Journal of Pediatric Surgery 54 (2019) 718–722

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Gangrenous appendicitis: No longer complicated☆,☆☆

Andrew B Nordin a,b, Karen Diefenbach a,c, Stephen P Sales a, Jeff Christensen a,
Gail E Besner a,c, Brian D Kenney a,c,⁎
a
Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205
b
State University of New York University at Buffalo, Department of General Surgery, 100 High St, Buffalo, NY 14203
c
The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210

a r t i c l e i n f o a b s t r a c t

Article history: Background: Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies
Received 12 February 2018 suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hy-
Received in revised form 10 October 2018 pothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of
Accepted 21 October 2018 stay (LOS) and antibiotic usage without increasing postoperative infections.
Methods: In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal
Key words:
fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and
Gangrenous appendicitis
Complex appendicitis
reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months
Perforation after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS,
presence of a postoperative infection, and 30-day readmissions.
Results: Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2.
Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p b 0.001) and antibiotic doses
decreased from 5.2 to 1.3 (p b 0.001). Only one gangrenous appendicitis patient required readmission, and one
patient in each group developed a superficial infection; there were no postoperative abscesses.
Conclusions: Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postopera-
tive infections or readmissions.
Type of study: Prognosis study.
Level of evidence: Level II.
© 2018 Elsevier Inc. All rights reserved.

1.1. Problem description and background
Appendicitis is the most common indication for urgent abdominal
surgery in the pediatric population, and its lifetime incidence is approx-
imately 9% [1,2]. Although the disease progresses along a continuum
ranging from simple inflammation to frank perforation, it is often cate-
gorized as either simple or complex, representing the extremes of this
spectrum. Gangrenous appendicitis lies somewhere in the middle, but
is often grouped with and managed as complex perforated appendicitis
[3,4]. Despite this common practice, some studies suggest that gangre-
nous appendicitis confers a lower risk of postoperative infection, ap-
proaching that of simple appendicitis [5,6].
1.2. Rationale and specific aims

☆ Disclosures: The authors report no proprietary or commercial interest in any product
mentioned or concept discussed in this article.
☆☆ Funding: This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
⁎ Corresponding author at: Nationwide Children's Hospital, Department of Pediatric
Surgery, 700 Children's Drive, Columbus, OH, 43205. Tel.: +1 614 722 3439.
E-mail addresses: abnordin@buffalo.edu (A.B. Nordin),
Karen.Diefenbach@nationwidechildrens.org (K. Diefenbach),
Stephen.Sales@nationwidechildrens.org (S.P. Sales),
Jeff.Christensen@nationwidechildrens.org (J. Christensen),
Gail.Besner@nationwidechildrens.org (G.E. Besner),
Brian.Kenney@nationwidechildrens.org Brian.Kenney@nationwidechilrens.org
(B.D. Kenney).
In our institution, appendicitis is classified as either simple or com-
plex based on intraoperative findings, and this classification determines
postoperative management. Given that gangrenous appendicitis may
represent less severe disease than perforated appendicitis, we devel-
oped a strict definition of complex appendicitis, which included moving
gangrenous appendicitis to the simple postoperative pathway [5–7].
Using a quality improvement (QI) framework, we sought to reduce in-
patient length of stay and antibiotic utilization for patients with gangre-
nous appendicitis, and hypothesized that treating these patients
according to the simple pathway would accomplish these goals without
adversely increasing postoperative abscess rates or readmissions.

