Utility of Distal Loopogram Prior to Post Typhoid Ileostomy Reversal

The Distal loopogram assesses distal bowel health pre-stoma reversal. Yet, its bene�ts for typhoid perforation patients require further evaluation. Objective: To assess the utility of distal loopogram before the ileostomy stoma reversal in patients of typhoid perforation. Methods: A comparative, cross-sectional study was conducted upon a sample of 76 patients of both gender with age from 13 to 70 years and being operated for reversal of post-typhoid perforation loop ileostomy with or without distal loopogram study at Liaquat University Hospital Jamshoro and Hyderabad. Non-consenting patients and the patients with deranged kidney function or comorbid conditions in which contrast material is contraindicated or patients allergic to contrast agent or having tendency of atopy to any allergens like patients of bronchial asthma and those who lost to follow up were excluded from the sample. Results: The loopogram accurately predicted anastomotic leakage and mucocutaneous separation in all cases during surgery. Bowel stricture was predicted in 66.7% of cases, and peristomal dermatologic problems in 50%. This highlights the loopogram's utility in anticipating surgical challenges, especially for critical issues like anastomotic leakage and mucocutaneous separation. Conclusions: It was concluded that distal loopogram was valuable for assessing post-typhoid ileostomy reversal patients, offering detailed small intestine images for identifying complications and enhancing surgical planning, thus improving outcomes.

spot solitary in about 85% of cases.This happens because of an infection in Peyer's patches, which leads to ulcers along the inner border of the intestine, close to the valve that connects the small intestine to the large intestine.Perforation may not be noticed early, especially in patients who are already very sick.When intestinal bacteria leak out, it can cause a serious infection called bacterial peritonitis.This makes the condition a common surgical emergency [6].The standard treatment for secondary peritonitis due to a hole in the intestines involves resuscitation followed by surgery called laparotomy.During this surgery, the hole in the intestine is either stitched closed directly, or a part of the intestine is removed and the ends are stitched back together, or a temporary opening called a stoma is made in the abdomen.The treatment choice depends on factors like where and how many holes there are, how bad the infection is, and sick the patient is [7].Ileostomy, a frequently performed surgical procedure, carries lower mortality rate due to the early start of enteral feeding and nutritional built up [8,9].However, stoma formation and later its closure is not devoid of complications and adverse events such as stoma necrosis, stoma retraction or stoma prolapse may occur [10].It is customary to perform distal loopogram contrast study before stoma reversal to detect distal obstruction or pathology like stricture, growth, kinking of distal loop or fecal impaction and continuity of distal loops as presence of any of the ndings are associated with higher rates of post ileostomy reversal complications [11].However, presence of any of these distal pathology are unlikely ndings, especially in patients undergoing Ileostomy reversal made secondary to typhoid perforation.At the same time distal loopogram is associated with signi cant risk due to contrast material, especially in patients with impaired kidney function, old age population, long standing hypertension, Diabetes mellitus & its associated cost and delay in treatment [12].This study was meant to assess the risks and bene ts associated with the routine use of distal loopogram in patients undergoing ileostomy reversal made typhoid ideal perforation as the data regarding its use in post typhoid per foration stoma closure are not standardized in literature.Distal loopogram, also known as computed tomography enterography (CTE), is a noninvasive imaging technique that utilizes computed tomography to create detailed images of the small intestine, which is performed with an intention to assess patency and integrity of distal bowel prior to closure of stoma in order to subvert lethal complications associated with loss of it.However, the process put an additional burden on the healthcare setup and patient apart from complications associated to it.Since data regarding the use of distal loopogram in patients of post typhoid perforation stoma closure were either insu cient in

