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Surgery Series: Typhoid Perforation in Sierra Leone | Lesley Hunt

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Summary

This on-demand teaching session will cover Typhoid perforation in Sierra Leone, a condition that is frequently seen and treated by medical professionals. We'll discuss the fecal-oral route of transmission, the symptoms and diagnosis of this condition, its relation to poverty, and its occurrence in children and young adults. We'll also explore management strategies, prognostic factors, and treatments available to treat Typhoid perforation, including antibiotics such as CefTRIAXone Cefixime, Cipro, Chloramphenicol, Trimetroprium, and Ampicillin, as well as Gentamicin and Metronidazole. Don't miss out on this essential session for medical professionals to help treat Typhoid perforation in Sierra Leone.
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Description

Typhoid fever, caused by the bacterium Salmonella typhi, remains a significant public health concern in many parts of the world, particularly in areas with poor sanitation. One of the most severe complications of typhoid fever is intestinal perforation, which can be life-threatening if not promptly diagnosed and treated. This needs assessment aims to evaluate the current clinical practices among qualified doctors in relation to the recognition, management, and prevention of typhoid perforation.

Learning objectives based on the topic of typhoid perforation:

  1. Clinical Diagnosis Proficiency:By the end of the session, participants will be adept at promptly recognizing and accurately diagnosing typhoid perforation based on a combination of clinical presentations, patient history, and initial investigations.
  2. Surgical Decision-Making:Attendees will demonstrate competency in assessing the severity of typhoid perforation and making informed decisions on the most appropriate surgical interventions, whether it be primary repair, ileostomy, or other relevant procedures.
  3. Antimicrobial Therapy Application:Participants will effectively select and prescribe the most suitable antibiotic treatments for typhoid perforation, taking into account the local microbial resistance patterns and current guidelines.
  4. Prevention and Advocacy Skills:By the end of this session, attendees will confidently implement and advocate for primary preventive strategies, including typhoid vaccination and public health initiatives, tailored to their respective clinical settings.
  5. Post-Operative Management Acumen:Participants will showcase comprehensive skills in overseeing post-operative care for patients with typhoid perforation, ensuring the minimization of complications like wound infections, sepsis, and other post-surgical challenges.

No conflict of interest

Learning objectives

Learning Objectives: 1. Identify the common causes of typhoid perforation in Sierra Leone 2. Recognize signs, symptoms, and prognostic factors of typhoid perforation 3. Distinguish between the differences in presentation of typhoid perforation in East and West Africa 4. Utilize appropriate antibiotic regimens for typhoid perforation treatment 5. Execute medically-sound management strategies for patients with typhoid perforation.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello everybody and welcome back. So the next in our series is on Typhoid perforation in Sierra Leone. Um a pretty common condition, something that everybody will see and deal with. Um It's been a really beautiful hot day here in England today and I've got, it's a nice evening and I've got the window open. So you may hear some other noises, my neighbors or the dog barking and even the church bells ringing because it, it's a Sunday evening. Um just ignore all of that. Ok. So salmonella typhi is the cause of typhoid fever. Everybody knows that it's a fecal oral route of transmission. And so we're looking at contaminated water strongly associated with poverty because sanitation is not so good in poor households, but anybody can actually catch it because if you are subject to improper food handling when you eat out or something like that, or if the cook doesn't wash their hands properly, you could catch it. The hydrochloric acid in our stomach is there for good reason to kill bacteria on entry to our body. And there is suggestion that increased PPI use may lead to more, more higher incidence of, of fecal oral infection such as mon typhi, there are typhoid carriers, some of them became notorious. Um So these are asymptomatic people who are shedding the bacteria all the time. And particularly if they work in food handling, they can be very dangerous individuals. And it's either a carrier or a contaminated water supply which can then lead to local hotspots. So for instance, there was a hot spot two or three years ago for typhoid perforating in y they even had members of the same family coming in with it. In Sierra Leone. Nearly all of the patients we see are Children or young adults. Now, we're interested in uh perforation and that's what this talk is about. Um But it's important to remember that Typhoid fever is actually a systemic condition and can attack multiple organs. So it can cause pancreatitis. It can cause septic arthritis and osteomyelitis. We don't know the microbiology of Osteomyelitis in Sierra Leone. But in a lot of African