https://doi.org/10.1016/j.jpedsurg.2018.10.064
0022-3468/© 2018 Elsevier Inc. All rights reserved.
 A.B. Nordin et al. / Journal of Pediatric Surgery 54 (2019) 718–722
2. Methods
2.1. Context
Our target population consisted of all patients less than 18 years of
age undergoing laparoscopic appendectomy at a free-standing, tertiary
care pediatric hospital over a 2-year period from February 2015 to Jan-
uary 2017. Appendicitis was diagnosed based on history, physical exam-
ination, and preoperative imaging; in our institution, ultrasound is
performed as a first-line imaging modality. Initial workup begins in
the emergency department (ED), with surgical consultation and labora-
tory testing obtained for positive and equivocal cases. Patients treated
nonoperatively with antibiotics and percutaneous abscess drainage
(b5% of patients) were excluded, as were those undergoing interval ap-
pendectomy. Additionally, we excluded patients with early acute ap-
pendicitis who elected for treatment with antibiotics alone as part of
an ongoing multicenter trial, since these patients did not undergo sur-
gery; this highly select group represents a minority of all appendicitis
patients. Data points were collected in a prospective, ongoing fashion
and included age, sex, body mass index (BMI), appendicitis classifica-
tion, overall and postoperative length of stay (LOS), the development
of a surgical site infection (SSI) or postoperative abscess, and 30-day
readmissions. SSIs were identified and defined according to National
Surgical Quality Improvement Program (NSQIP) criteria, and postoper-
ative abscesses were identified based on imaging studies obtained at
the discretion of the treating provider.
Appendicitis was classified by the operating surgeon as either simple
or complex based on intraoperative findings. Patients with simple ap-
pendicitis receive no additional postoperative antibiotics and are typi-
cally discharged within 24 h, whereas those with complex
appendicitis continue to receive intravenous antibiotics and are only
discharged once their fevers and ileus resolve. Based on review of the
literature and discussion with our infectious disease service, we modi-
fied our antibiotic regimen in 10/2015 such that all patients receive
the same preoperative antibiotics: ceftriaxone and metronidazole [8].
Complex appendicitis patients may continue oral antibiotics on dis-
charge based on the presence of persistent postoperative leukocytosis;
further details are presented in Table 1.
2.2. Interventions
To standardize reporting, we created an operative note template
within the electronic medical record, wherein surgeons selected various
descriptors of their findings (Table 1). Although surgeons could elect to
provide further detail, these specific categories were used to guide
Table 1
Appendicitis classification and management.
Descriptors Pathway Management
Simple Appendicitis
Erythema/Inflammation Discharge when:
Inflammatory Fluid Tolerating clear liquids
No Inflammation Afebrile
Gangrenous (added Pain adequately controlled
2/2016)
Complex Appendicitis
Extraluminal
Appendicolith Discharge when:
Visualized Hole in Tolerating regular diet (N50% of 3 consecutive
Appendix meals)
Well-formed Abscess
Diffuse Pus Afebrile
Gangrenous (removed Pain adequately controlled
2/2016)
CBC within 24 h of discharge
If WBC N12, oral antibiotics to complete 10 day
total course
719
selection of the appropriate postoperative pathway. The postoperative
pathway was determined using only intraoperative findings; thus, pa-
tients do not transition from one pathway to another based on their
postoperative course.
Using these templates, patients with gangrenous appendicitis were
identified as those with appendiceal gangrene – defined as any black
or gray discoloration of the appendiceal wall – but without characteris-
tics which would otherwise categorize them as complex. In 2/2016, we
strictly defined complex appendicitis as the presence of one or more of
the following: a visualized hole in the appendix, diffuse pus outside the
pelvis, an extraluminal fecalith or a well-formed abscess. Gangrenous
appendicitis, which was previously managed as complex appendicitis,
was simultaneously shifted to the simple pathway. Compliance with
these interventions was monitored, and surgeons were regularly up-
dated on compliance rates and educated on the importance of these
process measures. Although we standardized appendicitis classification
and postoperative management, specific surgical equipment and opera-
tive techniques were left to the operating surgeon's discretion.
2.3. Data collection and analysis
We analyzed and compared demographics and outcomes between
patients with gangrenous appendicitis undergoing appendectomy dur-
ing 12-month periods before (2/2015–1/2016; Group 1) and after (2/
2016–1/2017; Group 2) this protocol change. Data collection was pro-
spective and ongoing throughout this time period. The overall simple
and complex appendicitis groups were also analyzed as balancing mea-
sures. Continuous variables were analyzed using Student's t-test and di-
chotomous variables were analyzed with chi-square analysis or Fisher's
exact test to a significance level of p b 0.05. 95% Confidence intervals
(CIs) were also calculated for outcome variables. LOS and postoperative
abscess rates were further analyzed over time using process control
charts. For our control charts, process means and shifts were established
based on a minimum of 8 consecutive values. Control limits were
established at 3 standard deviations from the process mean, and varia-
tion within these limits was considered acceptable, or common-cause,
variation [9]. Shifts in the process mean were evaluated for statistical
significance using Student's t-test. This project was performed as part
of a comprehensive QI initiative to improve appendicitis care in our in-
stitution, was reviewed by our IRB, and was determined to represent QI
work exempt from full IRB review.
3. Results
During this 24-month period, a total of 1007 laparoscopic appendec-
tomies were performed. Of the 497 patients in Group 1, 63.98% were
classified as simple appendicitis and 36.02% as complex; this group
contained 35 patients with gangrenous appendicitis. By comparison,
72.35% of the patients in Group 2 had simple appendicitis and 27.65%
had complex appendicitis. In this group, 34 patients had gangrenous ap-
pendicitis. Demographic information for both groups is summarized in
Table 2, and, with the exception of BMI, there were no significant differ-
ences between the two groups overall. In the complex appendicitis sub-
group, patients in Group 2 had higher BMI and were more likely to be
female.
Among patients with gangrenous appendicitis, average hospital LOS
decreased from 2.46 days to 1.35 days (Fig. 1; Table 3; p b 0.001). Our
interventions also decreased overall LOS among the entire population
of appendicitis patients as demonstrated chronologically with control
chart methodology (Fig. 2), although this decrease was not statistically
significant when analyzed with Student's t-test (Table 4). Average LOS
for both simple (0.96 days versus 0.95 days) and complex (5.08 days
versus 5.36 days) appendicitis was unaffected by our protocol change
(Table 4). When postoperative LOS was analyzed, similar trends were
found. Of the 34 patients in Group 2 with gangrenous appendicitis, 25
(73.5%) were managed according to the simple pathway, and the
720 A.B. Nordin et al. / Journal of Pediatric Surgery 54 (2019) 718–722

