Question special

Interesting that perforation was not excluded in the CODA trial and there was a 16% incidence noted in the appendectomy group, with a comparatively higher percentage (32%) in the antibiotic group who eventually underwent appendectomy. First question is why perforation was chosen to be included and whether this was done to more accurately reflect true incidence in the population with appendicitis. Second, would you attribute risk of perforation in the antibiotic group solely due to presence of appendicolith, as the data in the trial suggests (61 to 24% for those with an appendicolith vs 14 to 13% without)? Since it is possible that some patients who had perforation but could not have pathologic certainty (as they did not undergo appendectomy), I wonder if you believe future studies examining perforation in a similar manner to how the CODA trial analyzed appendicolith would yield valuable clinical insights?