16

Tropical Doctor, January 1998

ARTICLES

Evaluation of best surgical

procedures in typhoid perforation
an experience of 60 cases

Dilip K Pal MS
Department of Surgery, North Bengal Medical College,
Sushrutanagar. Darjeeling, West Bengal, India, PIN 734432
TROPICAL DOCTOR,

1998, 28, 16-18

SUMMARY

The results of treatment of 60 cases of typhoid

perforation were reviewed over a period of 4.5 years.
Closure of the perforation was the method of treatment
in 28 (46.66%) cases and closure of the perforation with
side-to-side ileotransverse anastomosis was done in 32
(53.33%) cases. Faecal fistula was the most severe postoperative complication following simple closure of the
perforation, causing death in all patients and leading to
a 25% mortality in those treated by this technique. No
fistula was found following closure of the perforation
with side-to-side ileotransverse anastomosis, leading to a
much lower mortality of 6.22%. The overall mortality in
this series was 15%. Apart from toxaemia, surgical
failure was the main contributory factor to such a high
mortality. In this series, closure of the perforation with
side-to-side ileotransverse anastomosis was the better
surgical procedure.
INTRODUCTION

Typhoid fever continues to be a major health hazard

throughout the world, particularly in tropical
even at the end of the twentieth century.
Intestinal perforation leads to high mortality in typhoid
fever cases. Although perforation is a world-wide
problem, the incidence is much higher in developing
African and Asian countries including India2. Analysis
of 12 regional reports from different parts of India
reveals that out of 513 cases of non-traumatic small
bowel perforations, typhoid was responsible for 87.7%
of cases and the subsequent mortality from such
perforation in different series in the Indian population
varies from 11.5% to 34.5YO3.
Correspondence to: Dr Dilip K Pal, Ranikuthi, Rudra Main
Road, PO Bansberia, District Hoogly, West Bengal, India, PIN
712502

It has been a matter of great dispute whether these

cases should be treated conservatively or surgically, but,
nowadays the pendulum has swung in favour of prompt
surgical interventionk6. Newer surgical procedures are
evolving and there is no single, widely-accepted surgical
procedure for typhoid perforation cases7. Due to the
high incidence of typhoid perforation and subsequent
mortality in the Indian population, this study was
undertaken to discover what, in our experience is the
best surgical procedure in such cases.
MATERIALS AND METHODS

The present study is based on 60 cases of typhoid

perforation admitted to North Bengal Medical College
& Hospital from January 1991 to June 1995. Most cases
were diagnosed on a history of fever with a sudden onset
of abdominal pain, abdominal distension and constipation. The investigations included a haemogram, serum
urea, creatinine and a Widal test. An erect X-ray of the
abdomen was done. All patients were subjected to
surgical intervention after correction of dehydration.
Closure of the perforation in two layers after freshening
the edges was done in 28 cases and in 32 cases closure
of the perforation with additional side-to-side ileotransverse anastomosis was undertaken (Table 1).
OBSERVATIONS

Perforation in typhoid fever occurred mainly in rural

people of low socio-economic status. The youngest
patient was 6 years old and the oldest was 48 years.
Seven were below 12 years of age. Sixty two per cent of
patients were in the second or third decade of life. The
male:female ratio was 4.1. All had a history of
fever ranging from 5 to 21 days with an average
of 13 days. On admission, the patients presented with
clinical features of generalized peritonitis, abdominal
tenderness (~OOYO), guarding (86%), abodominal
distension (70%) and rigidity (46%). Liver dullness
was obliterated in 48% of the cases. X-ray of the
abdomen in the erect position revealed haziness in 100%

Table 1. Faecal fistula and mortality in primary closure

of perforation and primary closure with bypass (ileotransverse anastomosis)
Operafive
procedure

No. of
cases

Faecal
fistula

Mortality

Primary closure of
perforation in
two layers
Primary closure of
perforation with
bypass

28

6 (21.42%)

7 (25%)

32

2 (5.25%)

Total

60

6 (10%)

9 (15%)

