Management of Symptomatic Meckel's Diverticulum in Infants and Children

Objectives:The primary objective of the present study was to review the demographics of infants and children operated upon for Meckel's diverticulum. The secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and the outcome. Materials and Methods?This study is a single-institutional, retrospective study and descriptive in nature. It consisted of infants and children below 12 years who were operated upon for Meckel's diverticulum at the author's institute and included data from January 1, 2000 to December 31, 2020. Results?Eighty-four children below 12 years were operated upon for Meckel's diverticulum during the study period. The ratio for males to females was 3:1. This study consisted of infants, (n?=?22, 26.19%), children of 1 to 5 years of age (n =19, 22.61%), and children of 6 to 12 years of age (n?=?43, 51.19%). Clinically, children with Meckel's diverticulum presented in the following order of frequency: (1) intestinal obstruction (n?=?59, 70.23%), (2) perforation peritonitis (n?=?17, 20.23%), (3) lower gastrointestinal bleeding (n?=?4, 4.76%), and (4) incidental finding (n?=?4, 4.76%). In 35 (41.66%) children, bowel gangrene was detected. One-fifth (n?=?17) of Meckel's diverticulum was responsible for the secondary intussusception. The surgical procedures were performed in the following order of frequency: (1) resection of Meckel's diverticulum, an adjacent segment of ileum and ileoileal anastomosis (n?=?36, 42.85%); (2) Meckel's diverticulectomy (n?=?32, 38.09%); (3) resection of Meckel's diverticulum, an adjacent segment of ileum with or without cecum and an ileostomy (n?=?12, 14.28%); and (4) resection of Meckel's diverticulum, an adjacent segment of ileum, cecum, part of the colon, and ileocolic anastomosis (n?=?4, 4.76%). In 8 (9.52%) children, complications were documented during the postoperative period. The present study observed three (3.57%) deaths during the postoperative period. Conclusion?Meckel's diverticulum was one of the common causes of acute intestinal obstruction in infants and older children. Ninety percent of children with Meckel's diverticulum presented with features of an acute abdomen. Forty percent of children evidenced bowel gangrene during the surgical procedures. In these children, early diagnosis, timely referral, and institution of surgical therapy for acute abdomen/intestinal obstruction may prevent the development of bowel gangrene and the requirement of bowel resections to some extent.

A prospective study of effectiveness of Mannheim peritonitis index scoring system in predicting the morbidity and mortality in peritonitis due to hollow viscous perforation

Background: Peritonitis is defined as inflammation of the peritoneal cavity, caused by a number of etiologic agents including bacteria, fungi, viruses, chemical irritants, and foreign bodies. The Mannheim peritonitis index (MPI) is one of the simple scoring systems in use that allows the surgeon to easily determine outcome risk. Aims and objective: To estimate outcome of patients with perforation peritonitis. To evaluate effect of MPI score in identification of high risk cases.Methods: A prospective study was conducted in 100 patients with peritonitis due to hollow viscous perforation at surgical unit of tertiary care unit. The duration of study was 2 years. All the data was recorded. Written informed consent was obtained and data was analyzed using appropriate analysis strategy.Results: In this study, total 100 patients enrolled, out of which 54 % patients were in the age group <50 years and 46% patients were in the age group >50 years. Mortality was higher among patients with age group more than 50 years (21%) and in female patients (37.93%). 18 patients had organ failure. 87 patients had preoperative duration was >24 hours. 93% patients had non-colonic origin of sepsis. In 52 (52%) patients total MPI score was <21 while 25 (25%) patients total score was 21-29 and it was >29 in 23 (23%) patients. Mortality was higher among patients with MPI Score more than 29 (95.65%).Conclusions: MPI is accurate to be used with patients with peritonitis and should be considered reliable and simple reference for estimating their risk of death. This study differs in one adverse outcome variables, non-colonic origin of sepsis, we advocate need for further studies on Mannheim peritonitis index to include colonic origin of sepsis.

