# Appendicitis — GCMD Library living collection

Updated: n/a · 11 episodes · 62 cited statements

## Episodes
### Tools

### Guidelines and Tools

### In-depth Review
- [Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314) — podcast · 58:22 · [machine version](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314.md)

### Work-up and Treatment
- [Nonoperative Management of Uncomplicated Appendicitis: Practice Gap...](https://qa.library.globalcastmd.com/watch/nonoperative-management-of-uncomplicated-appendicitis-practice-gap-348) — video · [machine version](https://qa.library.globalcastmd.com/watch/nonoperative-management-of-uncomplicated-appendicitis-practice-gap-348.md)

### Technique Videos/OP Notes

### Updates
- [Journal Club: Appendicitis in 2021](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416) — podcast · 15:06 · [machine version](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416.md)
- [Acute Appendicitis 2020 Update](https://qa.library.globalcastmd.com/watch/acute-appendicitis-2020-update-3378) — podcast · [machine version](https://qa.library.globalcastmd.com/watch/acute-appendicitis-2020-update-3378.md)
- [Update Course Rewind: Perforated Appendicitis 2019](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934) — podcast · 12:08 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934.md)
- [Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized Controlled Trial](https://qa.library.globalcastmd.com/article/povidone-iodine-irrigation-for-pediatric-perforated-appendicitis-may-be-protecti-2806) — article · [machine version](https://qa.library.globalcastmd.com/article/povidone-iodine-irrigation-for-pediatric-perforated-appendicitis-may-be-protecti-2806.md)
- [Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic](https://qa.library.globalcastmd.com/article/delayed-presentation-and-sub-optimal-outcomes-of-pediatric-patients-with-acute-a-3202) — article · [machine version](https://qa.library.globalcastmd.com/article/delayed-presentation-and-sub-optimal-outcomes-of-pediatric-patients-with-acute-a-3202.md)
- [Clinical Pathway for Suspected Appendicitis](https://qa.library.globalcastmd.com/watch/clinical-pathway-for-suspected-appendicitis-2064) — video · [machine version](https://qa.library.globalcastmd.com/watch/clinical-pathway-for-suspected-appendicitis-2064.md)
- [Too Much Variability in Opioid Prescriptions for Pediatric Operations](https://qa.library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326) — video · [machine version](https://qa.library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326.md)

