Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Successful endoscopic hemoclipping and conservative management for typhoid fever complicated by massive intestinal bleeding and acute pancreatitis: Case report.

RATIONALE: Massive intestinal bleeding as a complication of typhoid fever has rarely been reported due to the advent of antibiotics. In addition, although several literatures have been issued on the use and success of endoscopic modalities in cases of massive typhoid ulcer bleeding, few have described hemostasis by endoscopic hemoclipping. PATIENT CONCERNS: We describe a case of a 61-year-old Korean female who presented acute episodes of massive lower gastrointestinal bleeding during admission to local hospital with a provisional diagnosis of acute gastroenteritis. She had returned from a trip to Southeast Asia 3 weeks prior to admission DIAGNOSES:: After the result of blood culture was identified as Salmonella typhi, we could make a diagnosis of typhoid fever complicated by massive intestinal bleeding and acute pancreatitis based on elevated serum lipase and computerized tomography (CT) findings. INTERVENTIONS: The patient was treated successfully by two repeat colonoscopic hemostasis procedures involving the deployment of hemoclips on ulcers in the terminal ileum and 10-day course of intravenous ciprofloxacin OUTCOMES:: The patient was stable and reported no further episodes of intestinal bleeding or fever during the follow-up time. In addition, acute pancreatitis, which is a rare complication of typhoid fever, resolved without complication on follow-up CT and a laboratory study. LESSONS: Considering the risk of procedure-related complications such as perforation of the small intestine wall, which become thin and friable due to ulceration, mechanical hemostasis methods, such as hemoclipping, might be safer than coagulation, when the bleeding spot can be identified and is not multiple, as in our case. In addition, our case demonstrates that S. typhi should be considered in the differential diagnosis of massive lower gastrointestinal hemorrhage, especially in the setting of recent travel in South or Southeast Asia.

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study.

BACKGROUND: Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. METHODS: Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. RESULTS: A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53-163.57, p = 0.021). CONCLUSIONS: With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances.

[Results after surgical management of ileal perforation due to typhoid fever, about 29 cases in Ouahigouya (Burkina Faso)]. / Résultats de la prise en charge des perforations iléales typhiques : à propos de 29 cas à Ouahigouya (Burkina Faso).

The aim of this study was to determine the results of management of typhoid perforations. This was a descriptive cross-sectional study carried out from January 1, 2016 to December 31, 2016 in the General Surgery Department of the Regional Teaching Hospital Center of Ouahigouya (Burkina Faso). It involved 29 operated patients, in whom the diagnosis of typhoid perforation was confirmed at laparotomy: age, sex, admission time, clinical, therapeutic and prognostic aspects were analyzed. Typhoid perforations accounted for 20% of acute generalized peritonitis and 38.1% of digestive perforations. Twenty-three patients were males and six were females (sex-ratio: 3.8). The average age of patients was 19 years. The mean diagnostic time was 9.8 days. The excision-suture of the perforation was the most used technique with 62% of the cases. The treatment lead to complications in 10 cases with a morbidity of 34.5%. Four deaths were recorded, representing an overall mortality of 13.8%. Prognostic factors were diagnostic delay, age, number of perforations and resection-anastomosis.

Single-layer closure of typhoid enteric perforation: Our experience.

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.

Surgical aspects of bacterial infection in African children.

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.

[Septic arthritis of hip due to Salmonella Typhi in a patient with multiple sclerosis]. / Multipl Sklerozlu Bir Olguda Salmonella Typhi'ye Bagli Kalça Eklemi Artriti.

The most common microorganisms isolated from septic arthritis are Staphylococcus aureus and streptoccocci. Septic arthritis due to Salmonella spp. are rare and the most commonly isolated species are S.Choleraesuis and S.Typhimurium. However the number of septic arthritis cases due to S.Typhi is low in literature. In this report, septic arthritis of hip due to S.Typhi in a multiple sclerosis patient who was under steroid therapy, was presented. A 25-year-old female patient was admitted to our clinic with the complaints of fever, left hip pain, standing and walking disability for 10 days. Her anamnesis revealed that she had had a multiple sclerosis attack and underwent triple pulse steroid therapy. Laboratory findings were as follows; WBC count: 16.300/mm3 (70% polymorphonuclear leukocyte), hemoglobin: 10.6 g/dl, erythrocyte sedimentation rate: 140 mm/hour, CRP: 28.7 g/L, AST: 86 U/L and ALT: 77 U/L. In lumbosacral magnetic resonance imaging, trochanteric bursitis and generalized myositis were detected in left hip joint compatible with septic arthritis. S.Typhi was isolated from patient's blood and operational tissue samples. Serum Salmonella TO and TH titers were found as 1/400 and 1/200, respectively. Antibiotic susceptibility test was performed by disk diffusion method, and the isolate was found susceptible to ampicillin, chloramphenicol, ceftriaxone, ciprofloxacin and trimethoprim-sulphametoxazole. The patient was treated by surgery and also by two weeks parenteral (2 x 400 mg) and 6 weeks oral (2 x 500 mg) ciprofloxacin treatment. Six months follow-up of the patient revealed that clinical, radiological and laboratory findings were normal. As far as the national literature was considered, this was the first S.Typhi septic arthritis case involving the hip joint and demonstrating bacterial growth both in blood and operational tissue. The presentation of the infection as arthritis plus diffuse myositis and bursitis, is also noteworthy.