Table 2 Table 3
Demographics. Gangrenous appendicitis outcome measures.

Group 1 Group 2 p value Group 1 Group 2 p value

(n = 35) (n = 34)
Simple appendicitis 318 (63.98%) 369 (72.35%)
0.004
Complex appendicitis 179 (36.02%) 141 (27.65%) Hospital LOS (days) 2.46 (0.8) 1.35 (1.2) b0.001
Mean age (years) 11.52 (3.6) 11.64 (3.5) 0.66 Postoperative LOS (days) 2.14 (0.8) 0.97 (1.2) b0.001
Simple 12.08 (3.3) 12.03 (3.3) 0.84 Antibiotic doses 5.23 (3.0) 1.26 (2.3) b0.001
Complex 10.53 (3.9) 10.59 (3.9) 0.89 Readmissions 0% (0) 2.9% (1) NS
Gangrenous 11.86 (3.8) 11.24 (3.2) 0.47
Sex (% male) 62.58% 60.78% 0.56
Simple 58.18% 62.33% 0.27
Complex 70.39% 56.74% 0.01 appendicitis patients decreased, but not to a statistically significant de-
Gangrenous 80.00% 41.18% 0.001 gree (Table 4; p = 0.17).
Mean BMI 20.13 (5.0) 21.17 (6.6) 0.003
Finally, to ensure that our protocol change did not adversely affect
Simple 20.47 (4.9) 21.24 (6.4) 0.08
Complex 19.57 (5.1) 21.00 (6.7) 0.03 postoperative infections, we analyzed postoperative abscess rates. In
Gangrenous 22.39 (5.6) 21.24 (5.4) 0.39 patients with gangrenous appendicitis, there were no postoperative ab-
scesses, but one patient each in Group 1 and Group 2 developed a super-
ficial SSI at the umbilical port site. There were three patients with simple
remaining 9 (26.5%) were treated as complex. LOS for gangrenous ap- appendicitis who developed postoperative abscesses over this 24-
pendicitis patients was significantly longer than for simple appendicitis month period; two occurred before our protocol change and one after-
patients following our interventions (1.35 days versus 0.95 days; p = wards. The overall postoperative abscess rate among simple appendici-
0.02), but this difference disappeared when only compliant cases were tis patients was 0.4%. Complex appendicitis patients had an abscess rate
analyzed (p = 0.11). of 12.0%, and this rate remained similarly constant.
Antibiotic usage significantly decreased among gangrenous appen-
dicitis patients following our classification change. In Group 1, patients 4. Discussion
received an average of 5.2 postoperative intravenous antibiotic doses,
whereas in Group 2, this decreased to 1.3 doses (Table 3; p b 0.001). The care of children with appendicitis has undergone a significant
For gangrenous appendicitis patients treated according to the complex evolution over the past two decades. Despite initial concerns for increased
pathway, 2 patients in Group 1 and 1 patient in Group 2 received oral risk of intraabdominal abscess formation in cases of perforated appendici-
antibiotics on discharge (p = 0.62). tis, most appendectomies are safely performed laparoscopically [10,11].
In our postintervention group, only one patient with gangrenous ap- Furthermore, multiple recent studies suggest that acute uncomplicated
pendicitis required readmission after presenting with nausea, vomiting, appendicitis can be successfully managed nonoperatively with antibiotics
and persistent abdominal pain. This patient was determined not to have alone [1]. Here, we have presented evidence from our institutional QI pro-
a postoperative abscess or SSI. Overall readmission rates were not sig- ject to suggest that gangrenous appendicitis can be successfully managed
nificantly different between the two groups (Table 4; p = 0.80). There according to a simple appendicitis pathway — i.e. without postoperative
were more readmissions in Group 2 for simple appendicitis patients, antibiotics.
which approached, but did not reach, statistical significance (p = As the management of appendicitis continues to evolve, it is crucial
0.06). Reasons for readmission in this population included postopera- to develop and apply standardized definitions of simple and complex
tive pain (n = 3), early adhesive small bowel obstruction (n = 2), appendicitis to allow providers to initiate appropriate treatment. A
prolonged postoperative ileus (n = 1), and continued weight loss in 2008 study strictly defined perforated appendicitis as a visualized hole
the context of a preexisting eating disorder (n = 1). One patient had in the appendix or the presence of an extraluminal fecalith, and found
fluid collections which were treated with antibiotics and percutaneous that this more stringent definition accurately identified patients at the
aspiration; fluid cultures were negative. Readmission rates for complex highest risk of developing postoperative abscesses [7]. They reported