A prospective study on pattern of superficial surgical site infections in patients undergoing emergency laparotomy for perforation peritonitis

Background: surgical site infections (SSIs) are recognized as a common surgical complication occurring in about 3% of all surgical procedures and in upto 20% of patients undergoing emergency intraabdominal procedures. Aims: To determine the incidence of SSIs in emergency laparotomies done for perforation peritonitis and the organisms involved and their sensitivity pattern in superficial SSI. The objective of the study was to determine the effect of planned intra operative intervention [antibiotic lavage with III generation cephalosporin e.g. ceftriaxone 1 gm and metronidazole 100 ml (5 mg per ml)] on superficial surgical site infection in emergency laparotomies done for perforation peritonitis.Methods: This prospective randomized case controlled study was carried out in P. G. Department of Surgery, S. R. N. Hospital associated with M. L. N. Medical College, Allahabad, from September 2018 to August 2019 after approval from the ethical committee and after obtaining written and informed consent either from patient or their guardian. Patients were divided into two groups viz. control group receiving the normal saline lavage and case group receiving the antibiotic lavage (III generation cephalosporins i.e., ceftriaxone (1 gm in 1000 ml NS) and metronidazole- 5 mg/ml (100 ml in 500 ml NS).Results: There is almost 50% incidence of SSI in emergency laparotomy done for perforation peritonitis. The most common organism involved in superficial SSI in present study was gut flora (E. coli) followed by normal skin colonizer (Staph. aureus).Conclusions: Intraperitoneal antibiotic lavage has a significant role in reducing the rate of SSI especially in gastroduodenal perforations.

Role of peritoneal drainage in moribund patients of perforation peritonitis

Background: Objective of the present study was to evaluate applicability of primary peritoneal drainage under local anesthesia in moribund patients as pre-laparotomy support when laparotomy under general anesthesia could not be done. Also to assess outcome in terms of survival, patients needing definitive surgery and complications associated with the procedure on immediate and follow up basis.Methods: We conducted this study in Teerthanker Mahaveer Medical College, Moradabad, UP, India from October 18 to October 2019. 71 patients were admitted as cases of perforation peritonitis in moribund condition, demographic data of all patients was noted, peritoneal drainage under local anesthesia in flanks was done and variable amount of fluid was drained in different patients, simple parameters were taken in to consideration in pre and post drainage phase. We also noted the complications after the definitive surgery.Results: Out of 71 patients, admitted in late and in very critical state, 61 patients improved after drainage and resuscitative procedures, although in ASA grade 3 and 4 they underwent surgical treatment and we were able to save their lives. 13 patients expired after definitive surgery inspite of best efforts.Conclusions: Peritoneal drainage under local anesthesia in late reporting and critical patients, not only improves general condition but makes patients better to undergo further surgery, and can prove to be life saver. It being a simple procedure can easily be done at even PHC level, before patient is referred or shifted to higher centre for further management.

The anatomical site of perforation peritonitis and their microbiological profile: a cross-sectional study

Background: Initiation of early appropriate antibiotic therapy influences the outcome of perforation peritonitis, which otherwise is delayed till culture reports are available. The knowledge of microbial profile and sensitivity of peritoneal fluid culture with respect to the anatomical site of perforation peritonitis will help in initiation of early appropriate antibiotic therapy in the post-operative period.Methods: A cross-sectional study conducted from January 2017 to December 2017 where intraoperative peritoneal fluid sample in patients of perforation peritonitis was subjected to culture (aerobic and anaerobic) and sensitivity and results analysed with respect to anatomical site of perforation.Results: 50 patients were studied. The most common site of perforation was ileum (32%) followed by appendix (18%) and stomach (18%). In aerobic culture, the culture positivity rate was highest in colonic perforation (100%) and least in gastric perforation (44.4%). The most common organism isolated in all sites of perforation peritonitis was E. coli followed by Klebsiella spp. In anaerobic culture, although facultative anaerobes were isolated, no strict anaerobe was isolated. The most sensitive antibiotics covering all isolated organisms were gentamycin (p=0.006), colistin (p=0.018), piperacillin and tazobactum (p=0.022).Conclusions: The predominant differential normal flora according to site of gastrointestinal tract was not reflected in the peritoneal fluid culture of patients with perforation peritonitis and E. coli was the most common organism isolated in all sites of perforation peritonitis. The antibiotic sensitivity profile showed the increasing resistance against third generation cephalosporins. Aminoglycosides, piperacillin and tazobactum, meropenem and colistin showed a significant antimicrobial activity against organisms isolated from cases of perforation peritonitis.