Progress in management of typhoid perforation.

Case fatality rate (CFR) for typhoid perforation (TP) has been on gradual but variable decline world wide. This review highlights the progress in management of TP from 1960 including the controversies, current principles of management and the advances associated with the best results of treatment. This is a review of publications on TP from 1960 to 2010 principally from Medline and Ovid databases. Main search terms used are typhoid and perforation. The median CFR by decade was estimated from studies that reported CFR. With advances in surgery and supportive care, median CFR for TP declined from over 50% in 1960 to single digits in the last decade in some countries but with West Africa lagging behind at 16%. Variations in CFR are attributed to differences in perforation-operation interval and quality of care. Opportunities now exist for patients with TP to recover from the disease but priority remains with prevention of enteric fever in endemic areas.

A simple prognostic scoring system for typhoid ileal perforation peritonitis.

The increasing awareness of the worse than expected outcome after typhoid ileal perforation (TIP) prompted us to prospectively prognosticate patients with the help of the Jabalpur prognostic score (JPS), a simplified scoring system for peptic perforation peritonitis (PPP). Eighty-two consecutive patients with TIP were studied from May 2005 to August 2008 in the Department of Surgery, NSCB Government Medical College, Jabalpur (MP), India. Six parameters used in the JPS were recorded: age, heart rate, mean blood pressure, serum creatinine, any co-morbid illness and perforation-operation interval. JPS correlated with morbidity and mortality in TIP patients and, as the score increased, so did the morbidity and mortality. Survivors had a significantly lower mean score (3.86 ± 2.23) than non-survivors (7.94 ± 3.6; P < 0.001). Expectedly, TIP patients had worse outcome, stage by stage, than PPP patients. JPS can be easily modified for TIP (JPS-TIP) and can be easily used for its prognostication.

[Primary ileostomy for typhoid-related ileal perforation: a 62-case series in Ouagadougou, Burkina Faso]. / Iléostomie première des perforations iléales d'origine typhique: 62 cas à Ouagadougou (Burkina Faso).

OBJECTIVES: The purpose of this report is to evaluate the efficacy of primary ileostomy for treatment of typhoid-related ileal perforation based on our experience. METHODS: This retrospective study included all cases of typhoid-related ileal perforation treated by primary ileostomy in the Visceral Surgery Department of the Yalgado Ouedraogo Teaching Hospital in Ouagadougou, Burkina Faso from January 2006 to June 2008. Diagnosis was based mainly on peroperative findings revealing specific anatomical lesions. There were 45 men (72.6%) and 17 women (27.4%) with a mean age of 26 years (range, 14 to 68). Asthenic forms were observed in 41 cases (66.1%) and sthenic forms in 21 (33.9%). The mean delay for seeking treatment was 6 days (range, 1 to 30 days). RESULTS: Primary ileostomy was used for treatment of typhoid-related ileal perforation in 78.5% of cases. Most cases (80.6%) involved single perforations. A temporary ileostomy was performed in 55 cases (88.7%) and terminal ileostomy was performed in 7 (11.3%). Complications were observed in 18 patients (29.03%) including suppuration of wall in 8 cases. The mean duration for re-establishing continuity and of hospital stay was 34 and 41 days respectively. Four deaths occurred due to hypovolemic shock. CONCLUSION: In our department, primary ileostomy for typhoid-related ileal perforation reduced mortality despite high morbidity.

[Cholecystitis as a complication of typhoid fever].

The problems of chronic infection, pertaining to typhoid fever, with main complication as an acute and chronic cholecystitis, were addressed. The main method of chronic cholecystitis treatment, pertaining to typhoid fever, is cholecystectomy with consequent speciphic treatment using various routes of the drug introduction.

An outbreak of peritonitis caused by multidrug-resistant Salmonella Typhi in Kinshasa, Democratic Republic of Congo.

