Clinical outcomes of perianal necrotizing fasciitis treated by skin classification : A retrospective single center study

Clinical outcomes of perianal necrotizing fasciitis treated by skin classification : A retrospective single center study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical outcomes of perianal necrotizing fasciitis treated by skin classification : A retrospective single center study Hexue Yuan, Xue Fang, Chunlai Pan, Lei He, Zongjian Liu, Liang Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7887573/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background The extent of debridement in perianal necrotizing fasciitis (PNF) has not been standardized, although skin-preserving debridement is increasingly used clinically. Methods The present study retrospectively analyzed the clinical data of 102 patients with PNF treated between December 2022 and February 2025 at Shenyang Coloproctology Hospital. The skin changes associated with PNF were classified into zones. All treatment effects were observed. Results A total of 102 patients underwent debridement for PNF. Of these, 61 patients had the surgical debridement range determined based on skin zoning (SZ), while 41 patients had the surgical debridement range determined based on non-skin zoning (NSZ). There was no significant difference in the cure rate between the two groups. The length of hospital stay for patients in the SZ group was 17 days (15.00–23.00 days), while that for patients in the NSZ group was 19 days (15.00–30.50 days) (17 vs. 19, P = 0.037). Meanwhile, the length of hospital stay was associated with LRINEC score (P = 0.034). Among the SZ group patients, 57 cases required one surgery for cure, and 3 cases required two or more surgeries for cure, while, among the NSZ group patients, 13 cases were cured with one surgery, and 28 cases required two or more surgeries for cure (13/28 vs. 57/3, P <0.001). Conclusions Determining the extent of surgical debridement based on the zoning of skin changes in PNF can reduce hospitalization time and the number of surgeries, making it an effective approach for treating PNF. Early diagnosis Necrotizing fasciitis Classification of the skin Sepsis Systemic inflammatory response syndrome Figures Figure 1 Figure 2 1. Introduction Necrotizing fasciitis is a rapidly progressing infection involving the superficial and deep fascia, often presenting with sudden onset and rapid spread. In severe cases, it can lead to multi-organ dysfunction, septic shock, and death. Due to the unique anatomical structure of the anorectum, the perianal region and perineum are common sites of origin. The mortality rate of PNF has been reported to range from 15% to 40%[ 5 ], although a recent meta-analysis found a lower average mortality rate of 7.3%[ 3 ]. Because PNF progresses rapidly, early diagnosis, prompt surgical debridement, appropriate determination of the extent of initial debridement, and careful postoperative care are critical factors for achieving clinical cure. Nonetheless, previous studies have lacked detailed descriptions of how to determine the extent of surgical debridement, and there is no established methodology to date. Moreover, due to its rarity, most surgeons may encounter only a few cases during their careers. To that end, we retrospectively analyzed the clinical outcomes of 102 patients with PNF and proposed a surgical strategy based on skin demarcation zones. The extent of debridement was guided by these zones, aiming to reduce the need for repeated surgeries due to disease progression and to inform therapeutic decision-making. Taken together, our proposed strategy might serve as a useful reference for the clinical management of PNF. 2. Methods 2.1. Patients The clinical data of 102 patients with perianal abscess complicated by necrotizing fasciitis, diagnosed and treated at Shenyang Coloproctology Hospital between January 2018 and December 2024, were retrospectively analyzed. Final diagnoses were made in accordance with the International Classification of Diseases, Tenth Revision (ICD-10), based on clinical features, laboratory tests, and intraoperative and pathological findings. All patients received aggressive surgical debridement and broad-spectrum antibiotic therapy. The treating physicians were from the same institution and had received standardized training. Exclusion criteria included non-infectious conditions such as gas gangrene. The study was approved by the Ethics Committee of Shenyang Anorectal Hospital and conducted in accordance with the principles of the Declaration of Helsinki (SGCYY202508140002). Written informed consent was obtained from all patients. Only one patient with septic shock was transferred to the intensive care unit for three days. Once his condition stabilized, he was transferred back to the general ward to continue treatment. 2.2. Treatment Protocol 102 patients with PNF underwent debridement surgery within 8 hours. Among them, 61 patients had the surgical debridement range determined based on SZ, while 41 patients had the surgical debridement range determined based on NSZ. All others treatment modalities were identical for all patients. Skin zone classification method: Based on the progressive skin changes in PNF patients, we categorized the infected tissue into zones as follows: zone 1 consists of necrotic skin at the center of the infection; zone 2 consists of swollen, erythematous, and painful tissue with pressure sensitivity adjacent to zone 1; zone 3 is edematous and may show finger indentations; and zone 4 consists of soft, healthy, uninfected tissue (Fig. 1 ). Surgical approach: The SZ group surgical approach used was as follows: After administering sacral or epidural anesthesia, the necrotic tissue and skin in zone 1 were excised. Zones 2 and 3 were surgically debrided via multiple small incisions, and a loose-elastic seton suture (elastic rubber band) was placed between each pair of drainage incisions (Fig. 2 ). Additional silicone tubing was inserted for irrigation and drainage if the abscess cavity was deep. However, the extent of surgical debridement in the NSZ group was not determined based on skin zoning. After debridement, the wound was flushed with hydrogen peroxide and metronidazole, and antibiotics were administered to control the infection. Rehydration therapy was provided based on the patient's condition. Initially, broad-spectrum antibiotics were used, and once the pathogens were identified, specific antibiotics were administered. The wound was flushed with hydrogen peroxide and metronidazole one to two times daily until healthy granulation tissue appeared at the incision site. 2.3. Data Collection Complete medical records were available for all patients, documenting sex, age, clinical manifestations of infection, and laboratory findings. Sepsis severity at admission was categorized as sepsis, severe sepsis, or septic shock, according to Bone et al.[ 1 ] Laboratory parameters included the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC)[ 15 ], which comprises total white blood cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein, as well as the Sequential Organ Failure Score (SOFA)[ 20 ] and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which includes the oxygenation index, platelets, bilirubin, and mean arterial pressure. Additional data collected included tissue specimens, pathogenic bacteria in blood, urine, and feces, histological evidence of fascial involvement, number and type of comorbidities, timing of the first debridement (hours), number of surgical debridement, type and number of antibiotics used, length of intensive care unit (ICU) stay, duration of hospitalization (days), and any complications. 2.4. Statistical Analysis Statistical analyses were conducted using IBM SPSS Statistics version 27.0. The t-test or U test was applied for measurement data, while the χ² test or Fisher's exact test was used for categorical data. Spearman rank correlation was used to test the correlation between length of hospital stay and various factors. For quantitative variables, descriptive statistics are presented as means and standard deviations. A P value of < 0.05 was considered statistically significant for all analyses. 