A comparative analysis between Mannheim peritonitis score and acute physiological and chronic health evaluation II score in predicting prognosis of patients of perforation peritonitis

Background: The early assessment and recognition of peritonitis patient is required in surgical emergency. Various scoring system have been designed successfully to assess the prognosis and outcome of peritonitis. The present study was carried out with an aim to evaluate the usefulness and severity of Mannheim peritonitis (MPI) score in comparison to acute physiological and chronic health evaluation II (APACHE II) scoring system for prediction of the outcome in patients with perforation peritonitis and thus decision making in perforation peritonitis.Methods: A prospective observational study was carried out at Department of Surgery, King George’s Medical University (KGMU), Lucknow for a period of one year from July 2018 to June 2019. A total of 100 patients were enrolled in the study.Results: Majority of patients were males compared to females. Maximum number of patients (40%) was aged 51-60 years. Maximum number of patients (42%) had duodenal perforation. A significant association between higher MPI scores and mortality was seen (p<0.001). Statistically, the association between APACHE II scores and mortality was significant (p<0.001).Conclusions: APACHE II had a slightly higher sensitivity as well as specificity as compared to MPI. MPI is easy to calculate but accuracy of APACHE II is more, compared to MPI.

A Comparative Study between Elebute and Stoner Grading and Mannheim Peritonitis Index in Prognostic Evaluation of Intraperitoneal Sepsis Due to Perforation Peritonitis in Suburban Teaching Hospital

Background: Peritonitis is one of the most common surgicalemergencies with significant morbidity and mortality. Multiplescoring systems have been proposed and assessed inpredicting the outcome in patients with peritonitis. A scoringsystem should be able to assess the need, type, and quality ofthe care required for a particular patient. Realizing the need fora simple and accurate scoring system in these conditions, thepresent study was undertaken to evaluate the Prognosticevaluation of intraperitoneal sepsis in perforation peritonitis byevaluating the efficacy of Elebute and Stoner grading andMannheim peritonitis index (MPI) in predicting the overall riskof morbidity and mortality in patients with peritonitis. This studywas conducted to identify the predicting ability of both thesescores and to compare MPI with Elebute and Stoner grading(ESG) system.Aim: To predict outcome of patients with peritonitis using theElebute and Stonjej grading of sepsis and Mannheim peritonitisindex in these patients and to predict the possible clinicaloutcome and to compare the results of both the scoringsystems.Patients & Methods: The present work is based on theobservations made in 48 patients of perforation peritonitisadmitted in surgical ward of Rama Medical College Hapur,Uttar Pradesh, India from March 2017 to March 2018. Thediagnosis of perforation peritonitis was made on the basis ofdetailed history, physical examination, investigations andoperative findings. A detailed record was maintained carefullyfor every patient and evaluation of Elebute and Stoner gradingof sepsis and Mannheim peritonitis index were made and thenresults of both the scoring systems are compared.Results: Comparison of both the scoring systems showed thatsensitivity was almost equal in both the scoring systems (80%).But specificity and accuracy were slightly improved withElebute and Stoner grading of sepsis (89.42% and 87.36% Vs84.16% and 83.22%) respectively. This may be because ofmore organ systems incorporated in Elebute and Stonergrading of sepsis like hepatobiliary system, temperature,bleeding diathesis, central nervous system which had not beenincorporated in Mannheim Peritonitis index.Conclusion: In the univariate analysis both scoring systemsstudied, were relatively accurate for identifying patients athigher risk for dying from peritonitis. It was found thatprediction among the dead was better than survived in both thescoring systems.

Clinical Study on Profile of Cases of Perforation Peritonitis

Perforation peritonitis is common cause of abdominal emergency. The morbidity and mortality associated with this condition is very high. Methods: The present hospital based study included 55 patients with perforation peritonitis admitted at the department of surgery. Data regarding clinical features, management and complications was noted. Results: Most of the patients had perforation in duodenum (58.2%). Pain abdomen was the most common complain (96.4%). Wound infection was seen in 23.6%, pneumonia in 27.3% and abdominal collection in18.2%. Conclusion: Timely diagnosis of perforation peritonitis is essential.