Fig. 1. Average LOS for gangrenous appendicitis. Control limits are set at 3 standard deviations from the process mean, and process means are established based on a minimum of 8
consecutive values. As demonstrated in Table 4, this shift in process mean is highly statistically significant (p b 0.001).
 A.B. Nordin et al. / Journal of Pediatric Surgery 54 (2019) 718–722 721

Fig. 2. Average LOS for appendicitis, all patients. Control limits are set at 3 standard deviations from the process mean, with means established based on a minimum of 8 consecutive values.
This control chart demonstrates a decrease in average LOS corresponding to our change in gangrenous appendicitis management, although the decrease was not significant by t-testing.

decreased abscess rates in simple appendicitis from 1.7% to 0.8% and studies show that gangrenous appendicitis patients can be successfully
increased perforated appendicitis abscess rates from 14% to 18% [7]. treated with shorter courses of antibiotics than the general population
Despite subsequent validation of these results using a national database, of complicated appendicitis patients, reducing LOS without increases
this categorization of perforated appendicitis remains inconsistently ap- in postoperative infections or readmissions [6,12]. In our algorithm, pa-
plied [2]. Explicitly defining groups of appendicitis patients allows tients with gangrenous appendicitis are managed equivalently to those
surgeons to more objectively categorize their intraoperative findings, with simple appendicitis, meaning that only preoperative antibiotics are
which are crucial in determining postoperative management [4]. Our administered. Even without postoperative antibiotics, we observed no
institution incorporated the definition of perforated appendicitis set difference in the development of abscesses or SSIs in this patient
forth by St. Peter et al. into our categorization of complex appendicitis group. Removing the requirement for postoperative antibiotics in this
by including the findings of well-formed abscess and diffuse purulence patient population meant that the majority were discharged on the
throughout the abdominal cavity. These intraoperative findings were first postoperative day, similar to patients with acute uncomplicated
thought to suggest appendiceal perforation, and potentially predict a appendicitis.
complicated postoperative course with a high potential for abscess Logically, shifting gangrenous appendicitis to a simple pathway
formation. Moving gangrenous appendicitis from the complex to the should increase the severity of illness in both the simple and complex
simple pathway did not change our abscess rates among simple or com- appendicitis groups. The former group now includes patients with
plex appendicitis patients, which supports the claim that gangrenous more advanced disease, whereas the latter contains those with the
cases have minimal risk of postoperative abscess formation. The influ- most severe illness and the highest risk of postoperative infection. De-
ence of our broadened definitions for complex appendicitis on abscess spite this change, we observed no increase in LOS or postoperative ab-
rates remains unclear, as we did not examine the impact of each individ- scess rates in either the simple or complex groups. In fact, the overall
ual component. It may be the case that further modification of our com- LOS decreased, as visualized in our control chart. Despite the decrease
plex appendicitis definition will continue to improve care by depicted in the control chart, this did not reach statistical significance
transitioning more patients to the simple pathway. This would require by t-testing; we believe that continued data collection, coupled with ad-
further study, to which our QI approach lends itself well. ditional interventions and improved compliance, will result in greater
Regardless of how complex or perforated appendicitis is defined, in- decreases in average LOS for all appendicitis patients. Furthermore,
terinstitutional rates vary widely. Our proportion of complex appendici- there were no significant differences in readmission rates between
tis cases decreased from 36.0% to 27.7%; in the literature, reported rates Group 1 and Group 2 for either simple or complex appendicitis. Admit-