3. Results A total of 102 patients with PNF were treated at Shenyang Anorectal Hospital. Of these, 61 patients underwent debridement surgery based on skin classification, while 41 patients underwent debridement surgery without skin classification. One patient in the NSZ group died, and one patient in the SZ group was transferred to another hospital for treatment and lost follow-up information. No significant difference in the cure rate was observed between the two groups. Baseline data, including sex, age, diabetes, hypertension, and coronary heart disease, were comparable between the two groups ( P > 0.05) (Table 1 ). The preoperative evaluation indexes of the two groups, including leukocytes, hemoglobin, platelets, C-reactive protein (CRP), sodium, potassium, glucose, creatinine, procalcitonin, bilirubin, mean arterial pressure (MAP), oxygen index and LRINEC score, also did not differ significantly between the groups ( P > 0.05) (Table 2 ). Moreover, the postoperative evaluation indexes of the two groups, including ICU custody time, Hospitalization time, Number of surgeries, Septic shock, SOFA score and APACHE II score in both groups were compared (Table 3 ). Eight patients developed septic shock, with five in the SZ group and three in the NSZ group, with no significant difference between the two groups ( P > 0.05) (Table 3 ). There was no statistically significant difference between the two groups in terms of APACHE II scores and SOFA scores ( P > 0.05) (Table 3 ). The length of hospital stay for patients in the SZ group was 17 days (15.00–23.00 days), while that for patients in the NSZ group was 19 days (15.00–30.50 days). The difference in hospital stay between the two groups was statistically significant ( P = 0.045) (Table 3 ). Among the SZ group patients, 57 cases required one surgery for cure, and 3 cases required two or more surgeries for cure; among the NSZ group patients, 13 cases were cured with one surgery, and 28 cases required two or more surgeries for cure. The difference in the number of surgeries between the two groups was statistically significant ( P 0.05) (Table 4 ). Table 5 shows that length of hospital stay is associated with LRINEC score ( P 0.05). Statistical results show that the hospitalization time and number of surgeries for cases in the SZ group were significantly lower than those in the NSZ group. Hospitalization time was correlated with LRINEC score, indicating its association with PNF severity. Table 1 The baseline data of the two groups were compared Variable NSZ (41 cases) SZ (61 cases) U /χ 2 P Age 48(36.5–62) 44(35.5–60) 1120.00 0.373 Sex (Male/Female) 40/1 57/4 0.23 0.633 Diabetes (No/Yes) 35/6 53/8 0.05 0.827 Hypertension (No/Yes) 39/2 55/6 0.29 0.591 Coronary heart disease (No/Yes) 40/1 60/1 0.00 1.000 Table 2 The preoperative indexes of the two groups were compared Variable NSZ (41 cases) SZ (61 cases) U P Leukocyte 16.43(14.09–20.34) 18.53(13.36–24.19) 1158.00 0.528 Hemoglobin 140.00(133.00-151.00) 145.00(137.50–155.00) 1024.50 0.174 Platelets 271.00(195.00-361.50) 289.00(223.00-379.50) 1124.50 0.390 CRP 123.00(77.50-207.35) 134.20(88.06-187.65) 1240.00 0.943 Sodium 138.00(132.4–140.00) 138.00(136.00-140.00) 1116.00 0.356 Potassium 4.13(3.84–4.45) 4.17(3.83–4.40) 1203.00 0.746 Glucose 7.40(6.10–9.90) 7.00(5.49–14.14) 1121.00 0.787 Creatinine 77.00(57.00–93.00) 41.00(55.00–83.00) 1085.50 0.260 Procalcitonin 0.85(0.51–1.25) 1.01(0.74–1.31) 1072.50 0.306 Bilirubin 18.50(11.60–27.30) 17.90(10.96–22.05) 1195.50 0.371 MAP 93.30(85.00-103.80) 94.70(87.50–104.00) 1100.50 0.305 Oxygen index 390.00(376.50-430.50) 403.00(381.00-421.50) 1138.00 0.442 LRINEC score 3.00(1.00–6.00) 4.00(1.00–6.00) 1230.00 0.888 Table 3 The postoperative indexes were compared between the two groups Variable NSZ (41 cases) SZ (61 cases) U /χ 2 P ICU(Yes/No) 22/19 23/38 2.53 0.112 ICU custody time 2.00(0.00–5.00) 0.00(0.00–5.00) 1015.50 0.077 Hospitalization time 19.00(15.00-30.50) 17.00(15.00–23.00) 919.50 0.037 Number of surgeries(1 time/≥2 times) 13/28 57/3 45.87 <0.001 Septic shock(Yes/No) 3/37* 5/55 # 0.00 1.000 APACHE II score 5.00(1.00-10.50) 2.00(1.00-7.75) 1084.00 0.309 SOFA score 1.00(0.00–2.00) 1.00(0.00–2.00) 978.00 0.052 *One patient died of organ failure #One case was transferred to hospital due to myocardial infarction Table 4 The relationship between the number of operations and each factor Variable Surgery 1 time (70 cases) Number of surgeries ≥ 2 (31 cases) U /χ 2 P Age 44.00(35.75-60.00) 46.00(36.00–61.00) 1003.00 0.546 Sex (Male/Female) 67/3 30/1 0.00 1.000 Diabetes (No/Yes) 59/11 28/3 0.25 0.619 Hypertension (No/Yes) 66/4 27/4 0.70 0.404 Coronary heart disease (No/Yes) 70/0 29/2 1.88 0.170 Leukocyte 17.63(13.50-24.07) 17.36(13.93–21.61) 1037.00 0.724 Hemoglobin 145.5(136.25-153.25) 140.00(127.00-152.50) 894.50 0.242 Platelets 273.00(217.75-376.25) 289.00(212.00-364.00) 1071.50 0.921 CRP 128.35(88.18-187.55) 123.00(76.50-203.40) 1024.00 0.653 Sodium 138.00(135.75–140.00) 137.00(135.00-139.00) 885.50 0.140 Potassium 4.19(3.89–4.46) 4.00(3.80–4.35) 977.50 0.428 Glucose 7.17(5.50-13.69;) 7.40(5.93–9.80) 1041.50 0.749 Creatinine 74.00(55.00-86.25) 76.00(57.00–93.00) 947.00 0.414 Procalcitonin 1.00(0.72–1.30) 0.78(0.41–1.35) 879.00 0.198 Bilirubin 17.99(11.48–23.63) 17.90(11.30-25.81) 1081.50 0.979 MAP 94.85(89.58-103.65) 90.00(83.30-104.30) 863.00 0.102 Oxygen index 404.00(385.50–427.00) 379.00(365.00-422.00) 828.00 0.058 LRINEC score 3.50(1.00–6.00) 3.00(1.00–6.00) 1044.00 0.761 Table 5 The relationship between length of hospital stay and various factors (Spearman rank correlation) Variable Spearman's ρ (rho) P Age -0.05 0.641 Leukocyte 0.09 0.370 Hemoglobin -0.19 0.055 Platelets 0.10 0.299 CRP 0.16 0.106 Sodium <0.01 0.987 Potassium -0.18 0.071 Glucose -0.07 0.468 Creatinine 0.09 0.385 Procalcitonin -0.04 0.726 Bilirubin -0.10 0.304 MAP -0.14 0.157 Oxygen index -0.11 0.293 LRINEC score 0.21 0.034 SOFA score 0.02 0.877 4. Discussion Necrotizing fasciitis is a severe bacterial infection marked by systemic toxicity and rapidly progressing soft tissue inflammation and necrosis. PNF originating from the rectum and anal canal is associated with the worst prognosis[ 5 ]. In recent years, the cure rate for this condition has gradually improved due to a better understanding of its pathophysiology[ 3 , 5 ]. Currently, most experts agree that early recognition, aggressive surgical debridement, and appropriate antibiotic therapy are crucial for improving survival[ 6 , 11 ]. Early clinical recognition of necrotizing fasciitis is challenging, and the extent of surgical debridement remains non-standardized. This is because the spread of the infection along fascial planes often precedes cutaneous changes[ 17 ] and is clinically unremarkable in most patients. While most experts now consider extensive necrotic tissue debridement as the primary approach[ 2 , 10 ], many patients still require two or more debridement procedures[ 7 ], placing a significant physical, psychological, and economic burden on them. Herein, 102 patients with PNF were retrospectively analyzed and divided into zoned and non-zoned groups. The clinical data of the two groups were compared, revealing no significant difference in the cure rate. However, the zoned group had shorter hospitalization times and fewer surgeries compared to the non-zoned group. The length of hospital stay for SZ group cases was correlated with hemoglobin levels, which may be considered a false positive due to the small number of cases. Furthermore, there are currently no reports in domestic or overseas regarding the correlation between the length of hospital stay and hemoglobin levels in patients with necrotizing fasciitis. Early recognition, prompt surgery, and thorough initial debridement of PNF are critical for survival[ 7 ]. Delayed diagnosis and extended initial surgical debridement are linked to increased morbidity and mortality[ 8 , 14 ]. Notably, early surgical debridement of necrotic tissue (within 6–12 hours of admission) has significantly reduced mortality[ 4 , 10 ]. The above findings suggest that early diagnosis and immediate and thorough surgical debridement are essential in order to prevent the systemic effects of sepsis and even death. Early diagnosis of PNF is primarily based on clinical symptoms and signs, which often begin with pain and swelling around the anus. These symptoms can quickly spread to the buttocks, perineum, scrotum, lower abdomen, posterior back, and lower limbs. The skin in the affected area lacks fluctuation, but a twisting sensation is felt upon palpation, and finger indentation may be observed. Necrosis often occurs, accompanied by a foul odor and severe systemic infectious toxicity. In the later stages, sensation in the affected area decreases or disappears, and the patient may develop widespread sepsis, potentially leading to septic shock. The patient also presents with persistent high fever, elevated white blood cell count, hypotension, unresponsiveness or loss of consciousness, acidosis, and other systemic symptoms. Notably, swelling, pain, and erythema are common early clinical features of PNF. Particularly, the disproportionate pain relative to the physical signs is a key indicator that aids in early diagnosis[ 7 ]. Nevertheless, the early signs and symptoms of PNF can be misleading, with skin marks often not matching the location of the necrotic fascia[ 8 ]. While the diagnosis of PNF typically relies on clinical signs and symptoms, imaging can be valuable when the diagnosis is unclear or the clinical presentation is ambiguous[ 16 ]. Imaging techniques used for the initial evaluation of PNF include radiography, ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI)[ 16 ]. Ultrasound is particularly effective for diagnosing PNF, especially in cases with negative CT and MRI results[ 12 ]. In addition, a triple diagnostic approach, combining incisional biopsy with visual, histologic, and microbiologic findings, can help promptly identify necrotizing fasciitis[ 8 ]. While these diagnostic methods form the basis for diagnosing PNF, the present study highlights the importance of systematically recording the progression of cutaneous signs and delineating affected areas based on skin changes. This approach will aid in early recognition, improve understanding of disease progression, and guide the extent of surgical debridement. PNF exhibits progressive cutaneous manifestations as it advances from early to late stages. Cutaneous changes may gradually extend from the primary perianal infection site to the surrounding fascial planes as the disease progresses. The boundaries of the affected tissue often blur, and the spread of the infection along the fascial planes typically precedes the visible cutaneous changes[ 17 , 21 ]. Wong CH et al.