## Chapters
- [0:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=5) Introduction and speaker background (Ep 1)
- [2:20](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=140) Diagnostic approach and imaging for suspected appendicitis (Ep 1)
- [10:52](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=652) Antibiotic selection and dosing protocols (Ep 1)
- [15:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=911) Surgical technique: single-incision versus three-port laparoscopy (Ep 1)
- [21:32](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1292) Defining and identifying perforation intraoperatively (Ep 1)
- [25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1546) Same-day discharge for non-perforated appendicitis (Ep 1)
- [28:22](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1702) Outcomes of single-incision versus three-port appendectomy (Ep 1)
- [34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2068) Irrigation versus suction-only for perforated appendicitis (Ep 1)
- [38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301) Technical considerations: staplers, energy devices, and cautery (Ep 1)
- [41:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2460) Postoperative management of perforated appendicitis (Ep 1)
- [45:34](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2734) Management of well-defined abscess: early versus interval appendectomy (Ep 1)
- [52:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3120) Non-operative management and future directions (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=0) Introduction and Clinical Context (Ep 6)
- [2:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=122) Diagnostic Accuracy of CT and Intraoperative Assessment (Ep 6)
- [5:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315) Standardized Definition and Irrigation Evidence (Ep 6)
- [7:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474) Large-Volume Irrigation and Aspiration (Ep 6)
- [10:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609) Audience Questions and Conclusion (Ep 6)
- [0:05](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=5) Case presentation and clinical prediction models (Ep 4)
- [3:39](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=219) Ultrasound standardization and diagnostic accuracy (Ep 4)
- [6:24](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=384) Operative versus non-operative management (Ep 4)
- [7:35](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=455) Preoperative antibiotics and intraoperative definitions (Ep 4)
- [10:33](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=633) Postoperative management: antibiotics and pain control (Ep 4)
- [13:14](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=794) Summary and resources (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Classic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging — Whit Holcomb (clinical) [Ep 1 · 3:25](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=205)
- At Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction — Whit Holcomb (clinical) [Ep 1 · 4:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=240)
- Symptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound — Whit Holcomb (clinical) [Ep 1 · 5:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=311)
- If ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed — Whit Holcomb (clinical) [Ep 1 · 6:25](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=385)
- Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero — Whit Holcomb (clinical) [Ep 1 · 7:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=448)
- Children's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians — Whit Holcomb (clinical) [Ep 1 · 8:40](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=520)
- Ceftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens — Whit Holcomb (clinical) [Ep 1 · 11:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=671)
- In 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges — Whit Holcomb (clinical) [Ep 1 · 14:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=858)
- Ceftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis — Whit Holcomb (clinical) [Ep 1 · 15:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=911)
- Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics — Whit Holcomb (clinical) [Ep 1 · 12:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=778)
- Once-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities — Whit Holcomb (clinical) [Ep 1 · 13:29](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=809)
- Single-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis — Whit Holcomb (clinical) [Ep 1 · 16:35](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=995)
- In double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy — Whit Holcomb (clinical) [Ep 1 · 17:51](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1071)
- Locking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen — Whit Holcomb (clinical) [Ep 1 · 19:40](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1180)
- Fascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp — Whit Holcomb (clinical) [Ep 1 · 20:53](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1253)
- Perforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation — Whit Holcomb (clinical) [Ep 1 · 21:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1318)
- This strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons — Whit Holcomb (clinical) [Ep 1 · 21:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1318)
- Children's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way — Whit Holcomb (clinical) [Ep 1 · 25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1546)
- Same-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics — Whit Holcomb (clinical) [Ep 1 · 25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1546)
- Rationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy — Whit Holcomb (opinion) [Ep 1 · 27:33](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1653)
- October 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis — Whit Holcomb (clinical) [Ep 1 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1710)
- Single-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity — Whit Holcomb (clinical) [Ep 1 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1710)
- Single-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port — Whit Holcomb (clinical) [Ep 1 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1710)
- For single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion — Whit Holcomb (clinical) [Ep 1 · 31:32](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1892)
- Interrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm — Whit Holcomb (clinical) [Ep 1 · 32:09](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1929)
- St. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate — Whit Holcomb (clinical) [Ep 1 · 33:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1980)
- Study used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix — Whit Holcomb (clinical) [Ep 1 · 33:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1980)
- Across 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk — Whit Holcomb (clinical) [Ep 1 · 34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2068)
- Surgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate — Whit Holcomb (opinion) [Ep 1 · 34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2068)
- At Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time — Whit Holcomb (clinical) [Ep 1 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301)
- Children's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model — Whit Holcomb (clinical) [Ep 1 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301)
- Standard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously — Whit Holcomb (clinical) [Ep 1 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301)
- In early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc — Whit Holcomb (clinical) [Ep 1 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301)
- When using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops — Whit Holcomb (clinical) [Ep 1 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2301)
- Murky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source — Whit Holcomb (clinical) [Ep 1 · 39:48](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2388)
- In single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal — Whit Holcomb (clinical) [Ep 1 · 39:48](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2388)
- For normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done — Whit Holcomb (clinical) [Ep 1 · 41:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2475)
- Initial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- Discharge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- If WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- Almost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- Follow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- Early discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5 — Whit Holcomb (clinical) [Ep 1 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2525)
- For well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy — Whit Holcomb (clinical) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- At 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment — Whit Holcomb (clinical) [Ep 1 · 50:23](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3023)
- 2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis — Whit Holcomb (clinical) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- Study found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges — Whit Holcomb (clinical) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- Initial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes) — Whit Holcomb (clinical) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- Holcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications — Whit Holcomb (opinion) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- Interval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure — Whit Holcomb (clinical) [Ep 1 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=2772)
