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A Pilot Study on the Role of T-Tube in Typhoid Ileal Perforation in Children

A Pilot Study on the Role of T-Tube in Typhoid Ileal Perforation in Children
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  A Pilot Study on the Role of T-Tube in Typhoid IlealPerforation in Children Anand Pandey   V. Kumar   Ajay N. Gangopadhyay   Vijai D. Upadhyaya   A. Srivastava   Ram B. Singh Published online: 30 September 2008   Socie´te´ Internationale de Chirurgie 2008 Abstract  Background   Ileostomy is usually performed for patientsof typhoid intestinal perforation with poor general condi-tion, but it is associated with significant morbidity. Wehave used the T-tube in such patients as an alternative toileostomy.  Methods  This is a prospective evaluation of a cohort of children with proven typhoid intestinal perforation.Patients with multiple perforations and poor general con-dition were managed with a T-tube inserted into the bowellumen after closing all distal perforations (group 3). Theywere compared with patients who had primary closure of perforation (group 1) or bowel resection (group 2) todetermine the efficacy of the use of T-tube.  Results  The total number of patients for groups 1, 2, and3 was 51, 4, and 12 (n  =  67). The mean number of per-forations for the three groups was 1, 3.5  ±  0.58, and4.25  ±  0.97. The operation time for the three groups was37.29  ±  3.24, 59.25  ±  3.09, and 59.17  ±  4.17 minutes,respectively. The T-tube was removed after 13.17 days.The mean duration of fistula at T-tube site to heal was8.58  ±  2.11 days. The overall follow-up period was10.94  ±  1.15 months and none of the patients with T-tubeplacement had features of intestinal obstruction. Conclusions  In children with multiple typhoid intestinalperforations and poor general condition, the use of T-tubemay be an effective management option. Introduction Typhoid fever is a common problem in developing coun-tries. Typhoid intestinal perforation—a complication of typhoid fever—has always been of concern because of itshigh morbidity and mortality rates. Most perforations occurin the terminal ileum [1]. The incidence of perforation hasbeen reported to be between 0.8% and 18% [2].Various surgical options for treatment of the typhoidperforation are primary closure, ileostomy, and resectionwith anastomosis (RA) [2]. Although surgery is accepted asthe definitive treatment of typhoid intestinal perforation,there is no general agreement regarding the choice of theprocedure [3]. Usually primary closure is performed forsingle perforation, RA for multiple perforations, and ile-ostomy for patients with poor condition [3]. Althoughileostomy is a life-saving procedure, it is associated withvarious complications, such as prolapse, stricture, retrac-tion, parastomal hernia, which add severely to the morbidityof the patient and delay the overall recovery period [4]. Inan attempt to avoid the ileostomy and its subsequent com-plications, we used a T-tube in its place in patients with poorgeneral condition. This study was performed to determinethe feasibility of T-tube in such patients. Material and methods This was a prospective study from January 2005 to January2007. It was approved by the hospital ethical and A. Pandey    V. Kumar    A. N. Gangopadhyay ( & )   V. D. Upadhyaya    R. B. SinghDepartment of Pediatric Surgery, Institute of Medical Sciences,Banaras Hindu University, Varanasi 221005, Uttar Pradesh,Indiae-mail: gangulybhu@rediffmail.comA. SrivastavaDepartment of Community Medicine, Sri RamMurty Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India  1 3 World J Surg (2008) 32:2607–2611DOI 10.1007/s00268-008-9746-y  postgraduate committee. We included only those patientsof proved typhoid ileal perforation for T-tube placementwho were having poor general condition, multiple perfo-ration, and severe peritoneal contamination at the time of presentation to the department in which primary closure orRA was judged to be very risky. The poor general condi-tion was judged on basis of state of shock, such as threadypulse, tachycardia, and tachypnea, and poor response toverbal or painful stimulus, fever [ 104  F, need of oxygensupplementation, and requirement of inotropic support.The diagnosis of typhoid fever was suspected on thebasis of history, clinical examination, and a positive Widaltest. The diagnosis of typhoid intestinal perforation wassuspected on clinical basis and confirmed by gas under thediaphragm in plain abdominal x-ray in erect view andparacentesis.After