Tropical Doctor, January 1998

17

Table 2. Mode of treatment in typhoid perforation

recommended by different authors

Table 3. Results in different series of primary closure of

perforation

Author and year

Author and
year

Mode of treatment

Huckstep R L 1960 (Ref 9) Conservative

Dickson-and Cole 1964
Closure of perforation when one
(Ref 2)
or two in number; exteriorization of bowel loop in multiple
perforations
Closure of perforation and
Lizarrakde B A 1966
ileotransverse colostomy
(Ref 13)
Closure of perforation with
Chamber C E 1972
proximal tube ileostomy
(Ref 14)
Kim J P et al. 1975
Ilear resection and anastomosis
(Ref 12)
ileostomy at the site of
perforation
K d U l B K 1975
Ileostomy at the site of per(Ref 11)
foration
Swadia et al. 1975 (Ref 5 )
Closure of perforation
Prasad et al. 1975 (Ref 4)
Closure of perforation with ileotransverse anastomosis
Egglestone et al. 1979
Closure of perforation with ileotransverse anastomosis
(Ref 10)
Closure of perforation with
Nadkarni rt al. 1981
(Ref 8)
exteriorization of bowel loop
Bose et al. 1987 (Ref 15)
Closure of perforation by simple
suture or by omental graft or
serosal patch and for multiple
perforations resection and
anastomosis of ileum
Singh et al. 1992 (Ref 16)
Temporary loop ileostomy
Closure of perforation with ileoPal et al. 1994 (Ref 7)
transverse anastomosis

of cases, pneumoperitoneum in 52% of cases and both

pneumoperitoneum and multiple fluid levels in 29% of
cases. A Widal test was done in 38 cases and was positive
in only 52%. On exploration, all had generalized
peritonitis. In the majority of the cases the perforation
was single and was located within the terminal 20 cm on
the antimesenteric border of the ileum. In five cases there
was a double perforation and in three cases there was a
triple perforation. In no case was a caecal perforation
found.

DISCUSSION

The incidence of typhoid perforation and subsequent

mortality in India remains a l a r m i ~ ~ g It
~ .is
~ .a disease of
the prime of life7,*, mainly occurring in the male
p o p ~ l a t i o n ~ ,In
~ -the
~ . early 1960s, Hucksteps conservative treatment for such cases enjoyed a brief popularity9,
but nowadays, the only accepted treatment is early
surgical intervention.
Though several operations are recommended by
different authors as shown in Table 2, we attempted
two types of operation in this study. In our study, the
simple closure group had a high incidence of faecal

Dunkerley 1946
(Ref 17)
Olurin et al. 1972
(Ref 19)
Welch and Martin
1975 (Ref 20)
Purohit P G 1978
(Ref 21)
Kala et al. 1978
(Ref 18)
Swadia et al. 1979
(Ref 5 )
Egglestone et al. 1979
(Ref 10)
Bose et al. 1987
(Ref 15)
Pal et al. 1994 (Ref 7)
Present series (1995)

No. of No. of
patients deaths Mortality
___
22
12
55%

Faecal
fistula

58

18

11

36.36%

41

14.63%

16

20.00%

104

30

28.84%

43

13

30.23%

26

7.69%

4 (15.38%)

21
28

3
7

11.11%
25.00%

5 (18.51%)

31.03% 12 (20.68%)
4 (36.36%)

2 (1.92%)

6 (21.42%)

fistula (21 YO)whereas in the bypass group there was no

fistula (Table 1). In typhoid fever there is always
extensive ulceration in the mucosa and submucosa, but
only one or two ulcers may perforate. Closure of the
perforation without a bypass results in continuous
contamination of the closed ulcer site by the faecal
stream, leading to poor healing, and a subsequent faecal
fistula may develop. In addition, during the postoperative period, other ulcers may perforate leading to
faecal fistulae which can be avoided rest in the diseased
segment by bypass surgery4x7.
Toxaemia due to peritonitis contributes to a high
mortality5 but our experience shows it is not toxaemia
alone, but that faecal fistula is also a major contributory
factor leading to high m ~ r t a l i t y ~Initially
.~.
we performed only a primary closure of the perforation, but
the large number of faecal fistulae followed by death in
all patients disappointed us and we switched over to
bypass surgery with encouraging results.
Table 4. Result of different series in primary closure of
perforation with bypass (ileotransverse anastomosis)
Author and
year
Prasad et al. 1975
(Ref 4)
Egglestone et al. 1979
(Ref 6 )
Pal et al. 1994 (Ref 7)
Present series (1998)

Faecal
cases jistula

No. of

No. of
deaths

Mortality

15

20%

29

31.03%

21
32

0
0

1
2

6.76%
6.25%

18

Tropical Doctor, January 1998

We are of the same opinion as Muligan (1972 cited in

Ref. 5) that at operation it seems rational in future to
do more than merely the repair of perforation. In our
experience, primary closure of the perforation in two
layers with ileotransverse anastomosis was the best
operative procedure in terms of reducing mortality and
morbidity. This is borne out by the experience of others
as shown in Tables 3 and 4.
ACKNOWLEDGEMENT