A Single Centre Experience of Perforation Peritonitis in a Tertiary Care Hospital in North-East India: A Retrospective Study

Perforation peritonitis is one of the most common surgical emergencies in India. The spectrum of etiology of perforation in tropical countries continues to be different from its Western countries.The objective of the study was to highlight the spectrum of perforation peritonitis as encountered at Jawaharlal Nehru Institute of Medical Sciences, Imphal Manipur. Methods: Sixty five consecutive cases of perforation peritonitis over a period of 16 months were reviewed in terms of clinical presentation, operative findings and post-operative course retrospectively at JNIMS, Imphal. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy the cause of perforation peritonitis was confirmed. Results: The most common cause of perforation in our series was perforated duodenal ulcer (54 cases) followed bygastric perforation and perforated appendix. Despite delay in seeking medical treatment, the overall mortality (3%) was better than other published series. Conclusion: In contrast to western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India. Most common cause of perforation peritonitis was perforated duodenal ulcer, followed by perforated gastric ulcer. There was no perforation due to malignant neoplasms during the study period.

Clinico-pathological Evaluation and Management of Gastrointestinal Hollow Viscous Perforation.

Background: Gastrointestinal hollow viscous perforations constitute one of the important causes of acute pain abdomen in adults and if not treated properly may lead to significant morbidity and sometimes mortality. Successful treatment requires a thorough understanding of anatomy, microbiology, pathophysiology of the disease process and in-depth knowledge of the therapy, including resuscitation, antibiotics, source control, and physiologic support. Aim: To evaluate the etiopathology, clinical signs and symptoms, investigations in the management of gastrointestinal hollow viscous perforations. Materials and Methods: This was a prospective study conducted on patients presenting with gastrointestinal hollow viscous perforations to the Department of General Surgery, Rajarajeswari Medical College and Hospital over a period of 2-year from July 2013 to June 2015. A total of 110 patients were included in the study. A written, informed consent was taken from all patients before enrolling into the study. The Institutional Ethical Committee clearance was taken before starting the study. A pre-formed questionnaire was used to collect the clinical information from the patients. Results: The majority of the patients involved were males (81%) and in the age group of 30-50 years. 80% of the perforations were noted in the Gastroduodenal region, and the remaining was seen in the small bowel (13%) and appendix (7%). Pain abdomen was the presenting complaint in all patients (100%) while vomiting was seen in 50% and abdominal distension was seen in 80% of the patients. 91% of the patients had gas under the diaphragm. Wound infection (9%) lead the list of post-operative complications with a residual abscess (6%) following behind burst abdomen (4%) and fecal fistula (1%). 2% (2 patients) of patients died due to varied reasons. Conclusion: Even after the introduction of proton pump inhibitors, the incidence of perforations resulting from acid peptic disease is still high. Early recognition of perforation, prompt surgical intervention, good post-operative care, recognition of co-morbid conditions and early recognition, and management of complications would reduce morbidity and mortality.

Intraperitoneal Drainage Under Local Anaesthesia In Patients Of Perforation Peritonitis Before Definitive Management: Is It Justified?

Introduction: Perforation peritonitis is one of the most frequently encounter surgical emergency around the world. In spite of advances in diagnosis, antimicrobial therapy, surgery, it remains a fatal affliction with high mortality rate. This high mortality rate makes way for innovation in techniques in addition to the persisting knowledge for a better outcome. Aims: A pilot study was conducted, to evaluate the efficacy of intraperitoneal drainage in patients of perforation peritonitis during the resuscitation period before definitive surgical treatment. Methods: This was a prospective control study, conducted on the patients of perforation peritonitis with gastro-intestinal perforation for a period of 2 years w.e.f. January, 2011 to November 2012. 100 patients were included in this study and were divided into two groups (50 each). Group I- patient with preoperative intraperitoneal drainage under local anaesthesia, group II- patient without preoperative intraperitoneal drainage, before definitive surgery. Results: The overall morbidity and mortality of the patients in group-I were comparable with those in group-II Conclusion: Intraperitoneal drainage under local anaesthesia, in patients of gastrointestinal perforation peritonitis seems to be effective in decreasing morbidity and mortality.

Electric Current Causing Sigmoid Perforation: Case Report.

Post electric burn sigmoid perforation is a rare but dreadful complication. It can lead to increased chances of mortality/morbidity if any delay is made during diagnosis or active management. We report a case of electric current burn on left hand, forearm, arm and shoulder with perforation of sigmoid colon with successful management by primary closure.

The spectrum of perforation peritonitis - central India experience.