initial resuscitation and intravenous (IV) antibi-otics administration, exploratory laparotomy wasperformed by right transverse supraumbilical incision in allthe patients. We had accepted peritoneal contamination assevere when the drainage amount was [ 1000 ml, moder-ate when the amount was between 500 and 1000 ml, andmild when the amount was \ 500 ml.After through peritoneal lavage, all perforations wereclosed in single layer by Vicryl 3-0 or 4-0 and the T-tube of size 12 or 14 Fr was placed inside the lumen through themost proximal perforation or impending perforation(Fig. 1). The size of T-tube was decided on basis of size of the perforation, which easily accommodated the 12 or 14number size in all patients. If the most proximal perforationwas [ 1 cm in diameter, then it was closed primarily andT-tube was placed just proximal to it. After placing the T-tube through the perforation, it was secured by a purse-string suture (Fig. 2) and fixed to the parietal wall. Thetube was brought through a separate small opening (Fig. 3).The removal of T-tube was performed after 12 to 14 days when contrast study done through T-tube showed noleakage of dye.The patients were compared with those patients in whomprimary closure or RA was performed during the same timeperiod. The evaluation was performed on basis of durationof hospital stay, complications related to T-tube and overallcomplications, start of oral feeds, and follow-up.The statistical analysis was done by using SPSS 12.0version for Windows. The results were evaluated by  v 2 testand one-way analysis of variance. The values are expressedas mean  ±  SD.  p \ 0.05 was considered as statisticallysignificant. Results A total of 67 patients were operated on for diagnosis of typhoid ileal perforation from January 2005 to January Fig. 1  Placement of the T-tube through the ileal perforation Fig. 2  Securing the T-tube by pursestring suture Fig. 3  Patient in the postoperative period showing T-tube exiting viaseparate opening2608 World J Surg (2008) 32:2607–2611  1 3  2007. Fifty-one (76.11%) patients had single perforationthat underwent primary closure (group 1). Four (5.97%)patients had RA (group 2) for multiple ileal perforationwith good general condition. Twelve (17.91%) patients hadpoor general condition, multiple perforations, and severeperitoneal contamination (group 3).The age of patients in the three groups was 6.75  ±  1.66(range, 4–11) years, 6.75  ±  2.22 (range, 5–10) years, and7.58  ±  2.11 (range 4–11) years, respectively. The agedifference was statistically insignificant (  p [ 0.05). Therewas history of fever for 12.11  ±  1 (range, 10–14) days,12.5  ±  0.58 (range, 12–13) days, and 11.17  ±  1.03 (range,10–14) days in the three groups, respectively (  p [ 0.05).The overall male to female ratio was 2:1 (  p [ 0.05 for allthe three groups). The Widal test was positive in all thepatients in group 3.The mean interval between presentation of the patient tothe department and exploratory laparotomy was5.92  ±  1.04 (range, 4–8) hours, 5.75  ±  0.9 (range, 5–6)hours, and 6.42  ±  1.24 (range, 4–8) hours in the threegroups, respectively (  p [ 0.05). T-tube as a treatment wasused in group 3. The perforations were located between 0and 60 cm from the ileocecal valve in all the patients.There was a single perforation in group 1. In the groups 2and 3, the mean number of perforations was 3.5  ±  0.58(range, 3–4) and 4.25  ±  0.97 (range, 3–6), respectively. Ingroup 3, the mean distance between two perforations was4.69  ±  2.56 (range, 1–11) cm. The mean size of perfora-tion in group 3 was 0.52  ±  0.21 (range, 0.3–1.5) cm. Theoperation time was 37.29  ±  3.24 (range, 30–44) minutes,59.25  ±  3.09 (range, 55–62) minutes, and 59.17  ±  4.17(range, 55–65) minutes in the three groups, respectively(  p \ 0.05 for group 1).In eight (66.67%) patients, T-tube was placed from themost proximal perforation and in 4 (33.33%) patients it wasplaced just proximal to the most proximal perforation afterclosing it. The patients were allowed orally on 4.27  ±  0.25(range, 4–5) days, 6 days, and 6  ±  0.74 (range, 5–7) days inthe three groups,respectively (  p \ 0.05 for group 1). T-tubewas removed on 13.17  ±  0.72 (range, 12–14) days. Afterthe removal of the T-tube, the mean duration that the tractcontinued to discharge before the fistula eventually healedwas 8.58  ±  2.11 (range, 5–12) days. None of the patients ingroup 3 required ileostomy subsequent to T-tube.The patients were discharged after 9.43  ±  4.42 (range,7–12) days, 10.75  ±  0.96 (range, 