# Non-perforated Appendicitis — GCMD Library living collection

Everything in the library about non-perforated appendicitis — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 40 cited statements

## Episodes
### Surgical Management
- [Perforated Appendicitis](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312) — video · 18:22 · [machine version](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312.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)

### Evidence & Research
- [Appendicitis Management & APPY Trial: Update Course 2016](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549) — video · 31:55 · [machine version](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549.md)
- [Quick Literature Updates Ep 26](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413) — video · 4:40 · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=0) APPY Trial Design and Background (Ep 1)
- [9:14](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=554) Protocol Details and Early Results (Ep 1)
- [20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245) Discussion: Antibiotic Stewardship, Fecoliths, and Clinical Applications (Ep 1)
- [0:01](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=1) CT scan accuracy in diagnosing perforated appendicitis (Ep 2)
- [2:28](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=148) Defining and identifying perforated appendicitis intraoperatively (Ep 2)
- [11:20](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=680) Role of irrigation in laparoscopic appendectomy for perforation (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=0) Introduction and Clinical Context (Ep 3)
- [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 3)
- [5:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315) Standardized Definition and Irrigation Evidence (Ep 3)
- [7:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474) Large-Volume Irrigation and Aspiration (Ep 3)
- [10:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609) Audience Questions and Conclusion (Ep 3)
- [0:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=16) Appendicectomy versus Antibiotics for Acute Uncomplicated Appendicitis in Children (Ep 4)
- [1:51](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=111) VACTERL Screening in Newborns with Anorectal Malformations (Ep 4)
- [3:01](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=181) International Consensus Criteria for Pediatric Sepsis and Septic Shock (Ep 4)
- [4:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=264) Closing (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The APPY trial is a multi-center randomized trial comparing appendectomy to non-operative treatment for non-perforated appendicitis. (clinical) [Ep 1 · 0:09](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=9)
- The initial working group included Agostino Piero, Nigel Hall, Simon Eaton, Thomas Wester, and several others, with the current group joining about 2.5 years ago. (clinical) [Ep 1 · 1:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=80)
- The first two rounds of funding failed, requiring modifications to sample size calculation and study design to make it more pragmatic. (clinical) [Ep 1 · 2:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=120)
- Appendicitis can be treated without surgery, as demonstrated by experience with complicated appendicitis where patients are treated to completion regardless of perforation severity. (clinical) [Ep 1 · 3:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=200)
- Bob Parry developed appendicitis in Ireland, was treated with antibiotics, and went a full year before having a recurrent bout requiring appendectomy. (clinical) [Ep 1 · 4:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=240)
- In the preference trial, any appendix that has to come out—even if due to parental preference after symptom resolution—must be considered a treatment failure because that reflects real-world practice. (clinical) [Ep 1 · 8:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=530)
- In the preference trial, parents of sicker-appearing children are less likely to choose non-operative management, even if objective measures like white count are similar. (clinical) [Ep 1 · 10:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=600)
- Patients who respond to antibiotics are literally normal the next day, going to school on Wednesday after discharge on Tuesday, whereas laparoscopic appendectomy patients restrict themselves for several days despite no formal restrictions. (clinical) [Ep 1 · 11:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=700)
- The APPY trial is designed as a non-inferiority study because non-operative management cannot possibly be superior to appendectomy, which has a 100% cure rate. (clinical) [Ep 1 · 13:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=800)
- The trial includes patients aged 5 to 16 with suspected non-perforated appendicitis, excluding those under 5 because they frequently have perforation regardless of presentation. (clinical) [Ep 1 · 14:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=850)
- The trial uses broad inclusion criteria without requiring specific Alvarado scores, PAS scores, or imaging findings, allowing surgeons to use their standard diagnostic approach for non-perforated appendicitis. (clinical) [Ep 1 · 15:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=900)