countries, salmonella, Typhi is a common organism um and it can also cause bleeding. So when I'm reading up about um Typhoid, what I discovered is that in East Africa patients present with bleeding from the terminal ileum and in West Africa, they present with perforation of the terminal ileum and I couldn't ascertain from, from my reading. Why the why, why it's different between the two? But as well as these surgical problemss, patients who have got Typhoid fever are also medically sick and may have any of these. And it's also important to remember that the perforation occurs relatively late in the illness. So the kid will already have been sick for two weeks before they perforate. So, how does the perforation actually occur? Well, you ingest the salmonella typhi, we said it's fecal oral, it will travel along the gut and it will enter the bowel wall and when it enters the bowel wall in the terminal ileum, it will encounter the pace patches. And I'll show you those in a second. And after a couple of weeks of being in the pace patches, you can get perforation. So the perforation usually occur in 14 to 21 days into the illness. So this is a microscope, uh sample of Cymbal and I'll just orientate you on it for a start. There's a bit of Masry here. You see the fatty tissue, there's a very slight crinkly edge right on the edge here, which is the, the visceral peritoneum. And then this quite solid looking area all the way around is the serosa of the bowel. The bet that we sta you'll see this freely, very loose tissue here. This is the mucosa and this explains why the mucosa prolapses when we're trying to operate. And over here you can see a pace patch. So it's an aggregation of lymphoid tissue which is sitting in the submucosa. So the submucosa is where your needle comes through when you're doing the, the, the serosal stitches. Um So it will enter there, it will ca harbor infection there and then that site will perforate. Um I like, I like this picture. I got it off the internet, but I like it for a completely separate reason as well. People ask why do you not pick up the mucosa when you do a single layer anastomosis? And the answer of course is if you pick up the mucosa, you can't see that you've got a good bite of cirrhosis. And this really clearly shows that the serosa is nice solid tissue here that we can get a good bite with our stitch. And this mucosa here, it's all phlegm fla imagine trying to stitch that. Um And that's why it doesn't work if you pick up mucosa instead of serosa. So er further on in this talk, there are various management strategies for different combinations of perforation and patient. Um and how we arrived at these conclusions well, from reading the medical literature. So first of all, we learn in medical literature for that for reasons. We don't understand it bleeds in East Africa and it perforates in West Africa. Now, there is no medical literature on typhoid perforation in Sierra Leone. But there are papers coming out from other countries such as Ghana and Nigeria and the recommendations in this um in this talk were initially garnered from the papers coming out about the Nigerian rural population. We've then followed that practice in Sierra Leone with good results. And therefore, that's what this talk is based on. So the map I showed on the second slide, the blue areas were all the areas where you can catch typhoid fever and internationally, it have known to affect the ileo scal area. So the terminal ileum, the um ascending colon etcetera worldwide, boys are more affected than girls. And it's a predominance of Children and young people. If we look at the data from the Nigerian rural population, all of their perforations were ideal. Um I have to say that every perforation I've seen so far in Sierra Leone has been ideal. Um but just be mindful, it's possible that you could see the first one in the cecum er in Nigeria, the incidence between boys and girls was equal and again, they're seeing it in Children and young people and he also published some figures about the number of perforations in each patient. So 62% were just a single perforation. 28% were double perforations and 10% had three or more perforations. And this is very much in accordance with what I've seen in Sierra Leone. It's usually 12 occasionally more. How did the patients present uh from the history? You will have severe pain? You may have diarrhea because obviously salmonella typhi causes diarrhea. But by the time the child perforates, the diarrhea will probably stop because they will then develop an IE ss, they're likely to have vomited at some point, but you may not get a clear history of vomiting. Um, and there may be this history that they've been unwell for two weeks beforehand, before, before the abdominal pain started on examination. They are usually very sick. So these kids come in in a, in a pretty poor state, they're often worryingly quiet. So they're not complaining, they're just lying there, they'll have a fever, uh, they're likely to be acidotic and you might see the raised respiratory rates and recognize and understand why that's come about. You examine their abdomen, you will find obvious signs of peritonitis. Please do not do rebound tenderness in a child with peritonitis. Um They're likely to be dehydrated and although we can't really tell in Sierra Leone, we can't measure it and find out they will have an electrolyte disturbance and