Between October 2004 and January 2005, 144 patients with peritonitis were admitted to the surgical wards of Kinshasa General Hospital and a few private city clinics. 63 patients (44%) underwent surgical intervention because of intestinal perforation consistent with typhoid fever; the case fatality rate was 53%. The majority of patients had received a course of first-line antibiotics such as chloramphenicol, ampicillin or co-trimoxazole before admission. On bacteriological investigation, Salmonella Typhi was isolated from the blood of 11 patients with peritonitis. The isolates were all resistant to ampicillin, chloramphenicol, tetracycline and co-trimoxazole, but sensitive to third-generation cephalosporins, quinolone (nalidixic acid, ciprofloxacine) and amoxicillin-clavulanic acid. Several factors contributed to the poor outcome of this disease including a) the use of inappropriate antibiotics, b) long delay in diagnosis, c) difficult access to health facilities. This is the first documented outbreak of typhoid fever caused by a multidrug-resistant S. Typhi in Kinshasa.

The range of abdominal surgical emergencies in children older than 1 year at the Komfo Anokye Teaching Hospital, Kumasi, Ghana.

BACKGROUND: Acute abdominal conditions are a common reason for emergency admission of children. Little is available in the literature about such conditions in our subregion, especially Ghana. OBJECTIVE: The aim of this study was to investigate the range of emergency abdominal surgical conditions amongst children in the subregion, with particular reference to Komfo Anokye Teaching Hospital, Kumasi, Ghana. A prospective survey of all children older than 1 year undergoing an emergency abdominal surgery was carried out. METHODS: Details of all children (except infants) operated for an acute surgical abdominal condition over a 5-year period were entered into a specially designed form, capturing patient characteristics, surgical causes of the emergency, operative procedure, complications, morbidity and mortality rates. RESULTS: Nine hundred fifty-five children aged > 1 year but < 15 years were enrolled in the study. The mean age was 8.8 +/- 3.2 years. The leading causes of surgical abdominal emergencies were typhoid perforation (TP) of the gastrointestinal tract (GIT), 68%; acute appendicitis, 16%; abdominal trauma and intestinal obstruction (including intussusception), 4.7% each; irreducible external hernias, 2.5%; primary peritonitis, 1.0%; gallbladder disease and gastric perforation, 0.8% each. Many children died from the TP group; case fatality for TP alone was 12.6%. The overall mortality was 9.7%. Morbidity was influenced by the presence of major peritoneal contamination, continuing peritonitis and surgical site infections (SSIs), which led to long hospital stay. CONCLUSIONS: In our hospital, TP of the GIT, acute appendicitis, intestinal obstruction, irreducible external hernias and primary peritonitis were the most common abdominal emergencies encountered in children after infancy. The high morbidity and mortality in TP is attributable to ignorance, poor sanitation and delay in reporting to hospital for treatment.

Outcome of primary closure of abdominal wounds following typhoid perforation in children in Ile-Ife, Nigeria

Background: Abdominal wounds following surgery for typhoid perforation are classified as dirty; with an infection rate of over 40. To date; the optimal method for closure of these wounds remains controversial. Delayed primary closure which was conventionally recommended as standard practice; is now considered to be of no value in preventing surgical site infection (SSI). This study evaluates the outcome of primary closure of this class of wounds in children in Ile-Ife; Nigeria; and advocates a multidisciplinary wound management protocol. Patients and Methods: This is a retrospective study of children aged 1-15 years who had had surgery for typhoid perforation in a teaching hospital in south western Nigeria; over a period of ten years. Results: Thirty-two patients; 18 males and 14 females; in the ratio of 1.3:1 were managed for typhoid perforation during the ten year period. All 32 patients had primary closure of their abdominal wounds. There was primary wound healing in six (18.8) patients; while 19 (59.4) patients had surgical site infections. Wound dehiscence; intraabdominal abscess; and faecal fistulas were the other complications documented in the study. Conclusion: Abdominal wounds of typhoid perforation; though classified as being dirty; can be closed primarily with good healing outcomes. A multidisciplinary approach to wound management will reduce the incidence of wound sepsis and its associated morbidity and costs

Pattern of presentation and management of typhoid intestinal perforation in Sagamu, South-West Nigeria: a 15 year study.

