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

Anand Pandey Æ V. Kumar Æ Ajay N. Gangopadhyay ÆVijai D. Upadhyaya Æ A. Srivastava Æ Ram B. Singh

Published online: 30 September 2008

� Societe Internationale de Chirurgie 2008

Abstract

Background Ileostomy is usually performed for patients

of typhoid intestinal perforation with poor general condi-

tion, but it is associated with significant morbidity. We

have used the T-tube in such patients as an alternative to

ileostomy.

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 bowel

lumen after closing all distal perforations (group 3). They

were compared with patients who had primary closure of

perforation (group 1) or bowel resection (group 2) to

determine the efficacy of the use of T-tube.

Results The total number of patients for groups 1, 2, and

3 was 51, 4, and 12 (n = 67). The mean number of per-

forations for the three groups was 1, 3.5 ± 0.58, and

4.25 ± 0.97. The operation time for the three groups was

37.29 ± 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 was

8.58 ± 2.11 days. The overall follow-up period was

10.94 ± 1.15 months and none of the patients with T-tube

placement had features of intestinal obstruction.

Conclusions In children with multiple typhoid intestinal

perforations and poor general condition, the use of T-tube

may 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 its

high morbidity and mortality rates. Most perforations occur

in the terminal ileum [1]. The incidence of perforation has

been reported to be between 0.8% and 18% [2].

Various surgical options for treatment of the typhoid

perforation are primary closure, ileostomy, and resection

with anastomosis (RA) [2]. Although surgery is accepted as

the definitive treatment of typhoid intestinal perforation,

there is no general agreement regarding the choice of the

procedure [3]. Usually primary closure is performed for

single perforation, RA for multiple perforations, and ile-

ostomy for patients with poor condition [3]. Although

ileostomy is a life-saving procedure, it is associated with

various complications, such as prolapse, stricture, retrac-

tion, parastomal hernia, which add severely to the morbidity

of the patient and delay the overall recovery period [4]. In

an attempt to avoid the ileostomy and its subsequent com-

plications, we used a T-tube in its place in patients with poor

general condition. This study was performed to determine

the feasibility of T-tube in such patients.

Material and methods

This was a prospective study from January 2005 to January

2007. It was approved by the hospital ethical and

A. Pandey � V. Kumar � A. N. Gangopadhyay (&) �V. D. Upadhyaya � R. B. Singh

Department of Pediatric Surgery, Institute of Medical Sciences,

Banaras Hindu University, Varanasi 221005, Uttar Pradesh,

India

e-mail: gangulybhu@rediffmail.com

A. Srivastava

Department of Community Medicine, Sri RamMurty Smarak

Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

123

World J Surg (2008) 32:2607–2611

DOI 10.1007/s00268-008-9746-y

postgraduate committee. We included only those patients

of proved typhoid ileal perforation for T-tube placement

who were having poor general condition, multiple perfo-

ration, and severe peritoneal contamination at the time of

presentation to the department in which primary closure or

RA was judged to be very risky. The poor general condi-

tion was judged on basis of state of shock, such as thready

pulse, tachycardia, and tachypnea, and poor response to

verbal or painful stimulus, fever [ 104�F, need of oxygen

supplementation, and requirement of inotropic support.

The diagnosis of typhoid fever was suspected on the

basis of history, clinical examination, and a positive Widal

test. The diagnosis of typhoid intestinal perforation was

suspected on clinical basis and confirmed by gas under the

diaphragm in plain abdominal x-ray in erect view and

paracentesis.

After initial resuscitation and intravenous (IV) antibi-

otics administration, exploratory laparotomy was

performed by right transverse supraumbilical incision in all

the patients. We had accepted peritoneal contamination as

severe when the drainage amount was [ 1000 ml, moder-

ate when the amount was between 500 and 1000 ml, and

mild when the amount was \ 500 ml.

After through peritoneal lavage, all perforations were

closed 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 the

most 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 14

number size in all patients. If the most proximal perforation

was [ 1 cm in diameter, then it was closed primarily and

T-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. The

tube 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 no

leakage of dye.

The patients were compared with those patients in whom

primary closure or RA was performed during the same time

period. The evaluation was performed on basis of duration

of hospital stay, complications related to T-tube and overall

complications, start of oral feeds, and follow-up.

The statistical analysis was done by using SPSS 12.0

version for Windows. The results were evaluated by v2 test

and one-way analysis of variance. The values are expressed

as mean ± SD. p \ 0.05 was considered as statistically

significant.