they will be immunosuppressed from the fact that they've been sick for two weeks before this happened. So we're talking about a pretty serious condition here. Um So these are some papers who have published their figures. You can see it's worldwide. So Nepal and Peru are on there, but a lot of these are West African countries and you can see that the mortality is very high. So the very best in this little scale is Neall. Um even if you look at more highly developed West African countries like Ghana, they're still seeing 10% mortality um cote to 4 34% and some of these Children will die. But a lot of them, you can say, despite the terrible condition that they come in, you need to be prepared for a lot of complications. So, wound infection, obviously the commonest of all. Um But there's a, there's a lot more morbidity that we look at the complications at the end, so be prepared to manage a lot of problems with these Children. So the Nigerians have looked at prognostic factors. Um and what they've found that is if you have more than three perforations, the mortality is higher than if you've just got the straightforward single one, er, surprise, surprise, a delayed presentation increases mortality and again, surprise, surprise, an increased respiratory rate increases mortality. So those Children that were a, those Children that were acidotic on arrival, um do do worse. And then in this little paper, they've looked at the time interval between the child perforating and them getting their operation. And as you can see that if the child has perforated and has had their operation within 24 hours of the perforation, the mortality is 11%. However, if it is 3 to 5 days between the child perforating and getting their operation, the mortality is 66%. And this makes sense. We know that early source clearance will save lives. Um So we, we can encourage early presentation. There's little we can do about that as individuals. But what we can do is when the child presents to us is look after them promptly and try and get in the theater as soon as, as soon as as possible before you take them to 30 you've obviously got to resuscitate them. Um, and this is becoming old hat. You've had it in the previous two talks. IV fluids, oxygen, even if their oxygen saturations are normal, we're going to give ou support because of corruption. Nasogastric tube to prevent aspiration pneumonia. They've got an ile SS, they could vomit antibiotics and we're going to give those antibiotics sta and I'll talk on the next slide about what you're going to give um analgesia because we are kind urinary catheter because we want to know that this child is making urine um and blood for hemoglobin and cross match. Ok. So the stuff that's coming out about antibiotics is mainly coming out of India. Um And there is more antibiotic resistance in India than there is in Sierra Leone. What they're currently recommending as the first line treatment is a third generation cephalosporin, cefTRIAXone or Cefixime. I have to say we don't widely use third generation cspine in the UK. We're still on cefuroxime as a sort of routine antibiotic. So this may not be possible. Um However, Cipro is widely available and highly effective. You can also give chloramphenicol trimethoprim and ampicillin. Now, because your patient is presenting late, they will not only have the salmonella typhi that you need to treat, but they have now got a bacterial peritonitis as well. So you're going to give some gentamicin and some metroNIDAZOLE. So lo and behold, we're looking at giving uh a GM and you might add in some Cipro. Now we said that the child will be very sick. So they may have renal failure and therefore you can give your first dose of antibiotics, give you a first dose of gentamicin. But if they're not passing urine, then you need to limit subsequent doses. It is the excessive doses and the build up in the system which causes the renal failure. So in terms of investigation, um we're going to take the kid to theater. So we're going to need to do a hemoglobin and a cross match. Uh and you'll probably be doing a V CCT as well and then you probably don't need to do any more investigations. If it's a borderline case, if it's a difficult abdomen to, to, to, to assess, then ultrasound will be very useful. Um in looking for free fluid. The test that I wish we did have was you. And e because I think a lot of these kids are in renal failure before we get them and it will be nice to know what the potassium is doing. Um But we, we don't have that available, so I'll take it off the list. Ok? We're surgeons, let's get on with some operating. So what incision you gonna make? You've got a child with peritonitis, you're gonna do the incision of incision and in a kid, the incision of incision is quite a small, delicate little thing. And you see it's making a tiny little hole here and we're looking for the fluid. So when you, when you're in there, you're going to recognize small bowel fluid. But remember that the, the kids probably had peritonitis for, for a couple of days and it will be purulent as well. So there'll be super anti bacterial infection. So a bit small bowel and a bit pussy, I'll show you some, a picture of some in a minute. You're then going to need to extend your incision just to get some room to work. Um And from the point of view of the operation, you could probably do it by extending the incision