Typhoid perforations
Sir
We read with interest the article on typhoid perforations by Gibney'. While listing the various procedures for operative treatment, mention of tube ileostomy in the treatment is omitted. This was originally described by Lusoya'.
We agree that all typhoid perforations must be managed operatively after resuscitation. However, in view of the severity of contamination and marked bowel distension due to ileus there is danger of reperforation or fresh perforation if adequate decompression is not achieved. To this end we have advocated a tube ileostomy through the perforation using a 24 Fr Foley catheter. In case of multiple perforations it is put via the most proximal perforation and the rest closed in two layers using Vicrylh (Ethicon Limited, Edinburgh, UK) and silk. The tube is removed after 2 weeks.
In patients with severe contamination and grossly distended bowel we perform laparostomy and repeat peritoneal toilet is done after 48 and 96 h. At this time any collections can be evacuated. It is also possible to identify re-or fresh perforations and treat them. This procedure markedly reduces intra abdominal abscess formation and delayed mortality.
During the period 1978-85, 71 cases of typhoid perforations were treated. The treatment undertaken and mortality respectively were: simple closure, 30; resection and anastomosis, 6; resection and ileotransverse colostomy, 5 ; and tube ileostomy, 28. Two cases were treated conservatively and both died.
Consequently, since 1985 we have adopted tube ileostomy as standard treatment with selective laparostomy. A further 27 cases have been thus treated and laparostomy done in nine cases. Postoperative mortality numbered 2 (7.4percent). Both patients presented more than 72 h after perforation and mortality is related to septicaemia and delay