A COMPARATIVE STUDY OF TWO SURGICALAPPROACHES – PRIMARY CLOSURE AND RESECTION ANASTOMOSIS IN ENTERIC ILEAL PERFORATION PERITONITIS IN APACHE GROUP B PATIENTS

Abstract

INTRODUCTION - Perforation peritonitis is the most common surgical emergency in India. The spectrum of etiology of perforation in tropical countries continues to be different from its western counterpart. In contrast to western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India and the Indian subcontinent. Despite advances in surgical techniques, antimicrobial therapy and intensive care support, management of peritonitis continues to be highly demanding, difcult and complex. METHODS - Patients with APACHE II score between10-19 were selected for this study and blindly randomized into two procedure i.e., primary closure and resection-anastomosis. The patients in study group were subjected to detailed history, complete general physical examination and selection of patients into groups by acute physiology and chronic health evaluation (APACHE II) scoring. Post-operative outcome was assessed by number of days after which patient pass atus and stool, number of days of post-operative antibiotics requirement, duration of hospital stay, postoperative complications and mortality/morbidity. RESULTS - In the present study male preponderance was found with male to female ratio of 5.4:1. Widal test positivity in our study was 95.56%. About 68.88% of patient presented within 48 hours of perforation and had favorable outcome from those who presented late. In our study different operative procedures – simple closure of perforation and resection- anastomosis were performed alternatively with 45 patients in each group. Wound infection was the most common post-operative complication - 13.33% (n=6) in Group I and 28.89% (n=13) in Group II (P=0.071). Most common systemic complication encountered was pleural effusion (23.33%; n=21). In primary repair group, it was seen in 8 cases (17.8%) and in resection-anastomosis group, it was seen in 13 cases (28.9%). Other systemic complications observed were pneumonia, sepsis and renal failure. Mean length of hospital stay in primary repair group was days and in resection-anastomosis group was days. CONCLUSION - Primary closure of perforation was advocated in patients with single, small perforation (<1cm) with APACHE II score 10-19 irrespective of duration of perforation. Resection-anastomosis is advocated in multiple perforations, diseased segment of bowel. The two procedures were found to be similar in terms of morbidity and mortality. The nal decision can be made based on surgeon's discretion.