upwards or downwards. It doesn't matter as long as you get a bit more room, but it is a kindness to take it downwards because the lower incision is less painful than the higher incision. So take it downwards in this case, be really gentle. I know I'm always saying, be very gentle, but a little kid and things will all be Dema you don't want to tear the meat and tree. Um And then systematically inspect the bowel. Now, my head is in the way, really, isn't it that says systematically inspect the bowel? Um So what we mean by this is, uh so you need to systematically look at the bowel and this means finding the cecum and the terminal ilium here identifying that is the terminal ilium. And then very carefully looking at both sides of the bowel gradually working your way all along and making sure you don't miss any bits. I would always retract here and have a quick look at the cecum and higher up the small bowel as well. Never found any anywhere else yet. But you just kind of worry about it. I said I show you the fluid. So here's small bowel fluid sees a bit of it on the swab. Um It always looks a little bit, it's thin, watery, it looks a bit like vomit. But in some cases of established pro Tiit, you may see more purulence as well. So more pussy stuff and also you see this kind of stuff here which is slough and that will be all over the place. Um So here he is, he's systematically working through it. So he's grasping it here. We'll grasp it there. We'll look at that segment, front and back, then grasp it here onto the next bit. So you don't miss any out. It's the same as when you're working through the small bowel looking for trauma and this is what we're looking for. So you've got to have your eyes open. Um, you, you will see it, you, you will find them, but just be careful because they are quite small, a bit bigger ones here and it's a bit more of a close up photograph as well. So this patient's got two, a ragged one here and a bit of a smoother one here. This here is the cecum. So you can see how close this distal perforation is to the terminal ium. And this does cause some consequences for us, particularly if we're making stoma, we just, this may limit what we can do here. Um I admit I do like a mantra and somebody has come up with this mantra for Typhoid and then it's getting used in lots of publications as well. And the mantra is do as much as necessary, but as little as possible. So it's quite easy to get carried away. And just because you can do a small bowel resection and anastomosis, it doesn't mean it's necessarily the right thing to do. So we mustn't over operate, but we must do as much as is needed. And there are a choice of options here. So you can do a simple closure, you can do a debridement enclosure and I'll come on to what debridement means in this context. You can do a local resection with an anastomosis. You can do a local resection with a stoma and you can exteriorize ie just pull a hole out and make a loop ileostomy out of that hole. Now, let's look at those options. So here, this is the picture we saw earlier. This little hole, you may, you may just stitch this across. So that's just a simple closure. Now, this is one where you're going to need to debride. Now, people get confused and I think it's because we often think of debridement as removing dead devitalized tissue. We're thinking of limbs and things like this and we're not debriding in typhoid to remove any dead tissue. There is no dead tissue. And in fact, if you look here at this, this perforation, it's actually very well perfused. It's almost hyperemic, It's flushed round because of the inflammation. So there's no dead tissue to remove, but we still need to debride because these are unfavorable shapes to close. So you just can't stitch that neatly. So the reason we're debriding is just to get a nice shape to take our stitches. So y you've got a circular hole, you really can't comfortably stitch that it's just kind of not gonna fit together nicely. If you've got a ragged old thing like this, you can't stitch that. You know, that is just not going to come together nicely. You're gonna have to take that piece off and smooth it out, make it nice. And then we all also know the rule of the ellipse. So we learn this in um basic surgical skills that for an ellipse to close its length needs to be at least three times its width for it to close comfortably. So the reason we're debriding a type of perforation is just to make it into a nicer shape. Now, when we debride him. We just have to be a little bit mindful that we don't narrow the lumen. Now, this, this is an adult and there's plenty of room here and you could debride that no problem and you could stitch it anywhere you like because you're not going to narrow that lumen this one here. You're obviously going to take off that ragged edge, smooth this out or one little tip that I've got to say, I nearly forgot to say it's very difficult with most of the forceps to hold these pieces of tissue. So you grab hold of them and especially in a child, they are very small and the forceps we've got are not delicate enough and you just slip and you hold it again and you slip and because you can't hold it, you then can't cut this in nicely. What I have learned is that you need to get hold of the bit that you're removing with the tooth forceps, hold that in the tooth forceps. And then either if you've got sharp