[ 22 ] were first to propose a cutaneous compartmentalization of necrotizing fasciitis, dividing the cutaneous changes into three zones: zone 1 represents the infected central area of necrotic skin, zone 2 encompasses the adjacent and surrounding areas, and zone 3 consists of healthy, uninfected tissue outside of zone 2. Here, to better assess the extent of surgical debridement, we divided the skin changes of PNF into four zones based on the pathophysiological changes of necrotizing fasciitis. Zone 1 represents the necrotic central area of the infection; zone 2 surrounds zone 1 and is characterized by swelling, induration, and erythema; zone 3 exhibits edematous skin, which may show finger indentation and is painless; and zone 4 consists of healthy, uninfected tissue. Using these skin zones can help define the scope of surgical debridement and allow for tailored debridement methods. Importantly, this approach not only ensures effective removal of necrotic tissues while preserving infected, non-necrotic tissues but also significantly reduces the chances for unnecessary secondary or multiple surgical debridement. The first surgical debridement for PNF is generally not considered a technically challenging procedure[ 9 ]. The traditional debridement approach involves surgically excising all infected areas of the fascia until healthy tissues are reached, including contractile muscles, shiny fat, and hemorrhagic tissues[ 10 , 13 , 22 ]. However, extensive tissue loss not only results in significant scarring, which can impact patients' quality of life[ 18 ], correlating with longer hospital stays and poorer survival outcomes[ 10 , 19 ]. As a result, skin-preserving debridement has been proposed as an alternative. This approach is comparable to traditional debridement in controlling PNF while offering a lower mortality rate[ 18 , 19 ]. Nonetheless, previous studies did not reach a consensus regarding the extent of debridement required. Interestingly, Yang B et al.[ 23 ] found that the loose-seton technique is an effective treatment for PNF. Its advantages include inhibiting the spread of inflammation, decreasing the frequency of debridement, reducing the wound area, and limiting the formation of broad scars. In the present study, we excised necrotic tissue and skin in zone 1 according to the skin subdivision. Surgical debridement was performed with multiple small incisions in zones 2 and 3, and loose-elastic seton sutures (elastic rubber bands) were placed between each pair of drainage incisions. After debridement, we flushed the wound with hydrogen peroxide and metronidazole, administered antibiotics to control the infection, and provided rehydration based on the patient's condition. This approach was effective in controlling PNF and maximized the preservation of salvageable tissues, limited skin defects, minimized scar formation, and reduced the need for unnecessary returns to the operating room[ 22 ]. In comparison with previous studies[ 3 , 5 ], the mortality rate of patients in this study was low. This is likely since most patients presented early with anal pain, which facilitated early recognition of necrotizing fasciitis. Furthermore, the low SOFA scores at presentation enabled prompt and effective treatment. Only a few cases resulted in death, primarily due to the extensive spread of infection and severe localized necrosis, which led to infectious shock and multi-organ failure during treatment. 5. Limitations This study has several limitations that must be acknowledged. First, PNF is a rare severe infectious disease with a small sample size. Second, as a retrospective single-center study, it may have inherent limitations, such as unavoidable patient selection bias. Therefore, a prospective randomized controlled trials are still needed to validate these findings. Our study only presents the experience of a single institution and has a limited sample size, which may reduce the ability to detect significant differences. Therefore, large-scale, multi-center studies are currently needed, and these results await further confirmation. 6. Conclusions It is well established that clinical assessment of skin survival in PNF is crucial for determining the extent of surgical debridement and skin removal. In this single-center study, we divided the skin affected by PNF into four zones based on the progression of the disease. Determining the extent of surgical debridement based on these zones not only allowed for early diagnosis based on skin area characterization, but also significantly reduces the potential for secondary or multiple surgical debridements. Our approach not only rapidly eliminates the infection and halts its progression but also minimizes the initial removal of skin and subcutaneous tissue, reducing the need for skin grafts in PNF patients. Importantly, this method did not lead to increased mortality or other postoperative complications. Abbreviations PNF Perianal necrotizing fasciitis SZ Skin zoning NSZ Non-skin zoning LRINEC Laboratory Risk Indicator for Necrotizing Fasciitis SOFA Sequential Organ Failure Score APACHE II Acute Physiology and Chronic Health Evaluation II ICU Intensive care unit CRP C-reactive protein MAP Mean arterial pressure USG Ultrasonography CT Computed tomography MRI Magnetic resonance imaging Declarations Funding This research was funded by Natural Science Foundation of Liaoning Province, No. 2024-MS-276. Ethics Statement Informed written consent was obtained from the patient for publication of this report and any accompanying images. Clinical Trial Number not applicable. Conflict of Interest Statement: The authors declare that they have no conflict of interest to disclose. Author Contribution Hexue Yuan, Liang Zhao drafted this article; Zongjian Liu, Chunlai Pan and Lei He collected the related references and gave some valuable suggestions; Liang Zhao provided the design and revision of the manuscript; Liang Zhao obtain funding supports. All authors made substantial, direct and intellectual contribution to the artical. All authors read and approved the final manuscript. Hexue Yuan [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China. Chunlai Pan [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China. Lei He [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China. Zongjian Liu [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China. Xue Fang [email protected] , Department of Epidemiology and Statistics, Shenyang Medical College, Shenyang110000, Liaoning Province, China. Liang Zhao [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China. Acknowledgement We thank Home for Researchers editorial team (www.home-for-researchers.com) for language editing service. Data Availability The data that support the findings of this study are available upon request from the corresponding author, Liang Zhao. References Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA et al (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101(6): 1644–1655 Bowen D, Hughes T, Juliebo-Jones P, Somani B (2024) Fournier's gangrene: a review of predictive scoring systems and practical guide for patient management. Ther Adv Infect Dis 11:20499361241238521 Bowen D, Juliebo-Jones P, Somani BK (2022) Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades. World J Urol 40(10):2399–2410 Boyer A, Vargas F, Coste F, Saubusse E, Castaing Y, Gbikpi-Benissan G et al (2009) Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 35(5):847–853 Eke N (2000) Fournier's gangrene: a review of 1726 cases. Br J Surg 87(6):718–728 Garg G, Singh V, Sinha RJ, Sharma A, Pandey S, Aggarwal A (2019) Outcomes of patients with Fournier's Gangrene: 12-year experience from a tertiary care referral center. Turk J Urol 45(1):S111–S116 Goh T, Goh LG, Ang CH, Wong CH (2014) Early diagnosis of necrotizing fasciitis. Br J Surg 101(1):e119–125 Hietbrink F, Bode LG, Riddez L, Leenen LP, van Dijk MR (2016) Triple diagnostics for early detection of ambivalent necrotizing fasciitis. World J Emerg Surg 11:51 Holena DN, Mills AM, Carr BG, Wirtalla C, Sarani B, Kim PK et al (2011) Transfer status: a risk factor for mortality in patients with necrotizing fasciitis. Surgery 150(3):363–370 Hua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N et al (2023) Necrotising soft-tissue infections. Lancet Infect Dis 23(3):e81–e94 Huayllani MT, Cheema AS, McGuire MJ, Janis JE (2022) Practical Review of the Current Management of Fournier's Gangrene. Plast Reconstr Surg Glob Open 10(3):e4191 Kehrl T (2014) Point-of-care ultrasound diagnosis of necrotizing fasciitis missed by computed tomography and magnetic resonance imaging. J Emerg Med 47(2):172–175 Leiblein M, Marzi I, Sander AL, Barker JH, Ebert F, Frank J (2018) Necrotizing fasciitis: treatment concepts and clinical