title: Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes.
abstract: BACKGROUND
  The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes.
  
  
  METHODS
  Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period.
  
  
  RESULTS
  Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay.
  
  
  CONCLUSIONS
  An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.
authors.affiliation: Division of Pediatric General Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada. Sherif.Emil@mcgill.ca
authors.forename: Sherif
authors.initials: S
authors.lastname: Emil
authors.forename: Fady
authors.initials: F
authors.lastname: Gaied
authors.forename: Andrea
authors.initials: A
authors.lastname: Lo
authors.forename: Jean-Martin
authors.initials: JM
authors.lastname: Laberge
authors.forename: Pramod
authors.initials: P
authors.lastname: Puligandla
authors.forename: Kenneth
authors.initials: K
authors.lastname: Shaw
authors.forename: Robert
authors.initials: R
authors.lastname: Baird
authors.forename: Chantal
authors.initials: C
authors.lastname: Bernard
authors.forename: Miriam
authors.initials: M
authors.lastname: Blumenkrantz
authors.forename: Van-Hung
authors.initials: VH
authors.lastname: Nguyen
mesh_terms: D000293:Adolescent; D001064:Appendicitis / Q000191:economics / Q000473:pathology / Q000628:therapy*; D001065:Appendix / Q000473:pathology; D002648:Child; D005260:Female; D005734:Gangrene / Q000191:economics / Q000628:therapy; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011446:Prospective Studies; D016896:Treatment Outcome