scissors, take that edge off with the sharp scissors. If you've got blunt scissors, you may need to just do that with the blade and then do remember to then wash your tip of your forceps in the Povidone so that you don't carry that infection onto the skin when you're closing the skin, right? I digress. Er, what was I saying? Yeah, about narrowing the lumen. So if, if we concerned and it's in a child and we're worried that we're going to narrow the lumen by debriding and closing. What we're gonna do is we're gonna debride longitudinally and stitch up horizontally. So you would, if you wanted to make this into a more favorable shape, you would extend it in this direction either side. So snip this bit out sharply with your scissors and then when you come to close it, you're going to pull it the other way and you're going to close it transversely. OK. And that will actually widen the lumen rather than narrow the lumen. Now take your closure seriously. Um What I mean is you're going to treat it as if it's the front wall of an anastomosis. So you can see here this is a debridement enclosure. So we've debrided it, we're sewing it up transversely across the bowel wall there. And we've got 12344 or five stitches, another one about to go in. So you will have several little stitches. We'll do the series submucosal technique, the interrupted technique, we'll space them at four millimeters, we'll keep the short ends on, we'll check for gaps. So we'll take it just as seriously as we would take the front wall of an anastomosis. You see slough here as well on this one, there's a lot of slough. Um And sometimes you will do a full blown anastomosis. So this is one where there were several um in the distal terminal ileum. We've done, done a resection and we're doing, um, an end to end anastomosis here. Um You can see we're right up against the cecum here and actually we've mobilized the right colon a little bit here to make this easier, but that's not absolutely necessary. And if you're in difficulty and if you can't get there, then there are other options. You don't need to do that anastomosis if you're not happy to do it. So there are other options. Um And when it comes to Typhoid, you will need to have the full gamut of your skills for ileostomy here. So there are circumstances for Typhoid where we will make an end ileostomy. There are circumstances, we'll make a double barrel, that's probably the commonest actually. And there are circumstances when you're exteriors, just bringing a hole onto the surface when you'll do a loop. So go back to where we were, these are our operative options. So we said do as much as necessary and as little as possible. And we've gone through them by turn simple closure, debridement, and closure, local resection and anastomosis, local resection with stoma and exteriorizing. But how do we pick which one for which patient? So when you're making a decision about which of those five options to, to pursue, you need to consider how bad the disease is ie how many perforations there are? How bad is the patient? Is the patient stable? Or are they absolutely more abundant? Acidotic. Have you got the right resources always an issue. And also how confident are you? And there may be certain things that some people are confident to take on and others aren't. And there's absolutely no shame in that. If you play safe and pull a stoma, you'll be saving the child's life. So, back to our little mantra and now let's pick each one for each situation. So, as much as necessary and as little as possible, when are we going to do a simple closure or a debridement enclosure? They're kind of almost the same thing really, aren't they? We're gonna do this when there is just one perforation. So single perforation, you are going to close it when there are two perforations that are separated by a little bit of distance. That is to say that you can get to put the stitches in one of them without it pulling on the stitches of the other one. If you have two that are very close together, you start to close one and it pulls the other one apart. So just one perforation will close two perforations when they're separated and when you've got a relatively stable patient. So um I know they're going to be sick but they're not crashing on the table. What about option C and D, which was resection when you're going to resect is when you've got several perforations close together because you're going to end up with less stitches overall. If you just do a simple resection and end to end anastomosis. If, when you start to put your stitches in to close the perforation, it's really edematous and your stitches are cutting out. It's like trying to stitch wet paper. Well, that is going to fail. So you're probably gonna have to resect that area to get back onto some healthier bowel when and when you're going to resect into a stoma, you're going to resect into a stoma when you need to resect and it is not safe to do an anastomosis. Now, we all know the small bow resection booklet. We've got the page in there of the safe anastomosis, the risky anastomosis and the dangerous anastomosis. And in typhoid perforation, there is no safe anastomosis, but there are anastomosis which you may take as a calculated risk. Um And there are other situations where you think no, it is just too dangerous to make an anastomosis here and I'm going to pull a stoma. So when are you going to