results. Eur J Trauma Emerg Surg 44(2):279–290 Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F (2020) Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 15:4 Raveendranadh A, Prasad SS, Viswanath V (2024) Necrotizing fasciitis: treatment concepts & clinical outcomes - an institutional experience. BMC Surg 24(1):336 Shyam DC, Rapsang AG (2013) Fournier's gangrene. Surgeon 11(4):222–232 Stamenkovic I, Lew PD (1984) Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 310(26):1689–1693 Suijker J, Zheng KJ, Pijpe A, Nasroe F, Meij-de Vries A (2021) The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review. J Surg Res 264:296–308 Tom LK, Maine RG, Wang CS, Parent BA, Bulger EM, Keys KA (2020) Comparison of Traditional and Skin-Sparing Approaches for Surgical Treatment of Necrotizing Soft-Tissue Infections. Surg Infect (Larchmt) 21(4):363–369 Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22(7):707–710 Wang YS, Wong CH, Tay YK (2007) Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol 46(10):1036–1041 Wong CH, Yam AK, Tan AB, Song C (2008) Approach to debridement in necrotizing fasciitis. Am J Surg 196(3):e19–24 Yang BL, Lin Q, Chen HJ, Gu YF, Zhu P, Sun XL et al (2012) Perianal necrotizing fasciitis treated with a loose-seton technique. Colorectal Dis 14(7):e422–424 Additional Declarations No competing interests reported. Supplementary Files figure3.jpg figure4.jpg Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 28 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 20 Oct, 2025 Submission checks completed at journal 20 Oct, 2025 First submitted to journal 17 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7887573","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617045357,"identity":"dcaed90f-fec3-4d4c-8f7f-b80e18e3e151","order_by":0,"name":"Hexue Yuan","email":"","orcid":"","institution":"Shenyang Coloproctology Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hexue","middleName":"","lastName":"Yuan","suffix":""},{"id":617045360,"identity":"905d3b47-6dc6-415f-882a-031632bc5fab","order_by":1,"name":"Xue Fang","email":"","orcid":"","institution":"Shenyang Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xue","middleName":"","lastName":"Fang","suffix":""},{"id":617045372,"identity":"d04c17c6-ee23-4236-a6c4-d3e19e5e85f7","order_by":2,"name":"Chunlai Pan","email":"","orcid":"","institution":"Shenyang Coloproctology Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chunlai","middleName":"","lastName":"Pan","suffix":""},{"id":617045374,"identity":"28021d87-24d0-446f-8d61-1e2de8dbd8c5","order_by":3,"name":"Lei He","email":"","orcid":"","institution":"Shenyang Coloproctology Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"He","suffix":""},{"id":617045376,"identity":"cecbae83-a850-4cf7-b2a5-b75e0ed94166","order_by":4,"name":"Zongjian Liu","email":"","orcid":"","institution":"Shenyang Coloproctology Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zongjian","middleName":"","lastName":"Liu","suffix":""},{"id":617045378,"identity":"0401dd18-195c-4bc5-a5ee-7b9e2781e000","order_by":5,"name":"Liang Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBAC+xlA4oEBiMl++OGHHzY8/PwN+LUwgrQkgLXwpBlL9qTJSM44QIwWCNtAgoftsI1BQwJ+LczSzQ8fJBTY5ck7AC2T4DnPY8BwgPHDxxzcWthkjhkbJBgkFxseYDzwoMDiNo85cwOz5MxtuLXwSCSYSSQYMCdubADbcpvHsuEAGzMvHi0SEunfgFrqQVpAfjnHY3AgAb8WA4kckC2HE+dDvH+AKC3FQL8cT9wACeRkHskZB5vx+sV+RvrGBx/+VCfObwBHpZ09P3/zwQ8f8WhBWHf/AYzJ2ECEeiCQJ1LdKBgFo2AUjEAAAGXDT9GB7+h1AAAAAElFTkSuQmCC","orcid":"","institution":"Shenyang Coloproctology Hospital","correspondingAuthor":true,"prefix":"","firstName":"Liang","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2025-10-17 14:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7887573/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7887573/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106255369,"identity":"c56a3f15-448f-42d1-9eea-955e10c51246","added_by":"auto","created_at":"2026-04-06 18:42:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":655372,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of skin zoning in PNF\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7887573/v1/501e8b3fb54e84c73f1d6c5a.jpg"},{"id":106403058,"identity":"d571cb2c-f91c-432b-8ac8-c8d0faf7070f","added_by":"auto","created_at":"2026-04-08 09:13:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5614201,"visible":true,"origin":"","legend":"\u003cp\u003eDetermine the extent of surgical debridement based on skin zoning and elastic rubber band drainage between incisions\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7887573/v1/66c9d3d4c0e4225efbbd255c.jpg"},{"id":106405808,"identity":"d9e93586-05f6-4345-a6e9-b4df30483e7a","added_by":"auto","created_at":"2026-04-08 09:28:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7027042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7887573/v1/6b0a3649-acfb-4286-a6fe-07359a8d1616.pdf"},{"id":106255371,"identity":"70dddac9-a7c7-4d62-bf8a-0b797f60f354","added_by":"auto","created_at":"2026-04-06 18:42:56","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":257469,"visible":true,"origin":"","legend":"","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7887573/v1/1407abfe24ef39e63e55fbe7.jpg"},{"id":106255372,"identity":"d6a5ec90-cf5e-492b-85fe-42ec5c87c82a","added_by":"auto","created_at":"2026-04-06 18:42:56","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":267379,"visible":true,"origin":"","legend":"","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7887573/v1/3e2874d8cccfbdc1322a2ea7.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical outcomes of perianal necrotizing fasciitis treated by skin classification : A retrospective single center study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eNecrotizing fasciitis is a rapidly progressing infection involving the superficial and deep fascia, often presenting with sudden onset and rapid spread. In severe cases, it can lead to multi-organ dysfunction, septic shock, and death. Due to the unique anatomical structure of the anorectum, the perianal region and perineum are common sites of origin. The mortality rate of PNF has been reported to range from 15% to 40%[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], although a recent meta-analysis found a lower average mortality rate of 7.3%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because PNF progresses rapidly, early diagnosis, prompt surgical debridement, appropriate determination of the extent of initial debridement, and careful postoperative care are critical factors for achieving clinical cure. Nonetheless, previous studies have lacked detailed descriptions of how to determine the extent of surgical debridement, and there is no established methodology to date. Moreover, due to its rarity, most surgeons may encounter only a few cases during their careers. To that end, we retrospectively analyzed the clinical outcomes of 102 patients with PNF and proposed a surgical strategy based on skin demarcation zones. The extent of debridement was guided by these zones, aiming to reduce the need for repeated surgeries due to disease progression and to inform therapeutic decision-making. Taken together, our proposed strategy might serve as a useful reference for the clinical management of PNF.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Patients\u003c/h2\u003e \u003cp\u003eThe clinical data of 102 patients with perianal abscess complicated by necrotizing fasciitis, diagnosed and treated at Shenyang Coloproctology Hospital between January 2018 and December 2024, were retrospectively analyzed. Final diagnoses were made in accordance with the International Classification of Diseases, Tenth Revision (ICD-10), based on clinical features, laboratory tests, and intraoperative and pathological findings. All patients received aggressive surgical debridement and broad-spectrum antibiotic therapy. The treating physicians were from the same institution and had received standardized training. Exclusion criteria included non-infectious conditions such as gas gangrene. The study was approved by the Ethics Committee of Shenyang Anorectal Hospital and conducted in accordance with the principles of the Declaration of Helsinki (SGCYY202508140002). Written informed consent was obtained from all patients. Only one patient with septic shock was transferred to the intensive care unit for three days. Once his condition stabilized, he was transferred back to the general ward to continue treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Treatment Protocol\u003c/h2\u003e \u003cp\u003e102 patients with PNF underwent debridement surgery within 8 hours. Among them, 61 patients had the surgical debridement range determined based on SZ, while 41 patients had the surgical debridement range determined based on NSZ. All others treatment modalities were identical for all patients.