- Even if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material — Whit Holcomb (opinion) [Ep 1 · 51:01](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3061)
- Current data suggests 50-60% of patients could likely be managed non-operatively with antibiotics — Whit Holcomb (clinical) [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- High-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation — Whit Holcomb (opinion) [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Long-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later — Whit Holcomb (opinion) [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Inflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years — Whit Holcomb (opinion) [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Current data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities — Whit Holcomb (opinion) [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Longer-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young — Whit Holcomb (opinion) [Ep 1 · 56:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3375)
- Children's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis — Whit Holcomb (clinical) [Ep 1 · 57:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3448)
- The postoperative antibiotic study did not report postoperative abscess rates, which is a more clinically relevant outcome than surgical site infections for uncomplicated appendectomy. (opinion) [Ep 4 · 11:20](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=680)
- Both groups in the irrigation trial had abscess rates of 18% and 19%, which are higher than some other studies — Matt Carbon (clinical) [Ep 6 · 7:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- The higher abscess rates in the irrigation trial may be due to the specific definition of perforation used at that institution — Whit Holcomb (opinion) [Ep 6 · 8:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=491)
- The best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation — Whit Holcomb (opinion) [Ep 6 · 10:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=649)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria — Whit Holcomb summarizing a resource [Ep 1 · 23:41](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1421)
- Wound infection rate was 3.3% (6/180) for single-incision versus 1.7% (3/180) for three-port, p=0.5, not statistically different — Todd Ponsky summarizes what Dr. Whit Holcomb said [Ep 1 · 30:23](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=1823)
- Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation — Whit Holcomb summarizing a resource [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages — Whit Holcomb summarizing a resource [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively — Whit Holcomb summarizing a resource [Ep 1 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3138)
- Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years — Whit Holcomb summarizing a resource [Ep 1 · 56:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-h-314?t=3375)
- The RIFT study prospectively evaluated 15 different clinical prediction models in children with right iliac fossa pain to determine their accuracy. — Jose Campos summarizing the discussion [Ep 4 · 3:39](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=219)
- The Shira score had an area under the curve of 0.84 and a failure rate of 3%, making it effective for ruling out appendicitis. — Rod Gerardo summarizing the discussion [Ep 4 · 4:11](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=251)
- Introduction of a standardized ultrasound reporting template reduced equivocal reports from 27% to 9%. — Jose Campos summarizing the discussion [Ep 4 · 4:56](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- The standardized ultrasound reporting template reduced CT scan utilization from 19% to 9% without affecting negative laparotomy rates. — Jose Campos summarizing the discussion [Ep 4 · 4:56](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- In a pilot RCT comparing laparoscopic surgery versus antibiotics for acute non-perforated appendicitis in children, the surgical failure rate was 0% and the medical failure rate was 45%. — Jose Campos summarizing the discussion [Ep 4 · 6:37](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- The pilot RCT on non-operative management had 26 patients in one arm and 24 in the other arm. — Jose Campos summarizing the discussion [Ep 4 · 6:37](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- A large retrospective cohort study based on NSQIP database showed a 90% reduction in surgical site infection when using ceftriaxone plus metronidazole compared to cefoxitin for non-complicated appendicitis. — Jose Campos summarizing the discussion [Ep 4 · 7:35](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=455)
- Doctor Sean Saint Peter and Whitt Holcomb in 2005 defined perforated appendicitis as a hole in the appendix or fecal material in the abdomen. — Jose Campos summarizing the discussion [Ep 4 · 8:24](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=504)
- A 2008 study validated that a hole in the appendix and stool in the abdomen predict abscess rates. — Jose Campos summarizing the discussion [Ep 4 · 8:24](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=504)
- A retrospective cohort study of 5000 patients identified four intraoperative findings that correlate with complicated postoperative course: visible hole, abscess, fecal material, and diffuse fibrinopurulent exudate outside the right iliac fossa or pelvis. — Rod Gerardo summarizing the discussion [Ep 4 · 9:13](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=553)
- These four intraoperative findings were associated with higher adverse effects, higher length of stay, higher emergency visits, and higher use of hospital and patient resources after adjusting for all variables. — The host summarizing the discussion [Ep 4 · 9:13](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=553)
- The recent study differs from Saint Peter's study in that pus in the abdomen was found to be a predictor of abscess, whereas in Sean's study it was not. — Rod Gerardo summarizing the discussion [Ep 4 · 10:07](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=607)
- A double-blinded RCT of 243 patients comparing two doses of postoperative IV antibiotics versus placebo after laparoscopic appendectomy for simple appendicitis found a significant reduction in skin infection rate from 6.6% to 0.8%. — Jose Campos summarizing the discussion [Ep 4 · 10:33](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=633)
- A 6% baseline infection rate for simple appendicitis seems too high. — Rod Gerardo summarizing the discussion [Ep 4 · 11:08](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=668)
- A pre-post intervention study that eliminated opioid prescriptions after non-perforated appendectomy showed no increase in self-reported pain or extra medication use after discharge. — Jose Campos summarizing the discussion [Ep 4 · 12:05](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=725)
- Patients do well with Tylenol and/or Motrin after appendectomy and do not typically return asking for opiates. — Rod Gerardo summarizing the discussion [Ep 4 · 12:45](https://qa.library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=765)
- CT scan reviewers (6 surgeons including 2 fellows and 2 radiologists) were only 72% accurate in distinguishing perforated from non-perforated appendicitis when reviewing 200 CT scans — Rod Gerardo summarizing the discussion [Ep 6 · 2:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=128)
- Among 62 attending surgeons (adult and pediatric, from university, community, and children's hospitals), agreement in defining intraoperative laparoscopic images as perforated or non-perforated appendicitis was 27% — Rod Gerardo summarizing the discussion [Ep 6 · 4:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=240)
- Inter and intra-observer variability in assessing perforation from intraoperative images was close to chance alone, with surgeons not agreeing with themselves when shown the same image flipped and rotated — Whit Holcomb summarizing the discussion [Ep 6 · 5:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315)
- A standardized definition of perforated appendicitis as a hole in the appendix or a fecalith in the abdomen was implemented at one hospital — Rod Gerardo summarizing the discussion [Ep 6 · 6:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=360)
- Patients without a hole in the appendix or fecalith in the abdomen had an incidence of postoperative abscess less than 5% — Rod Gerardo summarizing the discussion [Ep 6 · 6:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=400)
- After implementing a standardized definition for perforated appendicitis, the non-perforation abscess rate decreased and the perforation abscess rate increased, suggesting previous misclassification — Rod Gerardo summarizing the discussion [Ep 6 · 7:10](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=430)
- In a randomized trial with 110 patients per arm, irrigation with minimum 500cc (average 850cc) showed no difference in postoperative abscess rate, length of stay, hospital cost, or operative time compared to no irrigation — Rod Gerardo summarizing the discussion [Ep 6 · 7:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- A study comparing standardized large-volume irrigation (3-12L in small focused aliquots) to surgeon preference showed 0% abscess rate with standardized irrigation versus 19% with surgeon discretion — Whit Holcomb summarizing the discussion [Ep 6 · 8:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=520)
- A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in postoperative abscess rates — Whit Holcomb summarizing the discussion [Ep 6 · 10:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609)

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