E S U L T S
The demographic pro les of participants, categorized into Group A and Group B. The mean age of participants in both groups was 32.88 years, with a standard deviation of 8.29 years.When considering gender distribution, Group A comprised 27 males (71.1%) and 11 females (28.9%), while Group B had 28 males (73.7%) and 10 females (26.3%).Regarding the area of residence, the majority of participants in both groups hailed from rural areas, with 29 (76.3%) in Group A and 30 (78.9%) in Group B, whereas the remaining participants resided in urban areas, accounting for 9 (23.7%) in Group A and 8 (21.1%) in Group B (table 1).literature or do not put a conclusive evidence regarding its utility.This study was conducted to assess the utility of distal loopogram before the ileostomy stoma reversal in patients of typhoid perforation.A cross-sectional study was conducted at the Department of General Surgery, Unit 3, Liaquat University Hospital in Jamshoro and Hyderabad, from Jan 2022 to Dec 2022.Sample size was calculated using OpenEpi sample size calculator with estimated incidence of complications found in distal loopogram before ileostomy reversal as 8.69% [13] and a margin of error of 5% and a con dence level of 95%.A total of 76 cases undergoing reversal of post-typhoid perforation loop ileostomy, aged between 13 to 70 years, and of either gender were included in the study using a non-probability, consecutive sampling technique while patients with deranged kidney function or contraindications to contrast material, those allergic to contrast agents, individuals with a tendency towards atopy, and those lost to follow-up or not consenting to participate were excluded from the study.The study was approved by Institutional ERC vide letter no.LUMHS/REC/-84, dated; 03/05/2021.Patients were divided into two groups with equal number of participants like 38 in Group A, who underwent a distal loopogram prior to ileostomy reversal as compared to Group B. Both groups received similar preoperative bowel preparation and antibiotic prophylaxis.Surgical procedures involved hand-sewn end-to-end a n a s t o m o s i s w i t h o p e r a t i v e n d i n g s n o t e d .P o s t o p e r a t i v e l y, p a t i e n t s w e r e m o n i t o r e d fo r complications, including anastomosis leakage, intestinal obstruction, and wound infection.Patients who underwent contrast radiology were assessed for issues related to the distal loopogram.Data analysis was performed using SPSS version 24.0, with qualitative data expressed as number and percentage and quantitative data as mean and standard deviation.Statistical signi cance was determined using Pearson's coe cient and chi-square tests, with a p-value of ≤ 0.05 considered signi cant.
The majority of participants in both groups had a loop ileostomy, with 24 (63.16%) in Group A and 27 (71.05%) in Group B, while the remaining participants had an end ileostomy.Most participants in both groups had a single perforation, accounting for 28 (73.68%) in Group A and 30 (78.95%) in Group B. The proportion of participants with dual perforations was higher in Group B 9 (23.68%)compared to Group A 6 (15.79%).However, the occurrence of multiple perforations was minimal in both groups.The mean time elapsed ileostomy till reversal was slightly longer in Group A, at 19 weeks and 6 days as compared to 15 weeks and 2 days in Group B. Conversely, the mean postoperative hospital stay after reversal was shorter in Group A, at 5 days and 2 days, compared to 6 days and 3 days in Group B. (table 2) The abnormal ndings during surgery between patients in Group A and Group B. Group A had abnormality in 18 (47.37%),whereas Group B exhibited abnormalities in a higher proportion, with 32 (84.21%).Both groups displayed similar patterns of abnormalities, with the presence of anastomotic leakage being the most common.Other abnormalities included bowel obstruction, perforation, stricture, infection, peristomal dermatologic problems, mucocutaneous separation, and pyoderma gangrenosum.These ndings suggest a higher incidence of surgical complications in patients from Group B compared to those in Group A. (table 3)