\u003c/p\u003e \u003cp\u003eSkin zone classification method: Based on the progressive skin changes in PNF patients, we categorized the infected tissue into zones as follows: zone 1 consists of necrotic skin at the center of the infection; zone 2 consists of swollen, erythematous, and painful tissue with pressure sensitivity adjacent to zone 1; zone 3 is edematous and may show finger indentations; and zone 4 consists of soft, healthy, uninfected tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical approach: The SZ group surgical approach used was as follows: After administering sacral or epidural anesthesia, the necrotic tissue and skin in zone 1 were excised. Zones 2 and 3 were surgically debrided via multiple small incisions, and a loose-elastic seton suture (elastic rubber band) was placed between each pair of drainage incisions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additional silicone tubing was inserted for irrigation and drainage if the abscess cavity was deep. However, the extent of surgical debridement in the NSZ group was not determined based on skin zoning.\u003c/p\u003e \u003cp\u003eAfter debridement, the wound was flushed with hydrogen peroxide and metronidazole, and antibiotics were administered to control the infection. Rehydration therapy was provided based on the patient's condition. Initially, broad-spectrum antibiotics were used, and once the pathogens were identified, specific antibiotics were administered. The wound was flushed with hydrogen peroxide and metronidazole one to two times daily until healthy granulation tissue appeared at the incision site.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data Collection\u003c/h2\u003e \u003cp\u003eComplete medical records were available for all patients, documenting sex, age, clinical manifestations of infection, and laboratory findings. Sepsis severity at admission was categorized as sepsis, severe sepsis, or septic shock, according to Bone et al.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Laboratory parameters included the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which comprises total white blood cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein, as well as the Sequential Organ Failure Score (SOFA)[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which includes the oxygenation index, platelets, bilirubin, and mean arterial pressure. Additional data collected included tissue specimens, pathogenic bacteria in blood, urine, and feces, histological evidence of fascial involvement, number and type of comorbidities, timing of the first debridement (hours), number of surgical debridement, type and number of antibiotics used, length of intensive care unit (ICU) stay, duration of hospitalization (days), and any complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using IBM SPSS Statistics version 27.0. The t-test or U test was applied for measurement data, while the χ\u0026sup2; test or Fisher's exact test was used for categorical data. Spearman rank correlation was used to test the correlation between length of hospital stay and various factors. For quantitative variables, descriptive statistics are presented as means and standard deviations. A \u003cem\u003eP\u003c/em\u003e value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 102 patients with PNF were treated at Shenyang Anorectal Hospital. Of these, 61 patients underwent debridement surgery based on skin classification, while 41 patients underwent debridement surgery without skin classification. One patient in the NSZ group died, and one patient in the SZ group was transferred to another hospital for treatment and lost follow-up information. No significant difference in the cure rate was observed between the two groups. Baseline data, including sex, age, diabetes, hypertension, and coronary heart disease, were comparable between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe preoperative evaluation indexes of the two groups, including leukocytes, hemoglobin, platelets, C-reactive protein (CRP), sodium, potassium, glucose, creatinine, procalcitonin, bilirubin, mean arterial pressure (MAP), oxygen index and LRINEC score, also did not differ significantly between the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, the postoperative evaluation indexes of the two groups, including ICU custody time, Hospitalization time, Number of surgeries, Septic shock, SOFA score and APACHE II score in both groups were compared (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Eight patients developed septic shock, with five in the SZ group and three in the NSZ group, with no significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There was no statistically significant difference between the two groups in terms of APACHE II scores and SOFA scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The length of hospital stay for patients in the SZ group was 17 days (15.00\u0026ndash;23.00 days), while that for patients in the NSZ group was 19 days (15.00\u0026ndash;30.50 days). The difference in hospital stay between the two groups was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among the SZ group patients, 57 cases required one surgery for cure, and 3 cases required two or more surgeries for cure; among the NSZ group patients, 13 cases were cured with one surgery, and 28 cases required two or more surgeries for cure. The difference in the number of surgeries between the two groups was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is no obvious correlation between the number of surgeries and various factors (\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows that length of hospital stay is associated with LRINEC score (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while the other factors are not associated with length of hospital stay (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eStatistical results show that the hospitalization time and number of surgeries for cases in the SZ group were significantly lower than those in the NSZ group. Hospitalization time was correlated with LRINEC score, indicating its association with PNF severity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe baseline data of the two groups were compared\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSZ (41 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSZ (61 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e/χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48(36.5\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(35.5\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1120.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.633\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe preoperative indexes of the two groups were compared\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSZ (41 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSZ (61 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.43(14.09\u0026ndash;20.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.53(13.36\u0026ndash;24.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1158.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140.00(133.00-151.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145.00(137.50\u0026ndash;155.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1024.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e271.00(195.00-361.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e289.00(223.00-379.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1124.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123.00(77.50-207.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134.20(88.06-187.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1240.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138.00(132.4\u0026ndash;140.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138.00(136.00-140.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1116.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.13(3.84\u0026ndash;4.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.17(3.83\u0026ndash;4.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1203.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.746\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.40(6.10\u0026ndash;9.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.00(5.49\u0026ndash;14.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1121.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77.00(57.00\u0026ndash;93.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.00(55.00\u0026ndash;83.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1085.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.85(0.51\u0026ndash;1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.01(0.74\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1072.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.50(11.60\u0026ndash;27.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.90(10.96\u0026ndash;22.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1195.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93.30(85.00-103.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.70(87.50\u0026ndash;104.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1100.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxygen index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e390.00(376.50-430.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e403.00(381.00-421.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1138.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.442\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLRINEC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.00(1.00\u0026ndash;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.00(1.00\u0026ndash;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1230.