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ORIGINAL ARTICLE Table of Contents   
Year : 2013  |  Volume : 10  |  Issue : 2  |  Page : 167-171
Single-layer closure of typhoid enteric perforation: Our experience

1 Department of Surgery, Murtala Muhamad Specialist Hospital, Children Surgical Unit, Kano, Nigeria
2 Aminu Kano Teaching Hospital and Bayero University Kano, Kano, Nigeria

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Date of Web Publication15-Jul-2013


Background: Typhoid enteritis is rare in developed countries. The increasing prevalence of typhoid fever with enteric perforation in our environment is alarming. Peritonitis follows enteric perforation due to typhoid enteritis. Surgical treatments and repair of the perforated areas due to typhoid enteritis varies between institutions with high mortality and morbidity. Materials and Methods: We retrospectively studied the effects of single versus double layer intestinal closure after typhoid enteric perforation with peritonitis in 902 pediatric patients from September 2007 to April 2012. All the patients underwent laparotomy after resuscitation and antibiotic cover. The patients were divided into two groups: group A (n = 454) double layer closure and group B (n = 448) single layer closure. Results: There were 554 males and 348 females with male to female ratio 1.6:1. Ages of the patients were three years to 14 years with mean age at eight years and mode at nine years. The following clinical outcomes were recorded: burst abdomen 38 (8.3%) vs 3 (0.6%), enterocutaneous fistula formation 52 (11.4%) vs 8 (1.7%), superficial wound infection 215 (47.3%) vs 91 (20.3%), ligature fistula 13 (2.8%) vs 7 (1.5%), mean length of 29.4 ± 7.8 vs 45.3 ± 11.6. Conclusion: Our results showed that single layer closure of the perforated ileum due to typhoid enteric perforation with peritonitis in children was effective by reducing complication rates.

Keywords: Children, single layer closure, typhoid enteric perforation

How to cite this article:
Ibrahim M, Getso K I, Yashuwa A H, Mohammad A M, Anyanwu L. Single-layer closure of typhoid enteric perforation: Our experience. Afr J Paediatr Surg 2013;10:167-71

How to cite this URL:
Ibrahim M, Getso K I, Yashuwa A H, Mohammad A M, Anyanwu L. Single-layer closure of typhoid enteric perforation: Our experience. Afr J Paediatr Surg [serial online] 2013 [cited 2020 Oct 24];10:167-71. Available from:

   Introduction Top

Typhoid fever is a severe multisystemic infection caused by  Salmonella More Details typhi and occasionally Salmonella paratyphi. Typhoid enteritis is endemic in areas with poor socioeconomic facilities, including poor clean water supply and sanitary systems. [1],[2],[3] Typhoid infection is acquired by the faeco-oral route. Severe typhoid fever with enteric involvement perforates leading to serious surgical complications with high morbidity and mortality. [4],[5],[6],[7] Peritonitis follows typhoid enteric perforation. [8] Management of typhoid enteric perforation is surgically challenging. There are various surgical treatment options for typhoid enteric perforation [8],[9],[10],[11],[12] but the superiority of any one procedure over the other remains controversial. [8] However, simple, quick and less traumatic surgical procedure is advocated in the treatment of typhoid enteric perforation. [10] This study reviewed single versus double-layer intestinal closure in the surgical management of typhoid intestinal perforations in children in our centre.

   Materials and Methods Top

Nine hundred and two children 902 with peritonitis secondary to typhoid enteric perforations were enrolled into the study prospectively from September, 2007 to April, 2012 at the Department of Surgery, Children Surgical Unit of Murtala Muhammad Specialist Hospital, Kano in Northern Nigeria.

All the admitted patients were operated by one surgical team of the unit that included a pediatric surgeon, a principle medical officer, senior medical officers and medical officers.

Upon admission, after routine clinical investigations; patients were adequately resuscitated for fluid and electrolytes imbalances including intravenous administration of antibiotics. Anaemic patients were transfused appropriately. Negative nitrogen equilibrium was evaluated and managed by administering IV Astymine® or Mekoamine® as we do not have facilities for total parenteral nutrition in our centres. Nasogastric tubes were inserted for decompression and urethral catheter for urine output monitoring.

