licenced.
later. It is treated nonoperatively initially (IV fluid resuscitation, Evidence-Based Research
analgesics, regular reassessment—preferably by the same surgeon and The references cited in Tables 17.2 and 17.3 present the effects of oper-
antibiotics). If evidence of intestinal strangulation or nonoperative ations and surgical management of typhoid perforations in children.
treatment fails (intensification of abdominal pain, increased abdominal
distention with tenderness and rebound tenderness, and guarding Table 17.2: Evidence-based research.
or failure of the general condition of the patient to improve), a Title Comparison of three operations for typhoid perforation
relaparotomy is done to release adhesions. Authors Ameh EA, Dogo PM, Attah MM, Nmadu PT
8. Reperforation may occur at a new site in 7–9% of children with
5
TIP. It may be the result of an unidentified impending perforation or Institution Department of Surgery, Ahmadu Bello University Teaching
Hospital, Zaria, Nigeria
progression of ongoing infection. A relaparotomy is required and the
perforation is handled on its merit. Reference Br J Surg 1997; 84(4):558–559
9. Hypoproteinaemia occurs postoperatively in most cases. This Problem Extent of surgery in children with typhoid ileal perforation.
manifests in pitting oedema of the feet and ankles. A blood sample is Intervention Three different operations for typhoid perforation in children.
taken for serum proteins, and the condition is treated with fresh blood Comparison/ Compares three procedures in the operative management of a
or fresh frozen plasma (FFP) where available. control difficult problem of typhoid ileal perforation in children—simple
10. Pleural effusion, although rare, can occur in the postoperative (quality of closure, wedge resection and anastomosis and segmental
period and is usually unilateral. If the effusion is massive, either it is evidence) resection, and anastomosis—by using the same management
protocol for all patients.
drained by tapping, or a chest tube is passed immediately for drainage.
Outcome/ In all the three operative methods used, the mortality rates
Prognosis and Outcomes effect were still high, especially so in the wedge resection group.
Of the children treated for TIP, 53–79% 3,5,6 develop one or more Despite this high mortality, segmental resection with end-to-
end anastomosis, where appropriate, gave better results in
complications. One report suggests that the complication rate may this study.
3
be significantly higher in children younger than 5 years of age. The Historical Morbidity and mortality rates in typhoid perforation of the ileum
spectrum of these complications is discussed above. significance/ are high irrespective of the surgical procedure used. The need
Mortality from TIP appears to vary widely, ranging from 12% to comments exists to prevent the disease as a whole, but failing that, the
management protocol for children with typhoid ileal perforations
41%, 3–5 but a mortality of 0% was reported in children with typhoid should include early aggressive resuscitation, antibiotics and
9
colonic perforation. Most mortality is from overwhelming infection, analgesics, early limited/minimal surgery, thorough peritoneal
toileting (cleaning), blood transfusion and oxygen support (where
occurring usually after an average of 4–5 days postoperatively. The
necessary), and early enteral feeding with supportive care.
single most important significant predictor of death in patients with
TIP is the duration of abdominal pain after 7 days. 3,5,7 The number of
perforations does not appear to significantly affect mortality.