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.888\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe postoperative indexes were compared between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSZ (41 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSZ (61 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e/χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23/38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU custody time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.00(0.00\u0026ndash;5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00(0.00\u0026ndash;5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1015.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.00(15.00-30.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.00(15.00\u0026ndash;23.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e919.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgeries(1 time/\u0026ge;2 times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/37*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/55\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPACHE II score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00(1.00-10.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00(1.00-7.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1084.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOFA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00(0.00\u0026ndash;2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00(0.00\u0026ndash;2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e978.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*One patient died of organ failure #One case was transferred to hospital due to myocardial infarction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between the number of operations and each factor\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery 1 time (70 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of surgeries\u0026thinsp;\u0026ge;\u0026thinsp;2 (31 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e/χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.00(35.75-60.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.00(36.00\u0026ndash;61.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1003.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease (No/Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.63(13.50-24.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.36(13.93\u0026ndash;21.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1037.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145.5(136.25-153.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140.00(127.00-152.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e894.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e273.00(217.75-376.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e289.00(212.00-364.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1071.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.921\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128.35(88.18-187.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123.00(76.50-203.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1024.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138.00(135.75\u0026ndash;140.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137.00(135.00-139.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e885.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.19(3.89\u0026ndash;4.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.00(3.80\u0026ndash;4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e977.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.428\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.17(5.50-13.69;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.40(5.93\u0026ndash;9.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1041.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.00(55.00-86.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.00(57.00\u0026ndash;93.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e947.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00(0.72\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78(0.41\u0026ndash;1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e879.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.99(11.48\u0026ndash;23.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.90(11.30-25.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1081.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.979\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.85(89.58-103.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.00(83.30-104.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e863.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxygen index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e404.00(385.50\u0026ndash;427.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e379.00(365.00-422.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e828.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLRINEC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.50(1.00\u0026ndash;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00(1.00\u0026ndash;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1044.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.761\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between length of hospital stay and various factors (Spearman rank correlation)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpearman's ρ (rho)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxygen index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLRINEC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOFA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eNecrotizing fasciitis is a severe bacterial infection marked by systemic toxicity and rapidly progressing soft tissue inflammation and necrosis. PNF originating from the rectum and anal canal is associated with the worst prognosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In recent years, the cure rate for this condition has gradually improved due to a better understanding of its pathophysiology[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Currently, most experts agree that early recognition, aggressive surgical debridement, and appropriate antibiotic therapy are crucial for improving survival[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Early clinical recognition of necrotizing fasciitis is challenging, and the extent of surgical debridement remains non-standardized. This is because the spread of the infection along fascial planes often precedes cutaneous changes[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and is clinically unremarkable in most patients. While most experts now consider extensive necrotic tissue debridement as the primary approach[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], many patients still require two or more debridement procedures[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], placing a significant physical, psychological, and economic burden on them.\u003c/p\u003e \u003cp\u003eHerein, 102 patients with PNF were retrospectively analyzed and divided into zoned and non-zoned groups. The clinical data of the two groups were compared, revealing no significant difference in the cure rate. However, the zoned group had shorter hospitalization times and fewer surgeries compared to the non-zoned group. The length of hospital stay for SZ group cases was correlated with hemoglobin levels, which may be considered a false positive due to the small number of cases. Furthermore, there are currently no reports in domestic or overseas regarding the correlation between the length of hospital stay and hemoglobin levels in patients with necrotizing fasciitis.\u003c/p\u003e \u003cp\u003eEarly recognition, prompt surgery, and thorough initial debridement of PNF are critical for survival[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Delayed diagnosis and extended initial surgical debridement are linked to increased morbidity and mortality[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Notably, early surgical debridement of necrotic tissue (within 6\u0026ndash;12 hours of admission) has significantly reduced mortality[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The above findings suggest that early diagnosis and immediate and thorough surgical debridement are essential in order to prevent the systemic effects of sepsis and even death.