After adequate resuscitation with satisfactory urine output, patients were evaluated for peritonitis severity using Mannheim Peritonitis Index (MPI) and Multiple Organ Failure index (MOF) for prognostic purposes. [13],[14] Careful evaluation of Shock Degree Index (SDI) [15] was also carried out as a monitoring guidance during surgical manipulations.

Laparotomy effected with gentle revision of the peritoneal cavity. Perforated intestines were identified and secured with stay sutures followed by wedge resection or refreshment of the perforated edges with sharp surgical scissors to avoid repeated tissue handling of fragile and friable intestine.

Throughout the study period, we adopt a policy of using Ethicon [] Vicryl 2/0 or 3/0 with a round body needle size 18 mm or 22 mm to apply interrupted seromuscular single layer sutures [Figure 1]. Surgical knots are made with gentle pressure and an appropriate controlled tension to avoid tissue damage and ischemia to the secured edges [Figure 2]. Peritoneal lavage with warm normal-saline was carried out. Peritoneal drainage tubes were placed to the pelvic regions. Laparotomy wounds were closed in revised layers using nylon 2\0 and or 3\0 according to child's age. Continuation of the intravenous fluids and antibiotics are given in form of ceftriaxone, metronidazole to all our patients. Analgesics are given as required with continual monitoring of intake\output chart and electrolytes. On the resumption of the intestinal peristalsis and tolerable oral acceptance by the patients, a highly enriched meat/fish or chicken broth (bouillon) was introduced into the feeding menu that was followed by (PLUMPY) nuts from the pediatric unit of Murtala Muhammad Specialist Hospital, Kano. Protein-enriched milk powder formula COMPLAN® was provided to all the patients by the hospital authority free of cost.
Figure 1: Single-layer seromuscular suture application

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Figure 2: Appearance of single-layer seromuscular sutures

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The study was compared between the two groups and postoperative complications were recorded.

   Results Top

Within four years and seven-month period, a total number of 986 children with typhoid enteric perforations underwent surgical repair of the perforated intestine at Murtala Muhammad Specialist Hospital, Kano, in northern part of Nigeria. But only 902 patients had an adequate clinical data for analytical studies that are assigned into two groups: group A n = 454 (50.3%) and group B n = 448 (49.6%). There were 554 males and 348 females with male to female ratio 1.6:1. Ages of the patients were 3 years to 14 years with mean age of 8 years and mode of 9 years.

Eight hundred and eighty nine (97.9%) patients presented with classical clinical features of typhoid enteric perforation with generalized peritonitis [13] while 13 (1.4%) perforated few hours prior to surgical review and had a symptoms of appendicitis with localized peritonitis.

Forty-two patients 42 (4.6%) patients died out of which four death 4 (0.4%) occurred on table due to sudden cardiac arrest.

There were significant differences between overall complication rates and mean length of hospital stay between the two groups 75.7% in group A versus 27.4% in group B [Table 1].
Table 1: Postoperative outcomes

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   Discussion Top

Typhoid intestinal perforation is a principal cause of morbidity and mortality in children in an environment with poor socioeconomic and sanitary facilities. [16] Inappropriate and poor sewage disposal with unhealthy drinking water supply are the main causes of typhoid fever. [4],[5],[7],[17],[18] If not adequately treated, severe typhoid fever with enteric involvement perforates leading to generalized peritonitis with overwhelming septicaemia.

The management of typhoid enteric perforation is a serious and difficult surgical challenge.

In the early years of the 1960s and 1970s, the management of typhoid enteric perforation had high mortality and morbidity and for these reasons, few surgeons advocated a nonoperative approach. [19],[20] However, in modern clinical medicine and surgical practice, surgery is the only treatment of choice for typhoid enteric perforation. Even in the recent literatures, management of typhoid enteric perforation has a high rate of morbidity and mortality. [4],[8] Although, surgery is the treatment of choice, the mode to the surgery varies. [8],[9],[10],[12],[17],[21] Some authors documented their experiences with double-layer intestinal closure after typhoid enteric perforation, while others argued that, resection and anastomosis is a suitable surgical technique, [8] some suggested that, T-tube insertion into the bowel lumen after closing distal perforation may be an effective approach. [9] In the year 2011, Hussain M et al., [12] advocated for primary closure of the perforated ileum with additional omental patch for avoidance of faecal fistula formation.