exteriorize? So, exteriorizing is an incredibly quick, easy operation. Basically, if you've just got a single hole, what you're going to do is and the child is very, very sick. They have no BP on the table. They're acid dot They're in renal failure. You can just make, make a stoma wound and pull that hole out onto the surface of the stoma, extend it a little bit and make it into a loop ileostomy. So I'm not a great fan of algorithms, but I know most people like algorithms. So I've put algorithm in here. So this is the algorithm for a single perforation. And this, if we are the same as Nigeria, which we think we are is going to be 60% of our cases. So where there's just one perforation, you've got to decide, have you got a stable patient or an unstable patient? If you have a stable patient, you are going to debride it if needed and close it. If you have an unstable patient, you're going to decide whether that hole reaches up to the abdominal wall. And if that hole will reach up is in a part of the small bowel, it'll comfortably reach up to the abdominal wall. You are just going to bring that hole out, exteriorize it as a loop ileostomy. If that hole is very close to the terminal ileum, you're going to struggle to get that out as an end IOST toy. In which case, you're going to divide the terminal ilium, you know, like a like a tiny two millimeter resection, you're going to close the distal end inside which is the equivalent of a front wall, anastomosis, close that terminal ileum as it sits there down by the cecum and bring out the other end as an end IOST toy. This one's a bit more complicated because it's for two perforations. And we've got a bit more of the decision tree this will be about 30% of the patients, but actually, most of them are down this fairly straightforward end. Um So let's go to the straightforward end first. So what you're looking at is two perforations which are separated from each other. So you can stitch one of them without it impinging on the other one. You've got a stable patient or a relatively stable patient, you're just going to debride and close both of them the same as what you did for the previous patient with a single perforation. If that patient is unstable and it's not safe to divide and close both of them, then you're going to have to pull a stoma. And what we've got to do now is make a decision about how far apart these are. So if they're relatively close together, and I've said 20 centimeters is a little bit arbitrary there, but certainly if they're closer than that, um and probably up to 20 centimeters, then you can resect both of them together as a single um small bow resection. And if both of the ends will reach up to the surface, you will make a double barreled stoma. If the terminal ilium, if the, the distal one is too close to the termin ilium, you can't lift it up to the surface, you're gonna have to close the terminal ilium off inside you and bring out the other end, the proximal end as an in as an end iost toy what if they're very widely separated? If they're, you know, if these are 40 centimeters apart, you can't be resecting, you know, 40 centimeters of terminal ileum. We're going to have to think of another option. Um You can either do two separate resections, but then you've got four ends to deal with and potentially an anastomosis to leave inside. So I think the safest thing to do is to debride and close the distal one and then bring the proximal one out, exteriorize it as a loop ileostomy. So just bring it up onto the surface and then you've diverted the fecal stream away from the distal one that you've repaired inside. Well, if you've got two perforations and they're right on top of each other, so you try and close one and the stitches are impinging on the other. Then obviously, you've got to do a resection and you might not need to do a very big resection, you know, just, just a couple of centimeters or so. And if you've got a stable patient in that situation, you can do a primary anastomosis if you've got an unstable patient. Yeah, obviously, you can't do a primary anastomosis. So you're going to resect and you're going to bring out a stoma and the same as before, if both ends will reach onto the surface, you'll do a double barreled ileostomy. If the distal end is too, too near the, too near to the cecum and you can't get it up, then you're going to do um close that distal end in situ and bring out an end. Ileostomy. Phew. I'm glad that slide is done. This one. This one's easier. Uh So if you've got multiple perforations, uh you're obviously going to do a resection. Let's look at the stable patient first. So relatively stable patient, they've got a BP on the table. They're not too acidotic. You are going to do a resection and a primary anastomosis with an unstable patient, you are going to resect and bring out a stoma. Now, bearing in mind that we know that the multiple perforations are often associated with the sicker patients. You'll probably be coming down this side of the tree more often than this side of the tree. Um So an unstable patient resect and bring out a stoma. And again, if both ends reach up to the abdominal wall, you'll bring out a double barreled ileostomy. If the distal end does not reach the abdominal wall, you're going to close the distal end inside, you leave it down there in the abdomen and bring out an end ileostomy. The reason we want to make a double