Exploring Postoperative Outcomes of Primary Repair Versus Loop Ileostomy in Typhoid Ileal Perforation: A Systematic...

Typhoid ileal perforation, a severe complication of typhoid fever, often leads to peritonitis and high mortality, particularly in low-income countries. While conservative management was once standard, surgical interventions like primary repair and loop ileostomy have been preferred since the 1970s, though outcomes vary due to late presentations and resource constraints. This systematic review and meta-analysis, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, evaluates postoperative morbidity, mortality, and hospital stay for these techniques. A comprehensive search of PubMed, Google Scholar, Cochrane Library, and African Journals Online from database inception to May 2025 identified 2,157 articles. After removing 1,215 duplicates and excluding 851 articles during title and abstract screening, 91 articles were sought for retrieval. Full texts of 24 studies were unavailable. Thirty-eight articles were excluded after full-text screening of 67 studies, leaving 29 peer-reviewed studies comparing primary repair and ileostomy outcomes for typhoid ileal perforation. The analysis included 2,434 patients from five countries (Côte d'Ivoire, India, Nigeria, Pakistan, and Turkey, with India and Pakistan contributing the most). Of these, 1,315 underwent primary repair, and 1,119 had ileostomy. Study designs comprised comparative, randomized controlled, retrospective, prospective, observational, and quasi-experimental studies. Participants had a mean age of 28.04 years (SD=9.39), with a male predominance (62.9% male vs. 25.1% female). The meta-analysis of 23 studies showed that ileostomy is associated with an 18.4% higher postoperative complication rate compared to primary repair. For mortality, analysis of 22 studies indicated a 3.1% higher rate with ileostomy, though this difference was not significant, with variability suggesting influences beyond procedure type, such as patient condition and intraoperative findings. Hospital stay analysis from 12 studies revealed that ileostomy patients stayed approximately 1.8 days longer than those undergoing primary repair, with considerable variation likely due to complications, stoma management practices, and institutional discharge protocols. These findings highlight the need for individualized surgical decision-making based on intraoperative findings, patient physiology, and resource constraints, especially in low-resource settings where typhoid perforation is prevalent.