range from 27% to 51% [2,3]. In most reports, gangrenous appendicitis is tedly, the number of simple appendicitis patients requiring readmission
grouped with perforated appendicitis and considered complicated. did increase, but this was neither statistically significant nor owing to
However, when analyzed separately, patients with gangrenous appen- increased readmissions for gangrenous appendicitis patients. Only one
dicitis have been found to have lower rates of postoperative abscess for- of these patients had gangrenous appendicitis, and the other eight had
mation, similar to those of simple acute appendicitis [5]. Additionally, simple acute appendicitis. The majority of these patients were
readmitted with postoperative pain, which may be related to a concur-
Table 4 rent QI initiative to modify and standardize our postappendicitis pain
All appendicitis outcome measures. control regimen. Despite the potential influences of simultaneous QI
Group 1 Group 2 p value projects, our results validate the feasibility of treating gangrenous ap-
pendicitis as simple appendicitis, the importance of developing and ad-
2.44 (3.0) 2.17 (2.9)
Hospital LOS (days)
[2.18, 2.70] [1.92, 2.42]
0.15 hering to a strict definition for complex appendicitis, and the value in
Simple 0.96 (0.7) 0.95 (0.9) 0.87 continually monitoring outcomes and compliance with the goal of im-
Complex 5.08 (3.6) 5.36 (3.8) 0.50 proving healthcare quality.
1.98 (2.8) 1.73 (2.9) Ensuring compliance with interventions represents an inherent
Postoperative LOS (days) 0.16
[1.73, 2.23] [1.48, 1.98]
challenge in successfully implementing QI initiatives. In our project,
Simple 0.54 (0.7) 0.51 (0.9) 0.32
Complex 4.54 (3.2) 4.91 (3.8) 0.17 fewer than 75% of patients with gangrenous appendicitis were treated
3.6% (18) 3.3% (17) according to the simple pathway. A preliminary read of the data may
Readmissions 0.80
[0.02, 0.05] [0.02, 0.05] suggest that, owing to a longer average LOS relative to simple appendi-
Simple 0.6% (2) 2.4% (9) 0.06 citis, gangrenous appendicitis should be managed as a separate sub-
Complex 8.9% (16) 5.0% (7) 0.17
group. However, our analysis of compliant cases suggests that
722 A.B. Nordin et al. / Journal of Pediatric Surgery 54 (2019) 718–722
differences in LOS are the result of noncompliance rather than a differ-
ence in pathophysiology. Our marginal compliance rates could be be-
cause of a lack of knowledge or confidence in the protocol change, or
there may have been other signs of complex appendicitis which were
not recorded in the operative template. The latter appears less likely,
however, since we observed no differences in postoperative infection
rates, need for antibiotics on discharge, or readmissions among gangre-
nous appendicitis patients as a whole. It therefore seems most likely
that additional ongoing interventions, in the form of education and up-
dates on our outcomes with both attending surgeons and surgical
trainees, may improve our compliance. In accordance with QI practices,
we will continue to track compliance to determine whether these inter-
ventions are successful or whether further work is required. We antici-
pate that as compliance improves, the benefits of treating gangrenous
appendicitis along a simple postoperative pathway will become increas-
ingly apparent.
Although our results are important in caring for children with ap-
pendicitis and will hopefully change the management of gangrenous
appendicitis, they do have several limitations. This work represents pa-
tients from a single institution, and our patient population and appendi-
citis management may not be generalizable to other facilities. However,
we believe that our QI approach to changing postoperative manage-
ment practices for appendicitis patients can be applied in other institu-
tions to improve patient care. We did not attempt to standardize
intraoperative technique, which introduces variability into our results,
but may simultaneously make our project more generalizable to various
operative strategies. Our focus with these interventions was on improv-
ing postoperative care, and standardizing our intraoperative tools and
