# Appendicitis — GCMD Library living collection

Updated: n/a · 11 episodes · 61 cited statements

## Episodes
### Tools

### Guidelines and Tools

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

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

### Technique Videos/OP Notes
- [IPEG Academy: Single Incision Laparoscopic Appendectomy](https://library.globalcastmd.com/watch/ipeg-academy-single-incision-laparoscopic-appendectomy-4348) — video · [machine version](https://library.globalcastmd.com/watch/ipeg-academy-single-incision-laparoscopic-appendectomy-4348.md)

### Updates
- [Journal Club: Appendicitis in 2021](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416) — podcast · 15:06 · [machine version](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416.md)
- [Acute Appendicitis 2020 Update](https://library.globalcastmd.com/watch/acute-appendicitis-2020-update-3378) — podcast · [machine version](https://library.globalcastmd.com/watch/acute-appendicitis-2020-update-3378.md)
- [Update Course Rewind: Perforated Appendicitis 2019](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934) — podcast · 12:08 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934.md)
- [Appendicitis: conservative vs. operative treatment](https://library.globalcastmd.com/watch/appendicitis-conservative-vs-operative-treatment-4780) — video · [machine version](https://library.globalcastmd.com/watch/appendicitis-conservative-vs-operative-treatment-4780.md)
- [Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized Controlled Trial](https://library.globalcastmd.com/watch/povidone-iodine-irrigation-for-pediatric-perforated-appendicitis-may-be-protective-a-bayesian-pilot-randomized-controlled-trial-2806) — article · [machine version](https://library.globalcastmd.com/watch/povidone-iodine-irrigation-for-pediatric-perforated-appendicitis-may-be-protective-a-bayesian-pilot-randomized-controlled-trial-2806.md)
- [Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic](https://library.globalcastmd.com/watch/delayed-presentation-and-sub-optimal-outcomes-of-pediatric-patients-with-acute-appendicitis-during-the-covid-19-pandemic-3202) — article · [machine version](https://library.globalcastmd.com/watch/delayed-presentation-and-sub-optimal-outcomes-of-pediatric-patients-with-acute-appendicitis-during-the-covid-19-pandemic-3202.md)
- [Clinical Pathway for Suspected Appendicitis](https://library.globalcastmd.com/watch/clinical-pathway-for-suspected-appendicitis-2064) — video · [machine version](https://library.globalcastmd.com/watch/clinical-pathway-for-suspected-appendicitis-2064.md)
- [Too Much Variability in Opioid Prescriptions for Pediatric Operations](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326) — video · [machine version](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326.md)