10–12) days, and14.17  ±  0.72 (range, 13–15) days, respectively, in thethree groups (  p \ 0.05 for group 3). The follow-up periodwas 10.98  ±  1.16 (range, 9–13) months, 11  ±  0.82 (range,10–12) months, and 10.75  ±  1.29 (range, 9–13) months,respectively, for the three groups (  p [ 0.05). During thefollow-up, none of the patients with T-tube had features of intestinal obstruction, suggesting the possibility of stricturedevelopment at the operation site.The complications noted were superficial wound dehis-cence in four (33.33%), fever in six (50%), and intra-abdominal abscess in two (16.67%) patients. There was noperitube leakage. The wound dehiscence was managed bysecondary suturing. The intra-abdominal abscess wasaspirated with the help of abdominal ultrasound. The feverwas managed by change in the antibiotics. There was nomortality in group 3, but the mortality in group 1 wasapproximately 15% (Table 1). Discussion Typhoid perforation continues to be a scourge in childrenin developing countries [5]. There are at least 16 millionnew cases of typhoid fever around the world [6]. Theperforation results from necrosis of Peyer’s patches in theterminal ileum [3]. It usually occurs during the second orthird week of fever [7]. Surgery is the accepted mode of treatment; but there is no general agreement regarding thechoice of procedure, but ileostomy has been suggested forpatients with delayed presentation and severe abdominalcontamination [3].Various tube techniques reported in literature are mostlyfor meconium ileus and bowel atresia in newborn surgery.In 1968, Rehbein and Halsband reported the double-tubetechnique for the treatment of meconium ileus and small-bowel atresia [8]. They used two plastic tubes: the thick one was inserted above the anastomosis and was used fordecompression, and the thin one was inserted into distal Table 1  Comparative evaluation of various postoperative complications in the different groupsGroup 1 (primary closure) Group 2 (resection with anastomosis) Group 3 (T-tube placement)Wound dehiscence 16 (31.37%) 1 (25%) 4 (33.33%)Fever 23 (45.09%) 0 6 (50%)Intra-abdominal abscess 9 (17.65%) 0 2 (16.67%)Mortality 8 (15.69%) 0 0  p [ 0.05 for all variables, except the mortality for which the test could not be appliedWorld J Surg (2008) 32:2607–2611 2609  1 3  loop and served as a splint for the anastomosis andthe distal bowel. In 1981, Harberg et al. [9] described thetechnique and results of the T-tube ileostomy for thetreatment of uncomplicated meconium ileus without per-foration. T-tube ileostomies were placed through anenterotomy at the junction of proximal dilated bowel anddistal ileum with minimal bowel manipulation. Mathai andcolleagues used the procedure of proximal venting by aMalecot catheter in nine children with intestinal atresiawith median weight 2.6 kg [10]. T-tube drainage for thetreatment of high jejunal atresia (diaphragmatic type) infull-term newborns was used by Wen-Tsung Hung andcolleagues [11]. A T-tube was inserted through the openingof the jejunum. One arm of the T-tube laid in the distended jejunum and the other arm of the T-tube passed through thearea of excised diaphragm and lay in the distal collapsedloop. Encouraged by the successful outcome with the tubetechnique, we used it in patients of typhoid intestinal per-foration with poor general condition in an attempt to avoidileostomy.The ileostomy or colostomy has been in practice since1793 for emergency management. It became a standardprocedure by virtue of its low immediate mortality and easeof performance, but it necessitates staged procedures forclosure with repeated hospital admissions and prolongedhospital stay [12]. It has been associated with multiplecomplications, such as prolapse, stricture, parastomal her-nia, and perforation [4]. In a tropical country like ours,ileostomy diarrhea can lead to a lethal sequence in thesummer season. Analysis of pediatric series that had ile-ostomy revealed complication rates that often exceed 50%[4]. However, it is still needed in emergency when peri-toneal cavity is severely contaminated and RA is not safe[3]. We are using the criteria of mild, moderate, and severcontamination on the basis of volume of peritoneal fluidpresent at the time of laparotomy. Recently the same valuesalso have been accepted by Atamanalp et al. [3] in theirestimation of peritoneal contamination. The use of T-tubeused in these patients can be advantageous because itpromotes decompression of bowel, prevents further com-plications of hypoperistalsis and stasis, and allows