barrel whenever we can is because it means the reversal procedure is much more straightforward. So you can reverse a double barreled ileostomy without having to do a laparotomy and open the patient. Obviously, if we've been forced to leave the distal end inside, we can still reverse them. But we've got to do a full laparotomy to get in to make that reversal. Now with all of this. So this is just added on algorithms are helpful, but they are not the be all and end all of anything. And we will always find unusual situations. So you might find two close together and one somewhere else. So I want you to keep your brain engaged and prepared to follow the principles for the unusual cases. And the principles are you are going to do as much as necessary. But as little as possible, whenever it's safe to debride and close, you will do that. When you're forced to do a resection, you will do a resection. And when you've done a resection, you will have to make a decision about whether it's safe to anastomose or you bring a stoma. And whenever you have to bring a stoma, we prefer the double barrel stoma. But if you have to do an end ileostomy, so be it. Now, here's a question uh in the abdominal course and the refresher course and everything, we teach you where to site a stoma. And we know that you should site a stoma along the rectus muscle and away from all obstacles, et cetera. Um But what happens if you've got a very distal ileal resection there and by putting the stoma in the wrong place, maybe somewhere right down in the right ileac fossa, Bernie's point or even more lateral than that you can get both ends on the surface, but you can't get both ends to reach up to the rectus muscle. Is it better to bring both ends up to the surface? Is a double barreled ileostomy? But in the wrong place or is it better to close the distal end in situ and bring out an end ileostomy in the correct position? What do you think? Well, I think the answer is this one. I think it's better to bring it up in the wrong place. Now, the reason we put an ileostomy, the principal reason we put an ileostomy on the rectus muscle is to prevent parasal hernia. But actually, these are temporary stoma. And even if you've got parasal hernia, it's not going to be the end of the world because you're going to be reversing the stoma fairly soon. And in addition, these patients tend to be skinny and the hernia rate in them is fairly low. So I would strongly recommend if you can get both ends onto the surface, bring onto the surface where you can and worry less about the correct sighting of the stoma. Um I think one of the easiest stoma we've ever reversed at Masang was one that was done. And I think they come in from Ely and they put the stoma right down almost near the anterior super spine and it was because they could get both ends up at that position. They couldn't put it anywhere else and after three months, very straightforward reversal, just put it back in again, not having to do a laparotomy. So it was definitely a good call on their part. Ok. Wash out, wash out, washout, wash out, wash out. So they've had several days of Pru and peritonitis. You're going to do your washout everywhere we talked, um, in the, er, perforated peptic to talk about how to make your washout fluid go as far as possible by doing it in ants and be very, very careful about the pelvis because these kids very often have got an already established or developing pelvic abscess. Ok. Next question. What about a drain? So, are we going to drain this? The answer is you're going to drain it if you are draining a specific cavity such as the pelvic or a subphrenic abscess. So you're not going to drain your repair work. Um, the small bowels on the move anyway, you can't possibly drain it. But if you think this child is going to get a pelvic abscess, then I would put a drain down into the pelvis and leave it until you've got a good track. And I have to say the ones that I've been involved with the vast majority we have left a drain in. Um, I do not have randomized controlled trial evidence to support that. Ok. Ok. Um, POSTOP. So, uh, the usual, the usual things really, you're gonna give analgesia IV fluids, you're gonna keep your drip running and your nasogastric tube in situ until gut function returns and you're gonna expect a delayed return of gut function. Um, you're gonna give antibiotics as described above and you're going to keep the antibiotics on for at least five days. You're going to watch for complications and complications are, are quite common. Uh, you're going to mobilize but kids are pretty good at mobilizing anyway. They just get up and do the one thing that is different for these Children with the typhoid perforation as opposed to the young man with the perforated peptic ulcer is that that young man was perfectly well the day before he had his perforation. But these kids have already been sick for two weeks before they perforated. So nutrition is going to be a big issue here and this might explain the high rate of complications we have in terms of healing and I'll show you some pictures in a minute. You have to be mindful of a re feeding syndrome. But actually at the beginning, you're going to struggle to get the feed in anyway because of the ile s. So just start off feeding as soon as you possibly can and just build it up and remember that the child does need a high protein diet