## Chapters
- [0:05](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=5) Introduction and speaker background (Ep 1)
- [2:20](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=140) Diagnostic approach and imaging for suspected appendicitis (Ep 1)
- [10:52](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=652) Antibiotic selection and dosing protocols (Ep 1)
- [15:11](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=911) Surgical technique: single-incision versus three-port laparoscopy (Ep 1)
- [21:32](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1292) Defining and identifying perforation intraoperatively (Ep 1)
- [25:46](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546) Same-day discharge for non-perforated appendicitis (Ep 1)
- [28:22](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1702) Outcomes of single-incision versus three-port appendectomy (Ep 1)
- [34:28](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068) Irrigation versus suction-only for perforated appendicitis (Ep 1)
- [38:21](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) Technical considerations: staplers, energy devices, and cautery (Ep 1)
- [41:00](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2460) Postoperative management of perforated appendicitis (Ep 1)
- [45:34](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2734) Management of well-defined abscess: early versus interval appendectomy (Ep 1)
- [52:00](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3120) Non-operative management and future directions (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=0) Study background and opioid epidemic context (Ep 11)
- [3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180) Study findings on prescribing patterns and variability (Ep 11)
- [5:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=300) Conclusions and call for standardized protocols (Ep 11)
- [0:00](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=0) Introduction and Context for Perforated Appendicitis Discussion (Ep 6)
- [2:02](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=122) Diagnostic Accuracy of CT and Intraoperative Visualization (Ep 6)
- [5:15](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315) Standardized Definition and Abscess Prediction (Ep 6)
- [7:54](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474) Irrigation Studies: Conflicting Evidence (Ep 6)
- [9:22](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=562) Aspiration versus Irrigation (Ep 6)
- [10:49](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=649) Audience Questions and Conclusion (Ep 6)
- [0:05](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=5) Case presentation and initial assessment (Ep 4)
- [2:53](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=173) Clinical prediction models for appendicitis (Ep 4)
- [4:43](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=283) Standardized ultrasound reporting (Ep 4)
- [6:33](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=393) Non-operative versus surgical management (Ep 4)
- [7:29](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=449) Preoperative antibiotic selection (Ep 4)
- [8:24](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=504) Defining complicated appendicitis (Ep 4)
- [10:33](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=633) Postoperative antibiotics for simple appendicitis (Ep 4)
- [12:05](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=725) Opioid-free discharge protocols (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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=911)
- Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics — Whit Holcomb (clinical) [Ep 1 · 12:58](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Initial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes) — Whit Holcomb (clinical) [Ep 1 · 46:12](https://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3448)
- Both arms of the irrigation trial had abscess rates of 18-19%, which is higher than some other studies, potentially due to the definition of perforation used. — Matt Carbon (clinical) [Ep 6 · 7:54](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- 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 · 10:51](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=651)
- The postoperative antibiotic study did not examine postoperative abscess rates, which is the primary concern after uncomplicated appendectomy rather than surgical site infections. — Todd Ponsky (opinion) [Ep 4 · 11:20](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=680)

