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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 170-175

Determinants of outcome in gastrointestinal perforations with special reference to clavien–dindo classification of surgical complications: Experience of a Single Institute in Central Rajasthan


Department of General Surgery, J.L.N Medical College, Ajmer, Rajasthan, India

Date of Web Publication17-Mar-2017

Correspondence Address:
Amit Singh
Department of General Surgery, J.L.N Medical College, Ajmer, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.202365

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  Abstract 

Background: Perforation peritonitis is one of the most commonly encountered surgical emergencies across the world. In developing countries, gastrointestinal perforations have very high morbidity and mortality rates, irrespective of the type of operative procedure performed. The aim of the present study was to evaluate and find out various determinants for safe outcome in gastrointestinal perforation in terms of decreased morbidity and mortality and applying Clavien–Dindo classification for postoperative complications for evaluating the outcome.
Patients and Methods: A nonrandomized retrospective study with collected data from 350 patients with gastrointestinal perforations was conducted over a period of 3 years. Data from various preoperative and operative factors, surgical technique, and complications were recorded. The output was measured as better and worse, as per the classification proposed by Clavien–Dindo.
Results: The study enrolled 350 patients with a male:female ratio of 3.3:1; 58% of the patients were <40 years of age. The most common etiologies of perforation peritonitis were peptic perforation (duodenal 42%, gastric 8%), small bowel perforation (jejunum 3.14%, ileal 26.28%), appendicular perforation (10%), and cecum and colon constituting 4.85% each. The incidence of major complications was wound infections 18%, respiratory complications 16.57%, burst abdomen 5.14%, leak 4%, and septicemia 7.14%. Overall mortality was 10.85%. High mortality was observed in ileal perforation.
Conclusion: Preoperative comorbidities, operative techniques, and postoperative complications in this setting are associated with morbidity and mortality. Proper screening on admission should be done to identify premorbid illness, and with the use of some recommendations in surgical technique we can achieve safe outcome of gastrointestinal perforations. The Clavien–Dindo classification can be adapted to assess the severity of postoperative complications following gastrointestinal perforations.

Keywords: Clavien-Dindo classification of surgical complications, duodenal perforation repair, gastrointestinal perforations, omental patch


How to cite this article:
Singh A, Porwal R, Gupta HP, Sharma AK, Kumawat G. Determinants of outcome in gastrointestinal perforations with special reference to clavien–dindo classification of surgical complications: Experience of a Single Institute in Central Rajasthan. Arch Int Surg 2016;6:170-5

How to cite this URL:
Singh A, Porwal R, Gupta HP, Sharma AK, Kumawat G. Determinants of outcome in gastrointestinal perforations with special reference to clavien–dindo classification of surgical complications: Experience of a Single Institute in Central Rajasthan. Arch Int Surg [serial online] 2016 [cited 2019 Dec 12];6:170-5. Available from: http://www.archintsurg.org/text.asp?2016/6/3/170/202365




  Introduction Top


Perforation peritonitis is one of the most common acute abdominal conditions faced by surgery residents in emergency department. Because the disease mostly affects the middle and lower socioeconomical class, patients usually present late in the course of the disease, either due to ignorance or lack of resources. Management is quite challenging as patients present late with septicemia, fluid and electrolyte derangements, shock, and/or systemic inflammatory response syndrome. The combination of improved surgical technique, antimicrobial therapy, and intensive care support has improved the outcome of such cases. Moreover, complications are not uncommon in cases of perforated gastrointestinal tract, even at centres with best facilities, because the outcome also depends on certain patient factors. Therefore, in this study, we tried to find out various preoperative factors that may contribute to adverse outcome and to identify the best technique that could decrease the leakage rate from the perforation repair site at the J.L.N. Medical College, Ajmer, which is a tertiary care hospital in central Rajasthan.


  Patients and Methods Top


The present study included 350 patients with perforation admitted in various surgical wards of J.L.N. Medical College and Hospital, Ajmer over a period (August 2011 to September 2014) of 3 years.

Inclusion criteria

All patients in the age group of 15–65 years with peritonitis caused by perforation of the gastrointestinal tracts were included in this study.

Exclusion criteria

All patients of primary peritonitis, corrosive, postoperative peritonitis caused by anastomosis leakage, perforation due to trauma, and children below 15 years were excluded from the study.