\u003c/p\u003e \u003cp\u003eEarly diagnosis of PNF is primarily based on clinical symptoms and signs, which often begin with pain and swelling around the anus. These symptoms can quickly spread to the buttocks, perineum, scrotum, lower abdomen, posterior back, and lower limbs. The skin in the affected area lacks fluctuation, but a twisting sensation is felt upon palpation, and finger indentation may be observed. Necrosis often occurs, accompanied by a foul odor and severe systemic infectious toxicity. In the later stages, sensation in the affected area decreases or disappears, and the patient may develop widespread sepsis, potentially leading to septic shock. The patient also presents with persistent high fever, elevated white blood cell count, hypotension, unresponsiveness or loss of consciousness, acidosis, and other systemic symptoms. Notably, swelling, pain, and erythema are common early clinical features of PNF. Particularly, the disproportionate pain relative to the physical signs is a key indicator that aids in early diagnosis[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Nevertheless, the early signs and symptoms of PNF can be misleading, with skin marks often not matching the location of the necrotic fascia[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While the diagnosis of PNF typically relies on clinical signs and symptoms, imaging can be valuable when the diagnosis is unclear or the clinical presentation is ambiguous[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Imaging techniques used for the initial evaluation of PNF include radiography, ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Ultrasound is particularly effective for diagnosing PNF, especially in cases with negative CT and MRI results[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In addition, a triple diagnostic approach, combining incisional biopsy with visual, histologic, and microbiologic findings, can help promptly identify necrotizing fasciitis[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While these diagnostic methods form the basis for diagnosing PNF, the present study highlights the importance of systematically recording the progression of cutaneous signs and delineating affected areas based on skin changes. This approach will aid in early recognition, improve understanding of disease progression, and guide the extent of surgical debridement.\u003c/p\u003e \u003cp\u003ePNF exhibits progressive cutaneous manifestations as it advances from early to late stages. Cutaneous changes may gradually extend from the primary perianal infection site to the surrounding fascial planes as the disease progresses. The boundaries of the affected tissue often blur, and the spread of the infection along the fascial planes typically precedes the visible cutaneous changes[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Wong CH et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] were first to propose a cutaneous compartmentalization of necrotizing fasciitis, dividing the cutaneous changes into three zones: zone 1 represents the infected central area of necrotic skin, zone 2 encompasses the adjacent and surrounding areas, and zone 3 consists of healthy, uninfected tissue outside of zone 2. Here, to better assess the extent of surgical debridement, we divided the skin changes of PNF into four zones based on the pathophysiological changes of necrotizing fasciitis. Zone 1 represents the necrotic central area of the infection; zone 2 surrounds zone 1 and is characterized by swelling, induration, and erythema; zone 3 exhibits edematous skin, which may show finger indentation and is painless; and zone 4 consists of healthy, uninfected tissue. Using these skin zones can help define the scope of surgical debridement and allow for tailored debridement methods. Importantly, this approach not only ensures effective removal of necrotic tissues while preserving infected, non-necrotic tissues but also significantly reduces the chances for unnecessary secondary or multiple surgical debridement.\u003c/p\u003e \u003cp\u003eThe first surgical debridement for PNF is generally not considered a technically challenging procedure[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The traditional debridement approach involves surgically excising all infected areas of the fascia until healthy tissues are reached, including contractile muscles, shiny fat, and hemorrhagic tissues[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, extensive tissue loss not only results in significant scarring, which can impact patients' quality of life[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], correlating with longer hospital stays and poorer survival outcomes[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As a result, skin-preserving debridement has been proposed as an alternative. This approach is comparable to traditional debridement in controlling PNF while offering a lower mortality rate[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nonetheless, previous studies did not reach a consensus regarding the extent of debridement required. Interestingly, Yang B et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] found that the loose-seton technique is an effective treatment for PNF. Its advantages include inhibiting the spread of inflammation, decreasing the frequency of debridement, reducing the wound area, and limiting the formation of broad scars. In the present study, we excised necrotic tissue and skin in zone 1 according to the skin subdivision. Surgical debridement was performed with multiple small incisions in zones 2 and 3, and loose-elastic seton sutures (elastic rubber bands) were placed between each pair of drainage incisions. After debridement, we flushed the wound with hydrogen peroxide and metronidazole, administered antibiotics to control the infection, and provided rehydration based on the patient's condition. This approach was effective in controlling PNF and maximized the preservation of salvageable tissues, limited skin defects, minimized scar formation, and reduced the need for unnecessary returns to the operating room[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In comparison with previous studies[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the mortality rate of patients in this study was low. This is likely since most patients presented early with anal pain, which facilitated early recognition of necrotizing fasciitis. Furthermore, the low SOFA scores at presentation enabled prompt and effective treatment. Only a few cases resulted in death, primarily due to the extensive spread of infection and severe localized necrosis, which led to infectious shock and multi-organ failure during treatment.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study has several limitations that must be acknowledged. First, PNF is a rare severe infectious disease with a small sample size. Second, as a retrospective single-center study, it may have inherent limitations, such as unavoidable patient selection bias. Therefore, a prospective randomized controlled trials are still needed to validate these findings. Our study only presents the experience of a single institution and has a limited sample size, which may reduce the ability to detect significant differences. Therefore, large-scale, multi-center studies are currently needed, and these results await further confirmation.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eIt is well established that clinical assessment of skin survival in PNF is crucial for determining the extent of surgical debridement and skin removal. In this single-center study, we divided the skin affected by PNF into four zones based on the progression of the disease. Determining the extent of surgical debridement based on these zones not only allowed for early diagnosis based on skin area characterization, but also significantly reduces the potential for secondary or multiple surgical debridements. Our approach not only rapidly eliminates the infection and halts its progression but also minimizes the initial removal of skin and subcutaneous tissue, reducing the need for skin grafts in PNF patients. Importantly, this method did not lead to increased mortality or other postoperative complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePNF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003ePerianal necrotizing fasciitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eSkin zoning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNSZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eNon-skin zoning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eLRINEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eLaboratory Risk Indicator for Necrotizing Fasciitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSOFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eSequential Organ Failure Score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAPACHE II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eAcute Physiology and Chronic Health Evaluation II\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eIntensive care unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eC-reactive protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eMean arterial pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eUSG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eUltrasonography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eComputed tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eFunding\u003c/strong\u003e \u003cp\u003eThis research was funded by Natural Science Foundation of Liaoning Province, No. 2024-MS-276.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics Statement\u003c/strong\u003e \u003cp\u003e Informed written consent was obtained from the patient for publication of this report and any accompanying images.