Results

A total of 67 patients were operated on for diagnosis of

typhoid ileal perforation from January 2005 to JanuaryFig. 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 via

separate opening

2608 World J Surg (2008) 32:2607–2611

123

2007. Fifty-one (76.11%) patients had single perforation

that underwent primary closure (group 1). Four (5.97%)

patients had RA (group 2) for multiple ileal perforation

with good general condition. Twelve (17.91%) patients had

poor general condition, multiple perforations, and severe

peritoneal 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, and

7.58 ± 2.11 (range 4–11) years, respectively. The age

difference was statistically insignificant (p [ 0.05). There

was 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 all

the three groups). The Widal test was positive in all the

patients in group 3.

The mean interval between presentation of the patient to

the department and exploratory laparotomy was

5.92 ± 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 three

groups, respectively (p [ 0.05). T-tube as a treatment was

used in group 3. The perforations were located between 0

and 60 cm from the ileocecal valve in all the patients.

There was a single perforation in group 1. In the groups 2

and 3, the mean number of perforations was 3.5 ± 0.58

(range, 3–4) and 4.25 ± 0.97 (range, 3–6), respectively. In

group 3, the mean distance between two perforations was

4.69 ± 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. The

operation 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 the

most proximal perforation and in 4 (33.33%) patients it was

placed just proximal to the most proximal perforation after

closing 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 in

the three groups, respectively (p \ 0.05 for group 1). T-tube

was removed on 13.17 ± 0.72 (range, 12–14) days. After

the removal of the T-tube, the mean duration that the tract

continued to discharge before the fistula eventually healed

was 8.58 ± 2.11 (range, 5–12) days. None of the patients in

group 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, and

14.17 ± 0.72 (range, 13–15) days, respectively, in the

three groups (p \ 0.05 for group 3). The follow-up period

was 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 the

follow-up, none of the patients with T-tube had features of

intestinal obstruction, suggesting the possibility of stricture

development 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 no

peritube leakage. The wound dehiscence was managed by

secondary suturing. The intra-abdominal abscess was

aspirated with the help of abdominal ultrasound. The fever

was managed by change in the antibiotics. There was no

mortality in group 3, but the mortality in group 1 was

approximately 15% (Table 1).

Discussion

Typhoid perforation continues to be a scourge in children

in developing countries [5]. There are at least 16 million

new cases of typhoid fever around the world [6]. The

perforation results from necrosis of Peyer’s patches in the

terminal ileum [3]. It usually occurs during the second or

third week of fever [7]. Surgery is the accepted mode of

treatment; but there is no general agreement regarding the

choice of procedure, but ileostomy has been suggested for

patients with delayed presentation and severe abdominal

contamination [3].

Various tube techniques reported in literature are mostly

for meconium ileus and bowel atresia in newborn surgery.

In 1968, Rehbein and Halsband reported the double-tube

technique 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 for

decompression, and the thin one was inserted into distal

Table 1 Comparative evaluation of various postoperative complications in the different groups

Group 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 applied

World J Surg (2008) 32:2607–2611 2609

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loop and served as a splint for the anastomosis and

the distal bowel. In 1981, Harberg et al. [9] described the

technique and results of the T-tube ileostomy for the

treatment of uncomplicated meconium ileus without per-

foration. T-tube ileostomies were placed through an

enterotomy at the junction of proximal dilated bowel and

distal ileum with minimal bowel manipulation. Mathai and

colleagues used the procedure of proximal venting by a

Malecot catheter in nine children with intestinal atresia

with median weight 2.6 kg [10]. T-tube drainage for the

treatment of high jejunal atresia (diaphragmatic type) in

full-term newborns was used by Wen-Tsung Hung and

colleagues [11]. A T-tube was inserted through the opening

of the jejunum. One arm of the T-tube laid in the distended

jejunum and the other arm of the T-tube passed through the

area of excised diaphragm and lay in the distal collapsed

loop. Encouraged by the successful outcome with the tube

technique, we used it in patients of typhoid intestinal per-

foration with poor general condition in an attempt to avoid

ileostomy.