Diagnosis of perforation was made on the basis of acute attack of abdominal pain with signs and symptoms of generalized peritonitis and radiological evidence of gas in peritoneal cavity. All patients were preoperatively resuscitated with intravenous fluids, and electrolyte imbalance was corrected. Nasogastric aspiration and urethral catheterization were performed in every patient. Preoperatively, antibiotics, ceftriaxone, and metronidazole were given. Anemic patients required blood transfusion. Exploratory laparotomy under general anesthesia was carried out through a midline incision in all the patients. The entire bowel was explored, and its findings were noted in relation to the amount and nature of fluid; site, size, and number of perforations; and the condition of the adjacent bowel. Surgical procedure was performed according to the site of perforation and morbid condition of patient; drain was placed in the abdominal cavity, and the abdomen closed with Prolen No. 1 suture. All patients were followed in the ward or intensive care unit (ICU) postoperatively. Drug regimen was not uniform in all patients. The postoperative blood product requirement, total parenteral nutrition, need for ventilator support, and complications such as wound infection, burst abdomen, respiratory complications, anastomosis leak, and mortality were noted. The complications were graded (grade I–V), as per the classification proposed by Clavien– Dindo [Table 1].[1],[2]
Table 1: Classification of Surgical Complications proposed by Clavien-Dindo et al[1],[2]

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No complications

Grade I: wound infection

Grade II: Respiratory complications

Grade III: Burst abdomen, anastomosis leak

Grade IV: Septicemia

Grade V: Death

The outcome was measured as better (Grades I, II, and No complications) and worse outcome (Grades III, IV, and V) [Figure 1]. Data were collected and recorded on a predesigned proforma prepared for this study. Data analysis were done using the Statistical Package for the Social Sciences (Version 20.0 for windows, Developer(s) IBM Corporation, Armonk, New York.) software. In order to analyze data, z test (one-tailed) and analysis of variance (ANOVA) test is appropriate. All the tests were employed at 95% level of significance.
Figure 1: Shows outcome and grading with postoperative complications of various perforations surgeries according to Clavien–Dindo's classification of surgical complication

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  Results Top


A total of 350 patients were studied in a tertiary care teaching hospital in central Rajasthan. The age of the youngest patient was 16 years and the oldest patient was 65 years old (range: 15–65 years). Most of the patients were <40 year of age (58%). Majority of the patients were males (270 males and 80 females). The male-to-female ratio was 3.3:1. The majority of patients presented with the history of abdominal pain (97%), abdominal distension (75.42%), shock (65.7%) due to septicemia, altered bowel habit (60%), nausea or vomiting (54.28%), and fever (37.14%). Clinical presentation of patients varied according to the site and cause of perforation. Patients of duodenal ulcer perforation usually had a short history of pain originating in the epigastric region or upper abdomen. Approximately 40% of the patients gave a positive history of nonsteroidal anti-inflammatory drug (NSAID) use. Patients with ileocecal pathology mostly presented with a history of abdominal pain, abdominal distention, altered bowel habit, and nausea or vomiting. Patients with small bowel typhoid perforation also presented with a history of fever, followed by sudden onset of pain in the abdomen. Patients with perforated appendix presented with a typical history of pain starting in the periumbilical region shifting to the right iliac fossa, or originating directly in the right iliac fossa and spreading all over the abdomen. Generalized guarding, rigidity, and tenderness were found in all the patients. Pneumoperitonium were present in 100% of the patients who underwent standing X-ray tests. Preoperative investigative data included electrolyte imbalance hypokalemia 36.57%, anemia 65.14%, hypoproteinemia 64.57%, jaundice 3.4%, and raised creatinine in 42% of patients. The time taken for resuscitation, diagnosis, and optimizing the patients for surgery was less than 6 h in 23.42% whereas was more than 6 h in 76.58% of the patients [Table 2]. Perforated duodenal ulcer caused by acid-peptic disease was most common (42%), followed by and small bowel perforation due to typhoid 26.28%, appendicular perforation 10%, gastric perforation 8%, and cecum and colon in 4.85% each; the least common rectum perforation was 0.85% [Table 3]. Most of duodenal ulcer perforation was managed by omentopexy (65.98%) and figure of 8 repair (34.01%). Small bowel perforations were managed by primary double layer repair with free omental sheet graft (41.30%), simple primary double layer repair (32.60%), and resection and anastomosis was done in (13.04%) patients presenting with multiple small bowel perforation, primary double layer repair with ileotranseverse bypass anastomosis (6.52%), and primary double layer repair with loop ileostomy (6.52%). Appendix perforations were managed by appendectomy. Cecum perforations were managed either by ileoascending anastomosis or by right hemicolectomy. Colon and rectum perforation were managed by single layer repair with or without covering colostomy [Table 3]. Postoperative complications recorded were wound infection 18%, burst abdomen 5.14%, respiratory complications 16.57%, septicemia 7.14%, anastomosis leak/fecal fistula 4%, and overall mortality was 10.85% [Figure 1]. Using the Clavien–Dindo classification, 134 out of 350 (38.28%) patients had no complications, 63 (18%) had grade I complication, 58 (16.57%) had grade II complications, 32 (9.14%) had grade III complications, 25 (7.14%) had grade IV complications, and 38 (10.85%) had grade V complication rates [Figure 1].
Table 2: Preoperative data

