Update Course Rewind: Perforated Appendicitis 2019

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.

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%.

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.

At Kansas City (Doctor Saint Peter's group), perforated appendicitis is defined as a hole in the appendix or a fecalith in the abdomen.

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%.

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.

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.

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.

A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in the rate of postoperative abscess.