Pattern of nontyphoid ileal perforation over three decades in Pondicherry.

Two hundred and twelve cases of ileal perforation due to different causes (excluding typhoid) were treated in 3 phases in the Department of Surgery, JIPMER Hospital, Pondicherry, during the periods 1966-78 (phase I), 1981-88 (phase II) and 1990-1998 (Phase III). Forty per cent of the patients were in the second and third decades of life. Male-to-female ratio was 2.2:1. The majority of the perforations (52.8%) were due to non-specific causes. Trauma (19.3%) and mechanical factors (12.7%) were the other principal aetiologies. Pain abdomen (92.3%), constipation (63.6%) and fever (44.3%) were the principal presenting features. Abdominal guarding and rigidity (89%) were the main physical signs. Pneumoperitoneum was present in 66.8% of cases on plain X-ray abdomen. Widal and blood culture for Salmonella typhi were negative in all. Laparotomy was done in most of the cases after adequate resuscitation. Simple closure of the perforation, wedge resection and resection anastomosis were the different procedures of management. Histology of the margin of perforation/excised gut gave added evidence of a non-typhoid etiology. Broad-spectrum antibiotics in different combinations with metronidazole were administered postoperatively. Mortality was 28.2% in Phase I, and 9.4% and 11.9% in phases II and III respectively. The lag period (advent of symptoms and hospitalization) showed definite relationship with mortality and morbidity. Wound infection, wound dehiscence, enterocutaneous fistula and septicaemia were the principal postoperative complications.

Changing trends in outcome of typhoid ileal perforations over three decades in Pondicherry.

Two hundred and forty eight cases of proved typhoid ileal perforation were admitted and treated in three phases in the department of surgery during 1966-1998. Of these, 71% patients belonged to second and third decades of life. Male female ratio was 4:1. Abdominal pain (100%) fever (95%) and constipation (87%) were the main presenting symptoms. Abdominal guarding and rigidity (84%) were the principal physical signs. Plain radiograph of abdomen showed evidence of pneumoperitoneum in 57% of cases. The Widal test was positive for S. typhi in 74% of cases. Blood and bone marrow culture were positive for S. typhi in 9% and 30% respectively. Histology of the excised edges of perforation confirmed typhoid pathology in 62% of specimens. Many of the patients were treated conservatively in the first phase. In phase two and three vigorous resuscitation and early surgery was resorted to. Simple closure in two layers and wedge resection were the treatment of choice in most of the cases. Bypass, ileostomy and resection were done on few occasions. Chloramphenicol was the only drug used in the first phase. Other broad spectrum antibiotics were added to chloramphenicol with metranidazole in the second phase. Ciprofloxacin and metronidazole were the drugs of choice in the third phase. The mortality rate showed a dramatic improvement from 47.2% (first phase) to 17.7% (second phase) and as low as 7% in the last phase. The lag period (advent of symptoms to time of admission to hospital) showed definite correlation with mortality. Septicemia, wound infection, dehiscence, enterocutaneous fistula were the principal postoperative complications.

Volvulus of stomach in childhood.

Six children, aged upto one year, with volvulus of the stomach are reported. Vomiting and regurgitation of feeds were the main presenting symptoms. Eventration of the left hemidiaphragm was present in four cases. Barium meal confirmed the diagnosis. Five cases were operated on through an abdominal approach. Plication of the diaphragm (3 cases), colonic displacement (2) and gastrostomy (3) were resorted to. One child needed reoperation for a missed Ladd's band. There was no operative mortality.