Thanks are due to the Superintendent, North Bengal Medical

College & Hospital, for his kind permission to publish this
study from the Hospital records.
REFERENCES

Manson Bahar PEC, Bell DR. Typhoid fever. In: Mansons

Tropical Diseases. London: Baillikre Tindall; 1987:194-206
Dawson JH. Surgical management of typhoid perforation of
the ileum. A m J Surg 1970;36:620-2
Mahindra NN. XIIX Annual Conference, Association of
Surgeons of India. 26 December 1989
Prasad PB, Chowdhury DK, Prakash 0.Typhoid perforation
treated by closure and proximal side-to-side ileotransverse
colostomy. J Ind Med Asso 1975;65:297-9
Swadia ND, Trivedi PM, Thakkar AM. The problem of
enteric ileal perforations. Ind J Surg 1979;41:643-5 1
Egglestone FC, Santoshi B. Typhoid perforation - choice of
operation. Br J Surg 1981;68:341-2
Pal DK, Shrivastava GP, Tripathi TS. Bypass surgery the operation of choice in typhoid perforation. Ind J Surg
1994;56:213-21

Conducting a descriptive survey: 3.

summarizing and presenting data
Sarah B

J Macfarlane BA MSc Econ

Unit for Statistics and Epidemiology, Liverpool School of
Tropical Medicine, Pembroke Place, Liverpool L3 5QA, U K

TROPICAL DOCTOR,
1998,28,

18-28

INTRODUCTION

The collection of data often results in large quantities of

paper and lots of numbers, all of which can be extremely
overwhelming. There may be a strong temptation to
delay making sense of the data, blaming the lack of
clerical assistance, statistical assistance or of computing
facilities. This article will demonstrate that summarizing
and presenting data is an important and stimulating part
of conducting a survey. It is now that you have the
opportunity to explore the evidence, to discover the
story and to show others what you have found. This is

8 Nadkarni MM, Setty SD, Kagji RS. Small bowel

perforations. A study of 32 cases. Arch Surg

1981;116:53-7
9 Huckstep RL. Recent advances in surgery of typhoid fever.
Ann Roy Coll Surg Engl 1960;26:207-30
10 Egglestone FC, Santoshi B, Singh GM. Typhoid perforation of the bowel. Experience in 78 cases. Ann Surg
1979;190:31-5
11 Kaul BK. Operative management of typhoid perforation in
children. Int Surg 1975;60:407--10
12 Kim JP, Oh SK, Jarrett F. Management of ileal
perforation due to typhoid fever. Ann Surg 1975;181:
88-91
13 Lizarrakde BA. Typhoid perforation in ileum in children. J
Ped Surg 1963;161012-16
14 Chambers CE. Perforation of the ileum. Arch Surg
1972;105:552
15 Bose SM, Ananta K, Chowdhury A, Dhara I, Gupta MN
and Khanna KS. Small intestinal perforations. Ann I M A
Acad Med Specialities 1987;1:14
16 Singh J, Singh B. Enteric perforation in typhoid fever. Aust
N Z J Surg 1975;45:279-84
17 Dunkerly GE. Perforation of the ileum in enteric fever
notes of 22 consecutive cases. B M J 1946;2:454-7
18 Kala KP, Asopa HS, Mathur SK, et al. Resection and
ileocolostomy for enteric perforation of the terminal ileum.
Ind J Surg 1978;40:674-8
19 Olurin EQ, Ajayi 00, Bohrer SP. Typhoid perforations. J
R Col Surg Edin 1972;17:353-63
20 Welch TP, Martin NC. Surgical treatment of typhoid
perforation. Lancet 1975;l:1078-80
21 Purohit PG. Surgical treatment of typhoid perforation.
Experience of 1976 Sangli epidemic. Ind J Surg 1978;40:
221-38
-

the third article in a series of four on how to conduct a

descriptive survey. The first two
provide an
explanation of the planning process, methods of
sampling and some of the terminology used in this
article.
Two data sets are used to demonstrate the techniques
of summarizing and presenting data. Data set 1 relates
to a random sample of 32 babies born in a hospital who
were observed in a descriptive study of birth weight
(Appendixl). Data set 2 consists of some nutritional
data similar to that which might have been collected for
a random sample of 70 children from one of the refugee
camps in the example used in a previous article2
(Appendix 2). Some of the data are summarized in this
article and the remainder is left for you to investigate.

STEM-AND-LEAF PLOT

This is a simple way to obtain the story behind the data.

Take the birth weights of the babies in data set 1. The
values, as they appear on the data sheet, say little about
the distribution of birth weight but they can be
rearranged to provide interesting information (Table