The ileostomy or colostomy has been in practice since

1793 for emergency management. It became a standard

procedure by virtue of its low immediate mortality and ease

of performance, but it necessitates staged procedures for

closure with repeated hospital admissions and prolonged

hospital stay [12]. It has been associated with multiple

complications, 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 the

summer 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 sever

contamination on the basis of volume of peritoneal fluid

present at the time of laparotomy. Recently the same values

also have been accepted by Atamanalp et al. [3] in their

estimation of peritoneal contamination. The use of T-tube

used in these patients can be advantageous because it

promotes decompression of bowel, prevents further com-

plications of hypoperistalsis and stasis, and allows an

uneventful healing of the site of perforation. T-tube ileos-

tomy combines advantages of enterostomy, such as

intestinal decompression, early feeding, and rapid tech-

nique with those of primary anastomosis, such as

restoration of intestinal continuity and avoiding secondary

operation [13].

The lesser duration of operation time in group 1 can

easily be explained on basis of closure of single perfora-

tion, whereas RA in group 2 or careful closure of multiple

perforations with placement of T-tube in group 3 took more

time to complete the task. The oral intake was in form of

liquids on the fourth to sixth day followed by semisolid

food for the next 2 days and then full oral feeds and hence

the chance of blockade of T-tube was minimal; moreover

as 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 on

the assumption that the tube tract is formed during this

period thereby preventing the chances of peritoneal

contamination.

Although there were complications in our series, they

were not related to the use of the T-tube. The theoretical

chances 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 statistically

insignificant in all three groups, thus proving our statement

that the complications were not related to the T-tube usage

(Table 1). All of our patients had an uneventful recovery

with the use of the T-tube, suggesting that T-tube ileos-

tomy can be used as an effective alternative to ileostomy

and preventing its long-term morbidity. It can be argued

that the mortality in group 1 was significant compared with

group 3; however, we included only those patients in group

3 who, apart from having poor general condition and severe

peritoneal contamination, had multiple ileal perforation. In

group 1, not all patients had good general condition, but the

criteria of single or multiple perforations separated them

into group 1 or 3.

Overall, morbidity can be reduced and outcome opti-

mized by aggressive resuscitation in all cases of typhoid

intestinal perforation, and early limited surgery. Thus, T-

tube ileostomy in pediatric patients of typhoid fever with

multiple ileal perforations and poor general condition can

be used as an alternative to ileostomy. Given the better

outcome with T-tube, it may be necessary to include

patients with single perforation and poor general condition

among those who may benefit from T-tube in future

studies.

References

1. Chang YT, Lin JY, Huang YS (2006) Typhoid colonic perforation

in childhood: a ten-year experience. World J Surg 30:242–247

2. 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 18:696–700

3. Atamanalp SS, Aydinli B, Ozturk G, Oren D, Basoglu M, Yil-

dirgan MI (2007) Typhoid intestinal perforations: twenty-six year

experience. World J Surg 31:1883–1888

4. 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 1479–1493

5. Ameh EA (1999) Typhoid ileal perforation in children: a scourge

in developing countries. Ann Trop Pediatr 19:267–272

6. Parry CM, Hien TT, Dougan G (2002) Typhoid fever. N Engl J

Med 347:1770–1782

2610 World J Surg (2008) 32:2607–2611

123

7. Hosoglu S, Aldemir M, Akalin S, Geyik MF, Tacyildiz IH, Loeb

M (2004) Risk factors for enteric perforation in patients with

typhoid fever. Am J Epidemiol 160:46–50

8. Rehbein F, Halsband H (1968) A double-tube technique for the

treatment of meconium ileus and small bowel atresia. J Pediatr

Surg 3:723–726

9. Harberg FJ, Senekjian EK, Pokorny WJ (1981) Treatment of

uncomplicated meconium ileus via T-tube ileostomy. J Pediatr

Surg 16:61–63

10. Mathai J, Sen S, Zachariah N, Chacko J, Thomas G (2003)

Proximal Malecot vent in neonatal small-bowel anastomosis.

Pediatr Surg Int 19:245–246

11. Hung WT, Tsai YW, Lu WT (1995) T-tube drainage for the

treatment of high jejunal atresia. J Pediatr Surg 30:563–565

12. Asfar SK, Al-Sayer HM, Juma TH (2007) Exteriorized colon

anastomosis for unprepared bowel: an alternative to routine

colostomy. World J Gastroenterol 13:3215–3220

13. Rygl M, Pycha K, Strank Z, Skaba R, Brabec R, Snajdauf J

(2007) T-tube ileostomy for intestinal perforation in extremely

low birth weight neonates. Pediatr Surg Int 23:685–688

World J Surg (2008) 32:2607–2611 2611

123