Published online Mar 21, 2017. doi: 10.3748/wjg.v23.i11.1925
Peer-review started: January 12, 2017
First decision: February 9, 2017
Revised: February 20, 2017
Accepted: March 6, 2017
Article in press: March 6, 2017
Published online: March 21, 2017
Processing time: 67 Days and 17.4 Hours
Typhoid fever is a public health challenge mostly concentrated in impoverished, overcrowded areas of the developing world, with lack of safe drinking and sanitation. The most serious complication is typhoid intestinal perforation (TIP), observed in 0.8% to 39%, with a striking rate difference between high-income and low-middle-income countries. Although the mortality rate consequent to TIP in resource-poor countries is improved in the last decades, it is still fluctuating from 5% to 80%, due to surgical- and not surgical-related constraints. Huge economic costs and long timelines are required to provide a short- to middle-term solution to the lack of safe water and sanitation. Inherent limitations of the currently available diagnostic tools may lead to under-evaluation as well as over-evaluation of the disease, with consequent delayed treatment or inappropriate, excessive antibiotic use, hence increasing the likelihood of bacterial resistance. There is a need for immunization programs in populations at greatest risk, especially in sub-Saharan Africa. Uniform surgical strategies and guidelines, on the basis of sound or prospective surgical studies and adapted to the local realities, are still lacking. Major drawbacks of the surgical treatment are the frequent delays to surgery, either for late diagnosis or for difficult transports, and the unavailable appropriate intensive care units in most peripheral facilities. As a consequence, poor patient’s conditions at presentation, severe peritoneal contamination and unsuitable postoperative care are the foremost determinant of surgical morbidity and mortality.
Core tip: Typhoid perforation in low-middle-income countries has still a disappointing outcome, related to surgical and not surgical constraints: (1) safe water and sanitation are lacking in high risk settings like slums or overcrowded areas; (2) currently available diagnostic facilities have inherent limitations; (3) multiple drugs resistant bacteria are an increasingly threatening problem; (4) vaccination programs in some high risk regions, like sub-Saharan Africa, have not yet been carried out; (5) surgery is often delayed; (6) in peripheral facilities postoperative intensive care is problematic and often unsuitable; and (7) surgical standards and guidelines are not available due to the lack of sound prospective studies.