Division of Pediatric General Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
J Surg Res. 2012 Sep;177(1):123-6. doi: 10.1016/j.jss.2012.03.010. Epub 2012 Mar 30.
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.
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.
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.
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.
坏疽性阑尾炎的定义和治疗方法尚未达成共识。我们对儿童进行了一项前瞻性研究，以评估坏疽性阑尾炎的客观定义，以及相关的细菌学、组织病理学和结果。
如果满足以下五个标准，五名小儿外科医生在阑尾切除术中对符合条件的患者进行前瞻性研究：阑尾壁呈灰色或黑色变色；阑尾外无粪石；阑尾无可见穿孔；远离阑尾无明显脓性或纤维性渗出物；术中无阑尾漏。培养腹腔液，并进行标准组织病理学检查。每天记录发热（>37.5°C）和肠梗阻的持续时间。术后患者继续使用氨苄西林、庆大霉素和甲硝唑，直到能够耐受饮食、出现 24 小时无热期且白细胞计数正常。记录住院时间、再入院和感染并发症。研究在 12 个月内进行。
38 名患者入组，占当年阑尾炎治疗患者的 17%。平均年龄为 10.8 ± 3.5 岁。53%的病例腹膜培养阳性。61%的标本有组织学证实的坏疽。住院时间为 3.2 ± 1.1 天。无术后感染并发症或与疾病相关的再入院。培养结果或组织学坏疽对住院时间均无统计学显著影响。
坏疽性阑尾炎的客观定义是可重复的，与良好的组织病理学相关。坏疽性阑尾炎的恢复不受培养或病理结果的影响，术后并发症罕见。在坏疽性阑尾炎中，将术后抗生素限制使用 24 小时可能会显著降低治疗成本，而不会增加发病率。
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