complications. So we said that complications are common. We saw this slide at the beginning looking at complications in even in more developed countries like Ghana with very high incidence and this is the kind of list of things. So intra-abdominal abscess. And that is the reason that I would leave a drain in the pelvis to try and prevent and drain an abscess wound. Infection is very common. We're going to mitigate against that by putting in interrupted sutures rep for, I think this is the thing that we all fear and I used to really worry when I first saw things. Well, you'd see that there would be two perforations already and I think we'll repair those. But what's to stop the bit next door, immediately, immediately perforating and it just giving way in another place. And the answer to that is it's your antibiotics. Your antibiotics are working at this stage. But rep is a worry IES, they're going to have an IES, they've had pro Tiit, they may have diarrhea. Uh, and particularly if you're doing a small bowel resection, they may have diarrhea for a little while. First, abdomen, it does occur and I'll show you some photographs from Sierra Leone in a moment and abdominal fistulas occur. Now, abdominal fistulas are nature's way of saving the life. So the patient is making their own stoma when we didn't. The fortunate bit about this is if they do fistulation, it will be terminal ileum that is fistulizing and therefore you should be able to continue um, oral nutrition in that patient. You'll just have a difficult flush stoma to manage anemia. You may need to give them some blood malnutrition. We've already talked about pneumonia. We said at the beginning, um, salmonella type, it causes pneumonia on its own right now, mind about having pneumonia because of peritonitis and a laparotomy. And then you do have to be mindful of the consequences of a big terminal ileum resection. So, again, in the abdominal course, you'll have studied the physiology of the terminal ileum and it has two specific functions which the rest of the gut does not have, which are, can you remember them? Ok. So, um absorption of vitamin B 12 and the reabsorption of bowel salts. So, um you've got the intrahepatic circulation of bowel salts and it is the terminal ilium where these are reabsorbed. And if you've done a big terminal ileal resection, particularly if you've taken 30 centimeters or more, your patient will subsequently develop pernicious anemia unless they can get access to B 12 injections. Um And they, it has to be injection. There's no point in giving it orally because it's absorbed in the terminal ileum. Um and they will also have diarrhea because they will have, they won't be able to reabsorb the bowel salts and they'll probably need to take lifelong. So let's see some pictures of rep perforation. So this is a rep perforation. So this was stitched and repaired and then the child did OK for a few days and then got signs of peritonitis again. So was taken back to theater. What are you going to do in this situation, you are going to make a stoma. It's absolutely crazy to think that there's any other option here. Ok. So, uh here is some pretty unpleasant complications. Um You can see here, somebody made a stoma a smart move because this patient has no capacity to heal. So an anastomosis will fall apart, but then the abdominal wall fell apart and you've got a couple of choices here if it's very, very near to the time of the operation, if it's within a few days, and you can see the small Bowley still lying relatively free, you can take the child back to theater, you can wash everything out. Um, and you can have a go at reclosing probably using some deep tension sutures, which we will talk about in more detail in the lecture on how to get out of trouble if it slowly gives way. Um, some time after the operation, which is the more usual, the small bowel will be all matted and fused and you won't be able to wash out. And also there's no need to wash out in that situation. And what you're going to do is then just manage this with protection. Um They're in high risk of getting a fistula here. You could put a bugger to bag over, so a plastic bag dressing and stitch it all the way round. Um You don't want anybody being too enthusiastic about cleaning this wound up. So just gentle irrigation with saline. And even if you do all very careful protection, you can still develop a fistula in the midline. This is a different child and obviously, it's some time later. So this child's original abdominal dehiscence was worse than this one and she did develop a fistula, but then she was really well supported at the hospital. Um a real team effort, they gave her a high protein diet um and they really, really cared for her and gradually the wound contracted in and she's left now with a nice spouted ileostomy and a midline fistula. And this is the point where we can re operate on this child resect and close the fistula and reverse the ileostomy. Um So this poor child was really desperately sick at presentation. Um and she developed complications which were very well managed and she came through and the ultimate, the end result was extremely good. So, um don't lose heart, stick with it. Ok. Once again, thanks ever so much for watching. I hope you found it helpful. Please come to me if you can see anything that can be improved and come to me with any questions. Good evening to everybody.