However, Uba AF et al., [10] advised simple, quick and less traumatic surgical procedure in the treatment of typhoid perforation. They found that, simple closure, rather than resection and anastomosis was associated with the least incidence of anastomotic breakdown and reduction in operation time.

Many authors argued that, choice of surgical approach could affect the morbidity and mortality rates in the treatment of typhoid enteritis with perforation with various suggestions on the surgical closure of the perforated intestines. In their analysis of 100 cases, Shukla VK et al., [22] found out that, those patients who had double-layer intestinal closure had 42% morbidity rate, while in the year 1986 and 1989, Efem SE et al., [23],[24] advocated for seromuscular continuous 3\0 chromic catgut suture application. They found out that, the use of a two-layer anastomosis for closure of a perforation confers no advantage and might lengthen operating time. The authors reduced mortality rates to six percent (6%), but did not elaborate on the morbidity. Gedik E et al., [25] attributed the high rate of morbidity to severity of peritonitis rather than the surgical technique. In their analysis of 178 patients with typhoid enteric perforation, AA Nasir et al, [26] attributed attention to surgical details in reducing morbidity and mortality in patients with typhoid enteric perforation.

In purulent generalized peritonitis, the entire intestinal layers and particularly the subserosal and the muscular layers that provide blood circulations for the viability of the organ/tissue are grossly edematous. Therefore, applying double layer sutures could limit the circulations which could lead to ischemia and tissue necrosis with possible leakage [Figure 3] and [Figure 4].
Figure 3: Schema of double layer intestinal closure can worsen the tissue ischaemia

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Figure 4: Schema of anastamotic break down and leakage

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In addition, small intestinal mucosal layers are enriched with micro-villi that has abundant capillary circulations which clusters together to seal up defects effectively as single layer is applied [Figure 5] and [Figure 6]. When double layer is applied on an edematous small intestine, there is a tendency of narrowing the intestinal lumen at the suture sites [Figure 7] and this could as well increase intra-luminal pressure which might increase the chances of indehiscence.

Therefore, if all factors are excluded such as perforation-operation interval, severity of peritonitis, electrolytes and nitrogen equilibrium, multiorgan failure; then we can achieve relatively low mortality and morbidity rate by meticulously applying simple, quick and less traumatic surgical principles. Seromuscular single layer intestinal closure provides satisfactory tissue viability, less surgical trauma, less postsurgical tissue oedema, less ischemia, effective sealing effect without narrowing the intestinal lumen. From our series, the rate of complication is reduced by 48.3% and mean length of hospital stay to by 15.9 ± 3.8 days.
Figure 5: Schema of single layer seromuscular suture application

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Figure 6: Schema of intestinal lumen when single layer is applied

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Figure 7: Schema of narrowing of the intestinal lumen due to double-layer suture application

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   Conclusions Top

Our single centre experience showed that, meticulously applying surgical principles, single-layer closure of the perforated ileum due to typhoid enteric perforation with peritonitis in children was an effective method.