BACKGROUND: Mortality from typhoid intestinal perforation remains high in the West African sub-region. The aim of this retrospective analysis was to assess the presentation pattern, mode of therapy and outcome of cases diagnosed and treated as typhoid intestinal perforation at Olabisi Onabanjo University Teaching Hospital, Sagamu, between January 1990 and December 2004. METHODS: Complete records of 105 adult patients were studied. RESULTS: The male to female ratio was 2:1. The mean age was 27 years. Prior to arrival in our hospital, all the patients were on various combinations of antibiotics. Twenty-seven (26%) patients had been hospitalized elsewhere during the current illness. Chloramphenicol was the drug of first choice in the first ten years (phase 1). It was replaced with ciprofloxacin in the subsequent five years (phase 2). Blood culture was positive for salmonella organisms in 5(4%) patients. Resistance to chloramphenicol was found in three (60%) out of these five positive cultures. All patients had laparotomy after resuscitation. There were 112 perforations, mostly in the ileum and jejunum. Perforations were single in one hundred and one patients and multiple in four patients. Single perforations were treated by two-layered closure, multiple perforations by primary resection and anastomosis. Fifty-five (52.4%) patients developed complications. Fourteen (13.3%) patients died. There was a slight drop in mortality (8.8 %) in phase 2. Deaths were due to septicaemia in 8 (57%) patients. CONCLUSION: The pattern of presentation and outcome of management of typhoid intestinal perforation are similar to what is observed in other centres in our local environment. However the drop in mortality rate in the last 5 years of the study and the finding of strains of salmonella typhi resistant to chloramphenicol require further evaluation.

Typhoid sigmoid colon perforation in an 18-month-old boy.

BACKGROUND: Typhoid fever is a severe infective disease endemic in the areas where sanitation is poor. Its serious complication is bowel perforation with terminal ileum as the commonest perforation site. We report a case of an extremely unusual site of perforation in sigmoid colon due to typhoid fever. METHODS: An 18-month-old boy presented with no passage of flatus and feces along with guarding and rigidity. Exploratory laparotomy revealed sigmoid colon perforation and Widal test was strongly positive for typhoid fever. Sigmoid loop colostomy was performed on the patient. RESULTS: Postoperative period was uneventful. Colostomy started functioning on the 4th post-operative day. There was superficial wound dehiscence. The patient was given oral food intake on the 7th post-operative day. He was discharged from the hospital in satisfactory conditions on the 10th day after operation. CONCLUSIONS: While tackling a case of enteric perforation suspected with typhoid fever, one should keep in mind the extremely rare site of sigmoid colon perforation.

Brodie's abscess of the ulna caused by Salmonella typhi.

Osteomyelitis caused by Salmonella typhi is rare in patients with no haemoglobinopathies or other diseases causing immunosuppression. Brodie's abscess is a special variety of subacute or chronic osteomyelitis. An otherwise healthy woman who presented with forearm swelling for 6 months was diagnosed with a Brodie's abscess of the ulna caused by Salmonella typhi. Magnetic resonance imaging and a computed tomography-guided needle biopsy were performed. She was later found to be a Salmonella carrier. The Brodie's abscess was treated by surgical debridement and a course of antibiotics. The clinical, radiological, and management aspects of the disease are discussed.

Risk factors affecting morbidity in typhoid enteric perforation.

INTRODUCTION: Typhoid enteric perforation is a cause of high morbidity and mortality. This study aim is to determine the factors affecting morbidity in patients with typhoid enteric perforation. MATERIALS AND METHODS: Ninety-six patients with typhoid enteric perforation were reviewed. The variables are defined as follows: Age, gender, complaints, perforation-operation interval, typhoid fever treatment before the perforation or not, white blood cell (WBC) count, hemoglobin level (Hgb), intraoperative peritonitis intensity, the number of perforations, and type of surgery were examined. To determine the independent risk factors that might affect morbidity in typhoid enteric perforation, we made use of multivariate logistic regression analysis. RESULTS: Nine variables were applied the univariate analysis, which were greater than 30 years (P = 0.218), male gender (P = 0.02), preoperative treatment (P = 0.147), less than or equal to 48 h perforation-operation interval (P = 0.013), greater than 4,000 K/UL WBC (P = 0.388), less than 8 g/dL Hgb (P = 0.026), greater than 29 Mannheim Peritonitis Index (P < 0.0001), multiple perforation number (P = 0.614), and primary repair (P = 0.105). Logistic regression analysis showed that Mannheim Peritonitis Index (P = 0.014) and perforation-operation interval (P = 0.047) were defined as independent risk factors affecting morbidity. CONCLUSIONS: If liquid electrolyte, blood, antibiotics, and parenteral nutrition are applied in typhoid enteric perforation cases adequately, then severe peritonitis becomes an independent risk factor that affects morbidity. Early diagnosis and appropriate surgery type would decrease morbidity and mortality.