Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

Salomone Di Saverio,Richard Ten Broek,Gian Luigi De’ Angelis,Gia Tomadze,Ari Leppäniemi,Edward Tan,Carlos Augusto Gomes,Boris Sakakushev,Gabriele Sganga,Sandro Rizoli,Roland Andersson,Cino Bendinelli,Francesco Pata,Kjetil Søreide ,Belinda De Simone,Andrew B Peitzman,Richard J Davies ,Thomas M Scalea ,Dieter Weber ,Adolfo Pisanu,Zsolt J Balogh,Massimo Sartelli,Andrew W Kirkpatrick ,Luca Ansaloni,Michael Sugrue,Oreste Romeo,Massimo Chiarugi,Zaza Demetrashvili,Isidoro Di Carlo,Helmut Alfredo Segovia-Lohse ,Fabio Cesare Campanile ,Ernest E Moore,Gian Luca Baiocchi ,Rao R Ivatury ,A Gori ,Arianna Birindelli,Antonio Tarasconi,Nicola De Angelis ,Gustavo Pereira Fraga ,Rifat Latifi,Mauro Podda,Michael E Kelly ,Walter L Biffl ,Federico Coccolini,Osvaldo Chiara,Marco Ceresoli,Jeffry L Kashuk ,David W Da Costa ,Dimitrios Damaskos,Marja A Boermeester ,Harry Van Goor,George C Velmahos ,Goran Augustin,Andrey Litvin,Yoram Kluger,Raúl Coimbra ,Fakri Abu-Zidan,Matti Tolonen,Ronald V Maier,Fausto Catena

doi:10.1186/s13017-020-00306-3

Abstract

Background and aimsAcute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide.In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.MethodsThis executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.ConclusionsThe 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

Highlights

Background and aimsAcute appendicitis (AA) is among the most common causes of acute abdominal pain
Recommendation 1.6.2 In pediatric patients with suspected acute appendicitis, we suggest adopting both biomarker tests and scores in order to predict the severity of the inflammation and the need for imaging investigation [quality of evidence (QoE): Very Low; Strength of recommendation: Weak: 2D]
Statement 1.10 Patients with strong signs and symptoms and high-risk of Recommendation 1.9 We suggest that cross-sectional imaging (i.e., computed tomography (CT) scan) in Recommendation appendicitis according to AIR score/Alvarado score/Adult Appendicitis Score (AAS) score and younger than 40 years may not require cross-sectional pre-operative imaging (i.e., CT scan)

Summary

Introduction

Background and aimsAcute appendicitis (AA) is among the most common causes of acute abdominal pain. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of nonoperative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and perioperative antibiotic therapy. Acute appendicitis (AA) is among the most common causes of lower abdominal pain leading patients to attend the emergency department and the most common diagnosis made in young patients admitted to the hospital with an acute abdomen. There is great variation in the presentation, severity of the disease, radiological workup, and surgical management of patients having AA that is related to country income [5]

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