Surgical Indications for Tuberculosis Ileitis
Surgery is indicated for TB ileitis when complications develop that cannot be managed medically: intestinal obstruction unresponsive to medical therapy, intestinal perforation, massive hemorrhage, or high-grade strictures not amenable to endoscopic dilatation. 1, 2
Absolute Indications for Emergency Surgery
Intestinal Perforation
- Free perforation with pneumoperitoneum and peritonitis requires immediate surgical exploration 1, 3
- Multiple perforations are associated with higher mortality and should prompt urgent intervention 3
- Hemodynamically unstable patients with perforation require damage control surgery 4
- Mortality from septic shock due to hollow viscus perforation is significant (up to 17% in TB perforation series) 1, 3
Massive Hemorrhage
- Life-threatening gastrointestinal bleeding with hemodynamic instability despite resuscitation mandates immediate surgery 2, 5
- Bleeding accounts for 2-6% of surgical indications in abdominal TB 2, 5
Urgent Indications (Within 24-48 Hours)
Complete Intestinal Obstruction
- Intestinal obstruction is the most common indication for surgery in TB ileitis, occurring in 15-66% of surgical cases 1, 2, 5
- Fibrotic strictures causing complete obstruction require surgical intervention when medical therapy fails 2
- Patients with prolonged abdominal symptoms despite anti-tuberculous therapy should raise suspicion for subacute obstruction progressing to complete obstruction 3
Clinical Deterioration Despite Medical Therapy
- Patients who fail to improve or deteriorate after 48-72 hours of appropriate anti-tuberculous therapy with persistent obstruction require surgery 3, 2
- Persistent fever, worsening abdominal pain, or signs of peritonitis despite medical management indicate need for surgical exploration 4
Relative/Elective Indications
Recurrent Obstruction
- Recurrent intestinal obstruction despite completed anti-tuberculous therapy warrants surgical intervention 2
- Symptomatic strictures not amenable to endoscopic balloon dilatation require resection 2
Abscesses and Fistulas
- Intra-abdominal abscesses that fail percutaneous drainage or medical management (2-30% of cases) 5
- Complex fistulas not responding to medical therapy 5
Surgical Approach and Procedures
Operative Strategy
- Right hemicolectomy or ileocecal resection is the most commonly performed procedure, as the ileocecal region is the most frequently involved segment 1, 2
- Small bowel resection should be limited to preserve bowel length 5
- Primary anastomosis versus stoma creation depends on patient stability, nutritional status, and degree of contamination 2
Decision Algorithm for Anastomosis vs Stoma
Create a diverting ileostomy rather than primary anastomosis in: 4, 2
- Hemodynamically unstable patients
- Multiple perforations with significant contamination
- Malnourished patients
- Patients on prolonged steroid therapy
- Significant peritoneal contamination
Primary repair with diversion ileostomy is preferred over simple closure in perforation cases 4
Laparostomy may be considered when resection and anastomosis are too risky 3
Critical Pitfalls to Avoid
Delayed Surgical Intervention
- Delaying surgery in patients with prolonged symptoms despite anti-tuberculous therapy increases mortality from perforation 3
- Four deaths in one series resulted from delayed intervention in septic shock from perforation 1
- Patients with subacute obstruction symptoms should be monitored closely and surgery considered early to prevent perforation 3
Excessive Bowel Manipulation
- Excessive intraoperative manipulation may produce unexpected bowel lesions, increasing morbidity 5
- Resection should be limited to complicated cases to preserve small bowel length 5
Stoma-Related Complications
- Post-operative intra-abdominal collections (p=0.02) and incision dehiscence (p=0.05) are more common with stoma creation 2
- High-output ileostomy occurs in approximately 10-15% of cases 4
Predictors of Poor Outcome
Factors associated with increased complications and mortality include: 3
- Advanced age
- Multiple comorbidities
- Multiple perforations
- Prolonged time between symptom onset and surgical intervention
- Hemodynamic instability at presentation
Post-Operative Management
- All surgically managed patients should receive a full 6-month course of anti-tuberculous therapy unless organisms are resistant to first-line drugs 1
- Mean post-operative length of stay is approximately 7 days in uncomplicated cases 1
- Overall morbidity ranges from 5-15% and mortality from 3-17% depending on indication and patient factors 1, 3