- Exclusion criteria include suspicion of perforation, more than two doses of antibiotics initiated at an outside facility, previous episode of appendicitis treated non-operatively, and systemic disease. (clinical) [Ep 1 · 15:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=950)
- The trial uses central randomization with minimization based on sex, center, and duration of symptoms to maintain balance across these factors. (clinical) [Ep 1 · 16:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1000)
- The protocol was modified to allow patients to go home the next day if doing well, rather than requiring 24-48 hour evaluations at fixed time points, because the original schedule was impractical for overnight enrollments. (clinical) [Ep 1 · 17:30](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1050)
- If patients are not better after initial therapy, they are given another day, but after 48 hours of IV therapy (by Wednesday morning), it is time to proceed with appendectomy because 3 days in the hospital is too much when the alternative is going home Monday. (clinical) [Ep 1 · 18:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1100)
- The primary outcome is treatment failure defined as an intervention for appendicitis requiring general anesthesia within 1 year in both groups, which essentially compares negative appendectomy versus recurrent appendicitis. (clinical) [Ep 1 · 19:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1150)
- The non-inferiority margin is 20% because polling showed most people consider failure rates in the twenties too high for non-operative management. (opinion) [Ep 1 · 20:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1200)
- The actual failure rate percentage is what matters to parents when counseling, not whether the trial concludes non-inferiority—some parents will accept 26% failure to avoid surgery while others won't accept 2%. (opinion) [Ep 1 · 20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245)
- As of the presentation, 52 patients have been enrolled: Stockholm 25, Helsinki 7, with Vancouver, Ontario, and Calgary recently receiving IRB approval. (clinical) [Ep 1 · 21:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1300)
- Early results show in the operative group: 4 perforations and 2 negative appendectomies. In the non-operative group: 1 readmitted for abscess, 3 failed early (didn't leave hospital), 4 failed after discharge (within 2-5 days), and 1 recurrence at 6 months. (epidemiological) [Ep 1 · 22:25](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1345)
- All recurrences and failures in the non-operative group have had confirmed appendicitis; no normal appendix has been removed yet. (clinical) [Ep 1 · 23:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1400)
- The two negative appendectomies in the operative group had imaging showing secondary signs like fluid but not visualizing the appendix. (clinical) [Ep 1 · 20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245)
- Of the 3 early failures in the non-operative group, 2 were due to parental impatience on the morning after enrollment, not giving the treatment a real chance. (clinical) [Ep 1 · 21:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1280)
- The reason for limiting antibiotics is that Augmentin is given daily in pediatric offices to thousands of children with sniffles who don't need it, whereas the APPY trial treats an active intra-abdominal bacterial infection. (opinion) [Ep 1 · 23:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1380)
- All perforated appendicitis cases are treated with antibiotics, and if complications develop, long-term antibiotics are used until resolution, so treating intra-abdominal infection is different from unnecessary antibiotic use. (clinical) [Ep 1 · 23:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1430)
- The value of the study is knowing the exact failure rates and outcomes to counsel patients who might want to avoid surgery or are in circumstances where surgery isn't immediately feasible, even if non-operative management proves inferior. (opinion) [Ep 1 · 25:07](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507)
- No adult literature has examined long-term outcomes beyond one year for non-operative management of appendicitis. (epidemiological) [Ep 1 · 25:07](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507)
- The trial plans to follow the cohort in perpetuity with annual telephone follow-up to determine recurrence rates at 5 years, 10 years, and beyond. (clinical) [Ep 1 · 25:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1540)
- Perforation is defined as a hole in the appendix or a fecolith in the abdomen—irrefutable proof of contamination—and is only an intraoperative diagnosis, not a preoperative one. (clinical) [Ep 1 · 27:25](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1645)
- The presence of a fecolith is an exclusion criterion in the Midwest Pediatric Surgery Consortium preference trial but not in the APPY trial. (clinical) [Ep 1 · 28:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1690)
- At Nationwide, a separate small population with appendicoliths was allowed enrollment, but that arm was stopped based on the failure rate. — Todd Ponsky (clinical) [Ep 1 · 29:02](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1742)
- In a cohort of patients with post-appendectomy abscesses, outcomes were relatively equivalent between drain and no drain, but the biggest abscesses and worst patients received drains. — Todd Ponsky (epidemiological) [Ep 1 · 29:56](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1796)