Introduction: Peritonitis secondary to gut perforation is one of the most common surgical emergencies in India and is associated with high morbidity and mortality. The aim of this study was to recognize the spectrum of perforation peritonitis as managed at Govt. Chhattisgarh Institute of Medical Sciences hospital Bilaspur Chhattisgarh, in central India. Method: A retrospective analysis of 618 patients was done,in terms of clinical presentation, duration, seasonal variation, operative findings and post operative morbidity and mortality, admitted at Chhattisgarh Institute of Medical Sciences hospital Bilaspur. Chhattisgarh, over a period of 03 years. All the patients had undergone emergency laprotomy and the site of perforation was identified. Results: The most common site of perforation was prepyloric (393 cases. 63.6%).In 22.16% of the cases the perforation was associated with typhoid fever and in 2.7% cases with abdominal Koch’s. Trauma however showed perforation in only 5.6% cases, mainly jejunal. The overall mortality was 12.13%. Conclusion: Non traumatic upper gastrointestinal perforation peritonitis is common in our place. In contrast to the west, where lower gastrointestinal tract perforations predominate, in India upper gastrointestinal tract perforations constitute the majority of cases.

Typhoid Perforation of Gallbladder- A Rare Pathology.

Surgical complication of Typhoid fever when occurs, it commonly involves gut rather than the gallbladder. This is a case report of 24 years young male who came to emergency with the complaint of fever of 12 days duration and sudden severe pain in the abdomen for 2 days. Patient was evaluated and investigated. He underwent laparotomy; on laprotomy, gallbladder was found to have perforation and therefore, cholecystectomy was done. The investigations supported the diagnosis of Typhoid fever. Patient recovered uneventfully and was discharged after 10-days.

Management of Spontaneous Perforation of the Bile Duct in an Infant in a Semi-Urban Setup: A Case Report

Spontaneous perforation of the extrahepatic bile duct leading to biliary peritonitis is a rare occurrence once other causes of biliary peritonitis, such as trauma, choledochal cyst, stone diseases, and distal atresia of the bile duct, are ruled out. A 7-month-old male infant was brought to the hospital in critical condition with distension of the abdomen. He had a history of vomiting and diarrhoea, low-grade fever, and refusal to feed for 2 days. Signs of peritonitis were found upon examination. Due to the poor general condition of the patient, the case was taken up for laparotomy, and a diagnosis of spontaneous extrahepatic bile duct perforation was made intra-operatively. In the present case, the cause was idiopathic. An external drain was placed near the site of the leak for 2 weeks. The patient recovered well and was discharged on post-operative day 16. Disease awareness for correct pre-operative diagnosis and interventional planning is required to reduce mortality, morbidity, and complications in spontaneous perforation of the common bile duct.

Intestinal tuberculosis in a celiac disease patient.

Both intestinal tuberculosis and celiac disease can cause malnutrition and failure to thrive. High index of suspicion is required to diagnose intestinal tuberculosis in a known case of celiac disease as both conditions present with similar complaints. We report a case of celiac disease with intestinal tuberculosis and perforation peritonitis.

Perforation Peritonitis:A Two Year Experience.

Four hundred patients who presented in the emergency of GMC Jammu as a case of perforation peritonitis over a period of two years were studied. In most of the cases diagnosis was made by clinical examination supplemented by investigations in the form of standing X-ray chest PA view with domes of diaphragm, Ultrasound abdomen and abdominal paracentesis. Contrast enhanced CT scans of abdomen were conducted on patients where the diagnosis of perforation peritonitis was doubtful. After resuscitation, Laparotomy was done in all the patients and thorough peritoneal lavage was done. A note of the site, size, type, number of perforations was made and biopsy was taken from the edge of the perforation whenever indicated. The most common cause of gastrointestinal perforation in our study was duodenal ulcer perforation, followed by appendicitis, typhoid perforation, blunt/penetrating trauma, gastric perforation, obstruction, iatrogenic, malignancy, and recurrent perforation. Primary closure of the perforation was most commonly done procedure, followed by appendectomy, resection anastomosis of the gut and exteriorization of the gut. The overall mortality was 6 % and morbidity in the form of wound infection, fever, respiratory complications, residual abscess, dyselectrolytemia, burst abdomen, jaundice, sepsis, cardiac complications, anastomotic disruption was present