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Table 3: Various surgical procedures according to perforation site and outcome in relation to Clavien-Dindo classification

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  Discussion Top


Intestinal perforation is the most dreadful complication in developing countries leading to diffuse peritonitis. The disease and its complications are more common in young males when they are in their economically productive years.[3] As in our study, 58% of the patients were below the age of 40 years. The majority of patients were males (270 males and 80 females) and the male-to-female ratio was 3.3:1. Another study also showed that there were more male patients of perforation peritonitis, with a male-to-female ratio of 3:1and 4.9:1.[4],[5] Perforation of the proximal part of the gastrointestinal tract was more common,[5],[6] which is in contrast to the studies reported from western countries where perforations are common in the distal part.[5],[7] Not only the site but the etiological factors also show a wide geographical variation. Duodenal ulcer perforation (42%) and ileal typhoid perforations (26.28%) were the most common perforation noted in our study, other perforations have incidence of gastric (8%), jejunal (3.14%), appendix (10%), cecum and colon (4.85%), and rectum (0.85%). These figures show the importance of infection and infestation in the third world, with another study showing the similar result.[8],[9]

Gastroduodenal perforations are common in surgical practice and occur as a complication of peptic ulcer disease (PUD), abuse of NSAIDs, and gastric cancer.[10] As seen in our study, 40% of the patients have a positive history of NSAIDs. Perforation is a rare complication of gastric carcinoma, accounting for less than 1%. Perforated gastric ulcer has a high incidence of malignancy.[11] As seen in our study, out of 28 gastric perforations, 2 were malignant. It is noted in our study that proper hydration, good antibiotic cover, and simple closure of the perforation using an omentopexy significantly decreased mortality rate, as in our study, 84.53% in the better outcome group.[5],[12] Other treatment options for perforated peptic ulcer, such as figure of eight repair, showed very good and acceptable results, as in our study 88% in the better outcome group.[13] Rest of the treatment options for perforated peptic ulcer include Billroth I, Billroth II, and truncal and vagotomy drainage procedure; however, definitive acid reduction and bypass surgery were not possible in these patients due to compromised physiological status of the patient and septicemia, which appears to add to the risk of mortality and morbidity without appreciably improving the long-term outcome.[14] Laparoscopic repair of the perforated gastroduodenal ulcer by running suture with or without omental patch is an option for stable physiological state and early presentation of case.[15]

Causes of ileal perforations noticed in our study were tuberculosis and typhoid. The most common site of extrapulmonary tuberculosis is the ileocecal region and terminal ileum.[5],[16] It can be fatal even in the young and fit. Tubercular ileal perforations present alone or in combination with cecum. Typhoid fever is an endemic disease in the Indian subcontinent and is caused by a gram-negative bacillus,  Salmonella More Details typhi. Intestinal perforation is the most dreadful complication of enteric fever in developing countries leading to diffuse peritonitis.[17] The disease and its complications are more common in young males when they are in their economically productive years. Management of tubercular perforation of ileum depends on the condition of the gut, general condition of the patient, and the number of perforation. Ileocecal tuberculosis was managed by right hemicolectomy with or without stoma, perforation along with multiple stricture with resection anastomosis, and a covering stoma or only stoma.[5],[18] Typhoid enteric perforations were managed by simple primary double layer repair, primary double layer repair with free omental sheet graft, primary double layer repair with stoma, and primary double layer repair with ileotransverse anastomosis, and depending on the condition of the gut with multiple perforations, it was also managed by resection and anastomosis. Primary double layer repair with free omental sheet graft of the typhoid perforation is a safe and effective treatment;[19] as seen in our study, 38 patients of ileal perforation were managed by primary repair with free omental sheet graft and 76.31% were in the better outcome group (P =0.000588) [Table 4].
Table 4: Shows that P value is significant for four surgical methods that are given below
  • Wedge resection biopsy of perforation margin with omentopexy
  • Figure of 8 repair
  • Omentopexy
  • Primary double layer repair with free omental sheet graft