- After size-matching to 17.5 cm² (AP versus lateral in axial dimension), there was an advantage to not having a drain. — Todd Ponsky (epidemiological) [Ep 1 · 30:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1840)
- For abscesses less than 20 cm² (less than 4 x 5 cm), drains are typically discouraged because the advantage is small and drains add an extra anesthetic, procedure, and may increase length of stay. — Todd Ponsky (clinical) [Ep 1 · 31:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1870)
- Both groups in the irrigation trial had abscess rates of 18% and 19%, which are higher than some other studies — Matt Carbon (clinical) [Ep 3 · 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 3 · 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 3 · 10:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=649)
- A standardized definition of perforated appendicitis as a visible hole in the appendix or fecalith in the abdomen was developed by Doctor Saint Peter for prospective trials in the early 2000s and is still used. (guideline) [Ep 2 · 6:20](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=380)
- The abscess rates of 18% and 19% in the irrigation study are higher than some other studies because a standardized definition of perforation was used, ensuring non-perforated cases were not included in the perforated cohort. (clinical) [Ep 2 · 10:31](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=631)
- The Minnesota irrigation study had no definition of perforation mentioned and no standard antibiotic usage over the 10-year study period, and included only about 10 perforated appendicitis patients per year. (clinical) [Ep 2 · 11:27](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=687)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Recent literature has been supporting treating appendicitis with antibiotics rather than surgery — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=67)
- The Saint Peter et al. study was a multi-center randomized trial in Canada, the US, Finland, Sweden, and Singapore investigating whether antibiotic treatment is inferior to appendicectomy — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:12](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=72)
- 34% of children treated with antibiotics for appendicitis eventually required surgery within a year compared to only 7% in the surgery group — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=84)
- There were no deaths in either the antibiotic or surgery group for appendicitis treatment — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:32](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=92)
- Children in the antibiotic group had a higher risk of mild to moderate adverse events compared to the surgery group — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:32](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=92)
- Antibiotics were not as effective as surgery for treating non-perforated appendicitis in children, as it did not meet the threshold for non-inferiority — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 4 · 1:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=99)
- Zoo et al. used the PHIS database and performed a multi-institutional cohort study of all ARM patients between 2016 and 2022 — Alex Halpern summarizing a resource [Ep 4 · 2:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=136)
- In ARM patients, the rates of actual diagnoses across all hospital encounters were 45.4% vertebral spinal, 77.4% cardiac, 10.2% TEF, 39.9% renal and 15.7% limb — Alex Halpern summarizing a resource [Ep 4 · 2:25](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- 25.8% of female patients with anorectal malformations had a congenital gynecologic malformation diagnosed — Alex Halpern summarizing a resource [Ep 4 · 2:40](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=160)
- The most common anomalies associated with ARMs are cardiac, vertebrospinal, renal, and gynecologic — Alex Halpern summarizing a resource [Ep 4 · 2:45](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=165)
- The authors of the ARM screening study suggest changing the VACTERL acronym to VACTERL-GS — Alex Halpern summarizing a resource [Ep 4 · 2:53](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=173)
- The Schlapbach et al. study is a worldwide study with a Delphi consensus process that aimed to update the definitions of sepsis and septic shock — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 3:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=200)
- The Phoenix sepsis score includes variables in cardiovascular function, respiratory function, coagulation, and neurological function — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 3:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=209)
- The Phoenix sepsis score helped correlate the definition of sepsis with an actual mortality rate — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 3:42](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=222)
- The definition of sepsis is suspected infection plus 2 points in the Phoenix sepsis score — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 3:48](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=228)
- Septic shock is defined as sepsis plus cardiovascular dysfunction that is seen when there is 1 point in the cardiovascular variable of the Phoenix sepsis score — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 3:48](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=228)