## 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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-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://library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3375)
- In a study of 200 CT scans reviewed by 6 surgeons (including 2 fellows) and 2 radiologists, reviewers were only 72% accurate in determining whether an appendix was perforated or non-perforated. — Rod Gerardo summarizing the discussion [Ep 6 · 2:08](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=128)
- Among 110 surgeons (62 attendings and 48 fellows, including adult and pediatric surgeons from university, community, and children's hospitals), inter-observer agreement in defining intraoperative images as perforated or non-perforated appendicitis was 27%. — Rod Gerardo summarizing the discussion [Ep 6 · 4:00](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=240)
- In Doctor Ponsky's study, when the same laparoscopic image was shown upside down and flipped, surgeons did not agree with their own previous assessment, demonstrating intra-observer variability close to chance alone. — Whit Holcomb summarizing the discussion [Ep 6 · 5:15](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315)
- At Kansas City (Doctor Saint Peter's group), perforated appendicitis is defined as a hole in the appendix or a fecalith in the abdomen. — Rod Gerardo summarizing the discussion [Ep 6 · 6:00](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=360)
- When patients did not have either a hole in the appendix or stool in the abdomen, the incidence of postoperative abscess was less than 5%. — Rod Gerardo summarizing the discussion [Ep 6 · 6:30](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=390)
- After implementing a standardized definition for perforated appendicitis, the non-perforation abscess rate decreased and the perforation abscess rate increased, suggesting previous misclassification of cases. — Rod Gerardo summarizing the discussion [Ep 6 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=420)
- In a randomized trial with 110 patients per arm using minimum 500cc irrigation (average 850cc), there was no difference in postoperative abscess rate, length of stay, hospital cost, or operative time between irrigation and no irrigation groups. — Rod Gerardo summarizing the discussion [Ep 6 · 7:54](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- In a study comparing standardized large-volume irrigation (3-12 liters in small focused aliquots) to surgeon preference irrigation, patients receiving standardized irrigation had 0% abscess rate versus 19% with surgeon discretion. — Whit Holcomb summarizing the discussion [Ep 6 · 8:40](https://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 the rate of postoperative abscess. — Whit Holcomb summarizing the discussion [Ep 6 · 10:09](https://library.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609)
- The RIFT study prospectively evaluated 15 different clinical prediction models in children with right iliac fossa pain by calculating area under the curve and failure rates. — Jose Campos summarizing a resource [Ep 4 · 3:39](https://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 the best performing model for ruling out appendicitis. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 4 · 4:11](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=251)
- A standardized ultrasound reporting template reduced equivocal reports from 27% to 9%. — Jose Campos summarizing a resource [Ep 4 · 4:56](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- The standardized ultrasound reporting reduced CT use from 19% to 9% without affecting negative laparotomy rates. — Jose Campos summarizing a resource [Ep 4 · 4:56](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- In a pilot RCT of non-perforated appendicitis, surgical failure rate was 0% versus 45% medical failure rate, with failure defined as requiring laparoscopic appendectomy during follow-up. — Jose Campos summarizing a resource [Ep 4 · 6:37](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- The non-operative versus appendectomy study randomized 26 patients to surgery and 24 to antibiotics. — Jose Campos summarizing a resource [Ep 4 · 6:37](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- Ceftriaxone plus metronidazole showed a 90% reduction in surgical site infection compared to cefoxitin for non-complicated appendicitis in a large NSQIP-based retrospective cohort study published in Annals of Surgery in 2020. — Jose Campos summarizing a resource [Ep 4 · 7:35](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=455)
- Dr. Sean Saint Peter and Whitt Holcomb defined perforated appendicitis in 2005 as a hole in the appendix or fecal material in the abdomen. — Jose Campos summarizing a resource [Ep 4 · 8:24](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=504)
- Four intraoperative findings correlate with complicated postoperative course for appendicitis: visible hole, abscess, fecal material, and diffuse fibrinopurulent exudate outside the right iliac fossa or pelvis. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 4 · 9:13](https://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. — Todd Ponsky summarizes what Dr. Jose Campos said [Ep 4 · 9:56](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=596)
- Pus in the abdomen is a predictor of abscess in the recent study, which differs from Sean Saint Peter's study where it was not a predictor. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 4 · 10:07](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=607)
- A double-blind RCT of 243 patients randomized to two doses of postoperative antibiotics versus placebo found a significant reduction in skin infection rate from 6.6% to 0.8% for simple appendicitis. — Jose Campos summarizing a resource [Ep 4 · 10:33](https://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 summarizes what Dr. Jose Campos said [Ep 4 · 11:08](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=668)
- A pre-post intervention study completely eliminated opioid prescriptions after non-perforated appendectomy and found no increase in self-reported pain or extra medication use via phone interviews and surgical follow-up. — Jose Campos summarizing a resource [Ep 4 · 12:05](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=725)
- After converting from opiates to Tylenol and/or Motrin for post-appendectomy pain, patients are fine and do not come back asking for opiates. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 4 · 12:45](https://library.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=765)
- Of adolescents who use opioid prescriptions recreationally, 80% have their source from leftover medications. — Alex Gibbons summarizing a resource [Ep 11 · 0:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=0)
- There are currently no recommendations for opioid prescriptions for post-surgical patients in the pediatric population. — Alex Gibbons summarizing a resource [Ep 11 · 0:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=0)
- The study was a retrospective chart review of all patients who had an appendectomy for simple appendicitis between October 2016 and January 2018. — Alex Gibbons summarizing a resource [Ep 11 · 0:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=0)
- 62.5% of patients received narcotics after an appendectomy for simple appendicitis. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- There was no difference in narcotic prescribing based on race, sex, age, or insurance status. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- There was wide variability in oral morphine equivalents per kilogram per day prescribed. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- Prescription duration varied widely, with some patients receiving prescriptions for only one day while others received prescriptions for up to a month. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- Some surgeons gave only 6% of their patients a narcotic prescription, while others gave nearly 70% of their patients a prescription. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- Patients who received a prescription for opioids came to the emergency department over three times more often than those who did not. — Alex Gibbons summarizing a resource [Ep 11 · 3:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=180)
- The variability in opioid prescribing is evidence for the need for a standardized protocol for prescriptions after pediatric operations. — Alex Gibbons summarizing a resource [Ep 11 · 5:00](https://library.globalcastmd.com/watch/too-much-variability-in-opioid-prescriptions-for-pediatric-operations-1326?t=300)

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