   References Top

1.Saxe JM, Cropsey R. Is operative management effective in treatment of perforated typhoid? Am J Surg 2005;189:342-4.  Back to cited text no. 1
2.Carmeli Y, Raz R, Scharpiro J. Typhoid fever in Ethiopian immigrants to Israel and native-born Israelis: A comparative study. Clin Infect Dis 1993;16:213-5.  Back to cited text no. 2
3.Edino ST, Mohammed AZ, Uba AF. Typhoid enteric perforation in north western Nigeria. Niger J Med 2004;13:345-9.  Back to cited text no. 3
4.Osifo OD, Scott OO. Typhoid ileal perforation in children in Benin City. Afr J Paediat Surg 2010;7:96-100.  Back to cited text no. 4
5.Agbakwuru EA, Adesukanmi AR, Fadiora SO. A review of typhoid perforation in a rural African hospital. West Afr J Med 2003;22:22-5.  Back to cited text no. 5
6.Noorani MA, Sial I, Mal V. Typhoid perforation of small bowel: A study of 72 cases. J Coll Surg Edin 1997;42:272-6.  Back to cited text no. 6
7.Miguel S. Surgical complications of typhoid fever: Enteric perforations. World J Surg 1991;15:170-5.  Back to cited text no. 7
8.Ameh EA. Dogo PM, Attah MM, Nmadu PT. Comparison of three operations for typhoid perforation. Br J Surg 1997;84:558-9.  Back to cited text no. 8
9.Pandey A, Kumar V, Gangopadhyay AN, Upadhyaya VD, Srivastava A, Singh RB. A pilot study on the role of T-tube in typhoid ileal perforation in children. World J Surg 2008;32:2607-11.  Back to cited text no. 9
10.Uba AF, Chirdan BL, Ituen MA, Mohammed AM. Typhoid intestinal perforation in children: A continuing scourge in a developing country. Pediatr Surg Int 2007;23:33-9.  Back to cited text no. 10
11.Nasir AA, Lukman OA, Adeniran JO. Is intraabdominal drainage necessary after laparotomy for typhoid intestinal perforation? J Pediat Surg 2012;47:355-8.  Back to cited text no. 11
12.Hussain M, Khan RN, Rehmani B, Haris H. Omental patch technique for the ileal perforation secondary to typhoid fever. Saudi J Gastroenterol 2011;17:208-11.  Back to cited text no. 12
13.Notash AY, Salimi J, Rahimian H, Fesharaki MH, Abbasi A. Evaluation of Mannheim peritonitis index and multiple organ failure index in patients with peritonitis. Indian J Gastroenterol 2005;24:197-200.  Back to cited text no. 13
14.Bosscha K, Reijnders K, Hulstaert PF, Algra A, van der Werken C. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg 1997;84:1532-4.  Back to cited text no. 14
15.Pancyrev YM. Shock., Clinical surgery. Moscow Meditsina 1988;1:30-7.  Back to cited text no. 15
16.Ugwu BT, Yiltok SJ, Kidmas AT, Opaluwa AS. Typhoid intestinal perforation in north central Nigeria. West Afr J Med 2005;24:1-6.  Back to cited text no. 16
17.Merier DE, Trapley JL. Typhoid intestinal perforations in Nigerian children. World J Surg 1998;22:319-22.  Back to cited text no. 17
18.Abantanga FA, Wiafe-Addai BB. Postoperative complications after surgery for typhoid perforation in children in Ghana. Pediatr Surg Int 1998;14:55-8.  Back to cited text no. 18
19.Huckstep RL. Recent advances in the surgery of typhoid fever. Ann R Coll Surg Engl 1960;26:207-30.  Back to cited text no. 19
20.Rains and Ritchie surgical complications of typhoid and paratyphoid. In: Bailey and Love's Short Practice of Surgery. 17th ed. London: H. K. Lewis; 1977. p. 979.  Back to cited text no. 20
21.Onen A, Dokucu AI, Cigdem MK, Oztürk H, Otçu S, Yücesan S. Factors effecting morbidity in typhoid intestinal perforation in children. Pediatr Surg Int 2002;18:696-700  Back to cited text no. 21
22.Shukla VK, Sahoo SP, Chauhan VS, Pandey M, Gautam A. Enteric perforation- Single layer closure. Dig Dis Sci 2004;49:161-4.  Back to cited text no. 22
23.Efem SEE, Asindi AA, Aja Al. Recent advances in the management of typhoid enteric perforation in children. J R Coll Surg Edin 1986;31:214-7.  Back to cited text no. 23
24.Efem SE. The prognosis of typhoid enteric perforation. Am J Abd Surg 1989;31:25-7.  Back to cited text no. 24
25.Gedik E, Girgin S, Tacyildin HI, Akgün Y. Risk factors affecting morbidity in typhoid enteric perforation. Langenbecks Arch Surg 2008;393:973-7.  Back to cited text no. 25
26.Nasir AA, Lukman OA, Adeniran JO. Predictor of mortality in children with typhoid intestinal perforation in a Tertiary Hospital in Nigeria. Pediat Surg Int 2011;27:1317-21.  Back to cited text no. 26

Correspondence Address:
Musa Ibrahim
Turan 34/1, House 8, Astana-Republic of Kazakhstan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0189-6725.115046

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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