- Sepsis has a mortality rate of 7.1% — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 4:06](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=246)
- Septic shock has a mortality rate of 10.8 to 33.5% according to the research settings — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 4 · 4:06](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=246)
- In adult studies reviewing approximately 300 patients managed non-operatively versus 500 managed operatively, treatment failure trended toward favoring surgical approach, but complications favored non-operative management. — The host summarizing the discussion [Ep 1 · 5:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=350)
- Adult estimates of non-operative management success revolve around 80%, which was integral in developing the sample size for the randomized trial. — The host summarizing the discussion [Ep 1 · 7:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=420)
- Thomas Wester's pilot randomized trial in Sweden enrolled 50 patients, with 24 receiving antibiotics. 22 of 24 (92%) had initial resolution of symptoms, and one patient had recurrent appendicitis. — The host summarizing the discussion [Ep 1 · 8:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=480)
- At 77 patients in the preference trial, 30 chose non-operative treatment (about one-third), with 90% success at 30 days and fewer disability days, earlier return to school, and improved quality of life versus surgery. — The host summarizing the discussion [Ep 1 · 10:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=650)
- 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 10:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609)
- In a study of 200 CT scans reviewed by 6 surgeons (including 2 fellows) and 2 radiologists, reviewers correctly diagnosed perforated versus non-perforated appendicitis in 72% of cases, with cases containing abscesses excluded. — The host summarizing the discussion [Ep 2 · 0:01](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=1)
- In a study of 110 surgeons (62 attendings, 48 fellows) from university, community, and children's hospitals assessing images of appendices, agreement on whether an appendix was perforated was 27% among attendings. — The host summarizing the discussion [Ep 2 · 2:28](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=148)
- Inter-observer and intra-observer variability in assessing appendiceal perforation was close to chance alone, with surgeons not agreeing even with themselves when shown the same image rotated and flipped later in the study. — The host summarizing the discussion [Ep 2 · 5:40](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=340)
- When patients without a hole in the appendix or stool in the abdomen were grouped together, the incidence of postoperative abscess was less than 5%. — Todd Ponsky summarizing the discussion [Ep 2 · 7:30](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=450)
- In the two years before applying a standardized perforation definition, 292 non-perforated appendicitis cases had a 1.7% abscess rate and 131 perforated cases had a 14% abscess rate. — The host summarizing the discussion [Ep 2 · 8:20](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=500)
- After applying the standardized definition for two years, the abscess rate for non-perforated appendicitis dropped and the rate for perforated appendicitis rose from 14% to 18%, indicating that some perforated cases had previously been misclassified as non-perforated. — The host summarizing the discussion [Ep 2 · 9:20](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=560)
- In a prospective study comparing irrigation and suction versus suction alone during laparoscopic appendectomy for perforated appendicitis, with 110 patients in each arm and a minimum of 500cc irrigation (average 850cc), there was no difference in abscess rate, length of hospitalization, hospital charges, or operative time. — The host summarizing the discussion [Ep 2 · 10:31](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=631)
- A retrospective study from University of Minnesota (2007-2017, 432 patients, 105 perforated) found that standardized large-volume irrigation (3-12 liters in small focused aliquots) resulted in 0% abscess rate versus 19% with surgeon preference irrigation. — The host summarizing the discussion [Ep 2 · 11:27](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=687)
- A meta-analysis of irrigation versus suction alone for laparoscopic appendectomy included 3 randomized trials and 2 retrospective studies with 2500 patients (4/5 adults) and found no difference in abscess development, wound infection, or length of hospitalization. — The host summarizing the discussion [Ep 2 · 14:20](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=860)
- In the Minnesota study, the surgeon using high-volume irrigation performed focused irrigation in small aliquots with a push-suck technique, never irrigating the whole belly, using approximately 100cc at a time. — The host summarizing the discussion [Ep 2 · 16:34](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=994)
- In the standardized definition study, the presence of exudate everywhere did not correlate with abscess risk when there was no actual hole or stool present. — The host summarizing the discussion [Ep 2 · 17:03](https://qa.library.globalcastmd.com/watch/perforated-appendicitis-2312?t=1023)

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