techniques may offer an opportunity for further improvements in care
and cost reduction. Since this project was designed as a portion of a
comprehensive quality initiative to improve care for children with ap-
pendicitis, there are many confounding factors which may have im-
pacted our results. Potential confounders include our change in
antibiotic regimen to ceftriaxone and metronidazole, and the addition
of two new attending surgeons. Both of these changes occurred during
the Group 1 time period, and both surgeons had recently completed
either fellowship or subspecialty training at our facility; we therefore
expect that these changes would have had negligible effects on our
results. Furthermore, we also performed interventions to decrease the
number of narcotics prescribed at discharge during this time period,
which could conceivably have affected our readmission rates. Addition-
ally, our gangrenous appendicitis group was small in size, which may
have contributed to a type II error. Finally, we cannot account for
patients who sought care for postoperative complications outside of
our hospital system, which may have falsely decreased our postopera-
tive infection and readmission rates. However, given that our institution
represents the primary location for pediatric surgical services in the re-
gion, the potential number of patients seeking care elsewhere for their
postoperative complications should be negligible at best.
5. Conclusions
In conclusion, we suggest that children with gangrenous appendici-
tis can be treated without postoperative antibiotics, identically to
patients with simple acute appendicitis. This shift in appendicitis man-
agement can reduce inpatient LOS and antibiotic usage, with minimal
risks of increasing postoperative infections or readmissions. Our results
further demonstrate that effectively implementing management
changes requires ongoing education, communication, and monitoring
for the potential need for additional interventions. In this spirit, contin-
ued data collection and analysis of our own results may further
strengthen our conclusions, and multicenter study is warranted to
determine their generalizability.
References
[1] Rollins KE, Varadhan KK, Neal KR, et al. Antibiotics versus appendicectomy for the
treatment of uncomplicated acute appendicitis: an updated meta-analysis of
randomised controlled trials. World J Surg 2016;40(10):2305–18.
[2] Rogers AP, Zens TJ, Leys CM, et al. A call for a standardized definition of perforated
appendicitis. J Pediatr Surg 2017;52(1):89–92.
[3] Gorter RR, van den Boom AL, Heij HA, et al. A scoring system to predict the severity
of appendicitis in children. J Surg Res 2016;200(2):452–9.
[4] Farach SM, Danielson PD, Walford NE, et al. Operative findings are a better predictor
of resource utilization in pediatric appendicitis. J Pediatr Surg 2015;50(9):1574–8.
[5] Emil S, Laberge JM, Mikhail P, et al. Appendicitis in children: a ten- year update of
therapeutic recommendations. J Pediatr Surg 2003;38(2):236–42.
[6] Emil S, Gaied F, Lo A, et al. Gangrenous appendicitis in children: a prospective eval-
uation of definition, bacteriology, histopathology, and outcomes. J Surg Res 2012;
177(1):123–6.
[7] St. Peter SD, Sharp SW, Holcomb III GW, et al. An evidence-based definition for per-
forated appendicitis derived from a prospective randomized trial. J Pediatr Surg
2008;43(12):2242–5.
[8] St. Peter SD, Tsao K, Spilde TL, et al. Single daily dosing ceftriaxone and metronida-
zole vs standard triple antibiotic regimen for perforated appendicitis in children: a
prospective randomized trial. J Pediatr Surg 2008;43(6):981–5.
[9] Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and
healthcare improvement. Qual Saf Health Care 2003;12(6):458–64.
[10] Krisher SL, Browne A, Dibbins A, et al. Intra-abdominal abscess after laparoscopic ap-
pendectomy for perforated appendicitis. Arch Surg 2001;136(4):438–41.
[11] Canty Sr TG, Collins D, Losasso B, et al. Laparoscopic appendectomy for simple and
perforated appendicitis in children: the procedure of choice? J Pediatr Surg 2000;
35(11):1582–5.
[12] Shbat L, Emil S, Elkady S, et al. Benefits of an abridged antibiotic protocol for the
treatment of gangrenous appendicitis. J Pediatr Surg 2014;49(2):1723–5.