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical Trial Number\u003c/strong\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eConflict of Interest Statement:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of interest to disclose.\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHexue Yuan, Liang Zhao drafted this article; Zongjian Liu, Chunlai Pan and Lei He collected the related references and gave some valuable suggestions; Liang Zhao provided the design and revision of the manuscript; Liang Zhao obtain funding supports. All authors made substantial, direct and intellectual contribution to the artical. All authors read and approved the final manuscript.\u003c/p\u003e\u003cp\u003eHexue Yuan [email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China.\u003c/p\u003e\n\u003cp\u003eChunlai Pan \u0026nbsp;[email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China.\u003c/p\u003e\n\u003cp\u003eLei He \u0026nbsp;[email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China.\u003c/p\u003e\n\u003cp\u003eZongjian Liu \u0026nbsp;[email protected] Department of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China.\u003c/p\u003e\n\u003cp\u003eXue Fang \u0026nbsp;[email protected], Department of Epidemiology and Statistics, Shenyang Medical College, Shenyang110000, Liaoning Province, China.\u003c/p\u003e\n\u003cp\u003eLiang Zhao \u0026nbsp;[email protected]\u003cu\u003e\u0026nbsp;\u003c/u\u003eDepartment of General Surgery (Colorectal Anal Surgery), Shenyang Coloproctology hospital, Shenyang110002, China.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank Home for Researchers editorial team (www.home-for-researchers.com) for language editing service.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available upon request from the corresponding author, Liang Zhao.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA et al (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101(6): 1644\u0026ndash;1655\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen D, Hughes T, Juliebo-Jones P, Somani B (2024) Fournier's gangrene: a review of predictive scoring systems and practical guide for patient management. Ther Adv Infect Dis 11:20499361241238521\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen D, Juliebo-Jones P, Somani BK (2022) Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades. World J Urol 40(10):2399\u0026ndash;2410\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyer A, Vargas F, Coste F, Saubusse E, Castaing Y, Gbikpi-Benissan G et al (2009) Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 35(5):847\u0026ndash;853\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEke N (2000) Fournier's gangrene: a review of 1726 cases. Br J Surg 87(6):718\u0026ndash;728\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg G, Singh V, Sinha RJ, Sharma A, Pandey S, Aggarwal A (2019) Outcomes of patients with Fournier's Gangrene: 12-year experience from a tertiary care referral center. Turk J Urol 45(1):S111\u0026ndash;S116\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoh T, Goh LG, Ang CH, Wong CH (2014) Early diagnosis of necrotizing fasciitis. Br J Surg 101(1):e119\u0026ndash;125\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHietbrink F, Bode LG, Riddez L, Leenen LP, van Dijk MR (2016) Triple diagnostics for early detection of ambivalent necrotizing fasciitis. World J Emerg Surg 11:51\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolena DN, Mills AM, Carr BG, Wirtalla C, Sarani B, Kim PK et al (2011) Transfer status: a risk factor for mortality in patients with necrotizing fasciitis. Surgery 150(3):363\u0026ndash;370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N et al (2023) Necrotising soft-tissue infections. Lancet Infect Dis 23(3):e81\u0026ndash;e94\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuayllani MT, Cheema AS, McGuire MJ, Janis JE (2022) Practical Review of the Current Management of Fournier's Gangrene. Plast Reconstr Surg Glob Open 10(3):e4191\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKehrl T (2014) Point-of-care ultrasound diagnosis of necrotizing fasciitis missed by computed tomography and magnetic resonance imaging. J Emerg Med 47(2):172\u0026ndash;175\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeiblein M, Marzi I, Sander AL, Barker JH, Ebert F, Frank J (2018) Necrotizing fasciitis: treatment concepts and clinical results. Eur J Trauma Emerg Surg 44(2):279\u0026ndash;290\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F (2020) Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 15:4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaveendranadh A, Prasad SS, Viswanath V (2024) Necrotizing fasciitis: treatment concepts \u0026amp; clinical outcomes - an institutional experience. BMC Surg 24(1):336\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShyam DC, Rapsang AG (2013) Fournier's gangrene. Surgeon 11(4):222\u0026ndash;232\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStamenkovic I, Lew PD (1984) Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 310(26):1689\u0026ndash;1693\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuijker J, Zheng KJ, Pijpe A, Nasroe F, Meij-de Vries A (2021) The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review. J Surg Res 264:296\u0026ndash;308\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTom LK, Maine RG, Wang CS, Parent BA, Bulger EM, Keys KA (2020) Comparison of Traditional and Skin-Sparing Approaches for Surgical Treatment of Necrotizing Soft-Tissue Infections. Surg Infect (Larchmt) 21(4):363\u0026ndash;369\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22(7):707\u0026ndash;710\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang YS, Wong CH, Tay YK (2007) Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol 46(10):1036\u0026ndash;1041\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong CH, Yam AK, Tan AB, Song C (2008) Approach to debridement in necrotizing fasciitis. Am J Surg 196(3):e19\u0026ndash;24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang BL, Lin Q, Chen HJ, Gu YF, Zhu P, Sun XL et al (2012) Perianal necrotizing fasciitis treated with a loose-seton technique. Colorectal Dis 14(7):e422\u0026ndash;424\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Early diagnosis, Necrotizing fasciitis, Classification of the skin, Sepsis, Systemic inflammatory response syndrome","lastPublishedDoi":"10.21203/rs.3.rs-7887573/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7887573/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe extent of debridement in perianal necrotizing fasciitis (PNF) has not been standardized, although skin-preserving debridement is increasingly used clinically.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe present study retrospectively analyzed the clinical data of 102 patients with PNF treated between December 2022 and February 2025 at Shenyang Coloproctology Hospital. The skin changes associated with PNF were classified into zones. All treatment effects were observed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 102 patients underwent debridement for PNF. Of these, 61 patients had the surgical debridement range determined based on skin zoning (SZ), while 41 patients had the surgical debridement range determined based on non-skin zoning (NSZ). There was no significant difference in the cure rate between the two groups. The length of hospital stay for patients in the SZ group was 17 days (15.00\u0026ndash;23.00 days), while that for patients in the NSZ group was 19 days (15.00\u0026ndash;30.50 days) (17 vs. 19, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037). Meanwhile, the length of hospital stay was associated with LRINEC score (P\u0026thinsp;=\u0026thinsp;0.034). Among the SZ group patients, 57 cases required one surgery for cure, and 3 cases required two or more surgeries for cure, while, among the NSZ group patients, 13 cases were cured with one surgery, and 28 cases required two or more surgeries for cure (13/28 vs. 57/3, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDetermining the extent of surgical debridement based on the zoning of skin changes in PNF can reduce hospitalization time and the number of surgeries, making it an effective approach for treating PNF.\u003c/p\u003e","manuscriptTitle":"Clinical outcomes of perianal necrotizing fasciitis treated by skin classification : A retrospective single center study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 18:42:45","doi":"10.21203/rs.3.rs-7887573/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-28T19:31:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155103814136956340497856730995041517715","date":"2026-04-02T06:33:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T08:27:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-21T01:23:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-21T01:23:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2025-10-17T14:07:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2df431be-b90a-4dfd-a6de-18b3debffafb","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T18:42:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 18:42:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7887573","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7887573","identity":"rs-7887573","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}