WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis.

Salomone Di Saverio,Arianna Birindelli,Steve De Castro,Luca Ansaloni,Ernest E Moore,Osvaldo Chiara,Ferdinando Agresta,Roberto Cirocchi,Elio Jovine,Michael Sugrue,Micheal D Kelly,Fausto Catena,Yoram Kluger,Valeria Tonini,Mark De Moya,Roland Andersson,Sandro Rizoli,Manne Andersson,Carlos Augusto Gomes,Antonio Biondi,Cino Bendinelli,Fabio Cesare Campanile,Massimo Sartelli,Roberto Persiani,Ronald V Maier,Andrew B Peitzman,Aneel Bhangu,Gregorio Tugnoli,Alice Piccinini,F A Moore ,David W Da Costa ,Ewen A Griffiths ,Ari Leppäniemi ,Philip F Stahel ,Thomas M Scalea ,Zsolt J Balogh ,Raúl Coimbra ,Gustavo Pereira Fraga ,George C Velmahos ,Walter L Biffl ,Kurinchi Selvan Gurusamy ,Jeffry L Kashuk ,Dieter Weber ,Rao R Ivatury ,Kjetil Søreide

doi:10.1186/s13017-016-0090-5

Abstract

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Highlights

Acute appendicitis (AA) is a common cause of acute abdominal pain, which can progress to perforation and peritonitis, associated with morbidity and mortality
Statement 5.4.1: There are no clinical advantages in the use of endostapler over endoloops for stump closure for both adults and children. (EL 1, Grade of Recommendation (GoR) A) Statement 5.4.2: Endoloops might be preferred for lowering the costs when appropriate skills/learning curve are available. (EL 3, GoR B)
Imaging should be linked to Risk Stratification such as Appendicitis Inflammatory Response (AIR) or Alvarado score, low-risk patients being admitted to hospital and not clinically improving or reassessed score could have appendicitis ruled in or out by abdominal computed tomography (CT), in high-risk and young preoperative imaging may be avoided, magnetic resonance imaging (MRI) is recommended in pregnant patients with suspected appendicitis

Summary

Introduction

Acute appendicitis (AA) is a common cause of acute abdominal pain, which can progress to perforation and peritonitis, associated with morbidity and mortality. In order to elucidate the role of non-operative treatment of uncomplicated appendicitis, in 2012 Varadhan et al performed a meta-analysis including four randomized controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendectomy): the antibiotic treatment was associated with a 63 % success rate at 1 year and a lower complication rate with a relative risk reduction of 31 % if compared with appendectomy (RR 0.69, I2 = 0 %, P = 0.004).

Results

Conclusion