anuneventful healing of the site of perforation. T-tube ileos-tomy combines advantages of enterostomy, such asintestinal decompression, early feeding, and rapid tech-nique with those of primary anastomosis, such asrestoration of intestinal continuity and avoiding secondaryoperation [13].The lesser duration of operation time in group 1 caneasily be explained on basis of closure of single perfora-tion, whereas RA in group 2 or careful closure of multipleperforations with placement of T-tube in group 3 took moretime to complete the task. The oral intake was in form of liquids on the fourth to sixth day followed by semisolidfood for the next 2 days and then full oral feeds and hencethe chance of blockade of T-tube was minimal; moreoveras the ileal contents are liquid during the early part of recovery period the chances of tube block were not much.The removal of the tube after 12 to 14 days was based onthe assumption that the tube tract is formed during thisperiod thereby preventing the chances of peritonealcontamination.Although there were complications in our series, theywere not related to the use of the T-tube. The theoreticalchances of injury to the friable bowel by the application of pursestring sutures were not noticed in any of our patients.The occurrence of the complications was statisticallyinsignificant in all three groups, thus proving our statementthat the complications were not related to the T-tube usage(Table 1). All of our patients had an uneventful recoverywith the use of the T-tube, suggesting that T-tube ileos-tomy can be used as an effective alternative to ileostomyand preventing its long-term morbidity. It can be arguedthat the mortality in group 1 was significant compared withgroup 3; however, we included only those patients in group3 who, apart from having poor general condition and severeperitoneal contamination, had multiple ileal perforation. Ingroup 1, not all patients had good general condition, but thecriteria of single or multiple perforations separated theminto group 1 or 3.Overall, morbidity can be reduced and outcome opti-mized by aggressive resuscitation in all cases of typhoidintestinal perforation, and early limited surgery. Thus, T-tube ileostomy in pediatric patients of typhoid fever withmultiple ileal perforations and poor general condition canbe used as an alternative to ileostomy. Given the betteroutcome with T-tube, it may be necessary to includepatients with single perforation and poor general conditionamong those who may benefit from T-tube in futurestudies. References 1. Chang YT, Lin JY, Huang YS (2006) Typhoid colonic perforationin childhood: a ten-year experience. World J Surg 30:242–2472. Onen A, Dokucu AI, Cigdem MK, Ozturk H, Otcu S (2002)Yucesan S (2002) Factors effecting morbidity in typhoid intes-tinal perforation in children. Pediatr Surg Int 18:696–7003. Atamanalp SS, Aydinli B, Ozturk G, Oren D, Basoglu M, Yil-dirgan MI (2007) Typhoid intestinal perforations: twenty-six yearexperience. World J Surg 31:1883–18884. Gauderer MWL (2006) Stomas of the small and large intestine.In: Grosfeld JL, O’Neill JA Jr, Fonkalsrud EW, Coran AG (eds)Pediatric surgery, 6th edn. Mosby Elsevier, pp 1479–14935. Ameh EA (1999) Typhoid ileal perforation in children: a scourgein developing countries. Ann Trop Pediatr 19:267–2726. Parry CM, Hien TT, Dougan G (2002) Typhoid fever. N Engl JMed 347:1770–17822610 World J Surg (2008) 32:2607–2611  1 3  7. Hosoglu S, Aldemir M, Akalin S, Geyik MF, Tacyildiz IH, LoebM (2004) Risk factors for enteric perforation in patients withtyphoid fever. Am J Epidemiol 160:46–508. Rehbein F, Halsband H (1968) A double-tube technique for thetreatment of meconium ileus and small bowel atresia. J PediatrSurg 3:723–7269. Harberg FJ, Senekjian EK, Pokorny WJ (1981) Treatment of uncomplicated meconium ileus via T-tube ileostomy. J PediatrSurg 16:61–6310. Mathai J, Sen S, Zachariah N, Chacko J, Thomas G (2003)Proximal Malecot vent in neonatal small-bowel anastomosis.Pediatr Surg Int 19:245–24611. Hung WT, Tsai YW, Lu WT (1995) T-tube drainage for thetreatment of high jejunal atresia. J Pediatr Surg 30:563–56512. Asfar SK, Al-Sayer HM, Juma TH (2007) Exteriorized colonanastomosis for unprepared bowel: an alternative to routinecolostomy. World J Gastroenterol 13:3215–322013. Rygl M, Pycha K, Strank Z, Skaba R, Brabec R, Snajdauf J(2007) T-tube ileostomy for intestinal perforation in extremelylow birth weight neonates. Pediatr Surg Int 23:685–688World J Surg (2008) 32:2607–2611 2611  1 3
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