Abstract
The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.
Highlights
After adolescence, the incidence of acute appendicitis (AA) decreases with increasing of age [1]
Statement 4.5 We suggest the use of Magnetic resonance imaging (MRI) to confirm or exclude the diagnosis of acute appendicitis and to distinguish perforated from non-perforated appendicitis in elderly patients with an Alvarado score ≥ 5 who cannot undergo Computed tomography (CT) scan with IV contrast, if this resource is available
Statement 9 In elderly patients operated for acute appendicitis, there are no clinical evidences about advantages in the use of linear stapler against other methods for stump closure; we suggest the use of the preferred technique based on local expertise and availability (Conditional recommendation, moderate quality evidences)
Summary
The incidence of acute appendicitis (AA) decreases with increasing of age [1]. The complicated appendicitis rate ranges from 18 to 70% [2, 4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21] (compared to a rate ranging from 3 to 29% among patients younger than 65 years old) The reason for this high risk of perforation could be the vascular sclerosis that the vermiform appendix develops in elderly patients and the narrowing of the lumen by fibrosis. The muscular layers are infiltrated with fat and there is a structural weakness with tendency towards early perforation [6].These finding, together with the delay of the diagnosis and of the treatment, could explain a more aggressive course of the disease in this population
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