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The mortality rate in our study was 10.85% despite delay in seeking treatment; according to the world literature concerning mortality in perforation peritonitis ranges between 6 and 27%.[20] One of the most important factors responsible for mortality in our study was the presence of septicemia. Hence, contamination is a crucial factor in patients with perforation peritonitis and mortality is related to the presence of infection. Adequate preoperative resuscitation (e.g., with intravenous fluids, etc.), correction of electrolyte imbalances followed by an early surgical intervention to remove the source of infection and stop further contamination is imperative for good outcomes minimizing morbidity and mortality.[21] The lack of consensus on how to define and grade adverse postoperative events has significantly hampered the evaluation of surgical procedures. A new classification of complications, proposed by Clavien–Dindo, is a simple way of reporting all complications following perforation surgery. It allows us to distinguish a normal postoperative course from any deviation and the severity of complications, which may be useful for comparing postoperative morbidity.[1],[2],[22] This classification seems to be applicable in most parts of the world and may even be used by surgeons who are less experienced. The broad implementation of this classification into surgical literature may facilitate the evaluation and comparison of surgical outcomes among different surgeons, centres, and therapies.[1],[2],[22] However, the Clavien–Dindo classification was developed and validated using a cohort of general elective surgical patients; patients undergoing emergency general surgical procedures differ significantly from elective general surgical patients. Therefore, emergency surgical patients are an important target group for quality improvement, and negative outcomes should be measured and classified in order to find more specific targets for quality improvement. The suitability of the Clavien–Dindo classification for emergency surgical patients has not been validated. Particularly, organ failures classified as grade IV complications in the Clavien–Dindo classification may be inappropriate for classifying complications of emergency surgical patients who may already have organ failures preoperatively. Because peritonitis may cause organ dysfunctions, all postoperative organ dysfunctions should not be classified as surgical complications.[23]


  Conclusion Top


In conclusion, mostly perforations are noticed in the duodenum due to acid-peptic disease and small bowel typhoid followed by small bowel tuberculosis in our study. Malignancy was the least common cause of perforation peritonitis in our centre. Aggressive resuscitation and early minimum surgery are required to avoid high morbidity and mortality. Figure of eight and free omental sheet graft technique of surgery are advocated in duodenal and ileal perforations because they show exceptional results in term of better outcome. The Clavien–Dindo classification can be adapted to assess the severity of postoperative complications in emergency surgeries for gastrointestinal perforations in view of easy understanding and applicability and assessment of different surgical therapies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Malangoni MA, Inui T. Peritonitis - The western experience. World J Emerg Surg 2006;1:25.  Back to cited text no. 7
    
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Roviello F, Rossi S, Marrelli D, De Manzoni G, Pedrazzani C, Morgagni P, et al. Perforated gastric carcinoma: A report of 10 cases and review of the literature. World J Surg Oncol 2006;4:19.  Back to cited text no. 11
    
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Gupta SP. A Safer Technique of Closure of Peptic Ulcer Perforation. Indian J Surg 2011;73:361-2.  Back to cited text no. 13
    
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Koninger J, Bottinger P, Redeeke J, Butters M. Laproscopic repair of perforated gastroduodenal ulcer by running suture. Langenbecks Arch Surg 2004;389:11-6.  Back to cited text no. 15
    
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Ara C, Sogutlu G, Yildiz R, Kocak O, Isik B, Yilmaz S, et al. Spontaneous small bowel perforation due to intestinal tuberculosis should not be repaired by simple closure. J Gastrointest Surg 2005;9:514-7.  Back to cited text no. 18
    
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Singh A, Gora N, Soni ML, Khandelwal RG, Vidyarthi Sh, Thounaojam CK, et al. Comparative Study of Free Omental Sheet Graft and Other Operative Procedures of Enteric Perforation Repair. J Gastrointest Surg 2014;18:751-6.  Back to cited text no. 19
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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