D I S C U S S I O N
Typhoid fever is a bacterial infection caused by Salmonella typhi that can result in severe damage to the intestinal wall, leading to intestinal perforation and peritonitis.Once the infection has been treated and the intestinal damage has healed, the ileostomy can be reversed, allowing the patient to resume normal bowel function.The utility of distal loopogram prior to post-typhoid ileostomy reversal lies in the fact that it can provide valuable information on the condition of the small intestine, including the presence of adhesions, strictures, or other abnormalities that may impact the success of the reversal procedure.In the United States and Canada, the number of temporary stomas being created is decreasing because of better surgical techniques like planned laparotomy and continuous closed peritoneal lavage, which help reduce infections and deaths.Also, newer surgical methods mean fewer permanent stomas are needed [14,15].Anastomotic leakage emerged as the most common complication in both groups, with a prevalence of 13.16% in Group A and 23.68% in Group B. This nding is consistent with existing Complications, such as the presence of anastomotic leakage and mucocutaneous separation were accurately predicted by the loopogram as their occurrence during surgery in 100% of cases.For bowel stricture, the loopogram predicted the abnormality in 66.7% of cases, while for peristomal dermatologic problems, it predicted the abnormality in 50% of cases.This underscore the utility of the loopogram in predicting potential problems during surger y, par ticularly for complications such as anastomotic leakage and mucocutaneous separation (table 4).literature, as anastomotic leakage is recognized as a frequent complication following ileostomy reversal, attributed to factors such as surgical technique, patient comorbidities, and postoperative care protocols [16].Bowel obstruction and infection were also prevalent complications in both groups, with higher incidences observed in Group B. This aligns with prior research indicating that bowel obstruction and postoperative infections are common complications associated with gastrointestinal surgery and can contribute to morbidity and hospital stays [17,18].In our study, the loopogram demonstrated a high accuracy in predicting the presence of certain complications, notably anastomotic leakage and mucocutaneous separation, with a 100% prediction rate while it showed a moderate predictive capability for bowel stricture, correctly identifying this abnormality in 66.7% of cases.This indicates that the loopogram effectively identi ed these issues before surgery.Our results align with previous research demonstrating the utility of the loopogram in predicting surgical complications.Studies conducted in other countries have also reported high accuracy rates for the loopogram in anticipating complications such as anastomotic leakage and bowel strictures [19][20][21].However, the loopogram predictive ability was relatively lower for peristomal dermatologic problems, with a prediction rate of 50%.Despite this, the loopogram still provided some insight into the likelihood of encountering peristomal dermatologic issues during surgery.These variations in predictive performance may exist across different healthcare settings and patient populations [22].Several studies have investigated the use of distal loopogram prior to post-typhoid ileostomy reversal, with promising results [23,24].For example, a study reported that distal loopogram was able to accurately identify signi cant small bowel abnormalities in patients with a history of typhoid fever, with a sensitivity of 100% and a speci city of 97%.The authors of the study concluded that distal loopogram can be a valuable tool in the evaluation of patients undergoing post-typhoid ileostomy reversal, particularly in those with a history of complicated typhoid fever [25].Another study published in the Journal of Surgical Research found that distal loopogram was able to accurately detect the presence of adhesions and other small bowel abnormalities in patients undergoing posttyphoid ileostomy reversal, with a sensitivity of 86% and a speci city of 96%.The authors of the study concluded that distal loopogram can aid in the identi cation of potential complications during the reversal procedure, allowing for better surgical planning and improved patient outcomes [26].Despite its many bene ts, distal loopogram does have some limitations.For example, it may not be able to detect very small lesions, and it may not be able to provide a The loopogram accurately predicted complications like anastomotic leakage and mucocutaneous separation in all cases during surgery.It also identi ed bowel stricture in 66.7% and peristomal dermatologic problems in 50% of cases.This highlights the loopogram's value in anticipating surgical challenges, especially for critical issues like anastomotic leakage and mucocutaneous separation.

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O N C L U S I O N S C o n  i c t s o f I n t e r e s t

Table 1 :
Demographic Pro les of Participants

Table 3 :
Abnormal Findings during Surgery in Group A and Group B

Table 2 :
Variables Related to Ileostomy Comparison of Group A and Group B

Table 4 :
Comparison of Abnormal Findings Detected During Surgery and Predicted by Loopogram