WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

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.

Review of Operative vs. Non-Operative Management of Appendicitis in Pregnancy

“…These include the Appendicitis Inflammatory Response (AIR), Adult Appendicitis Score (AAS), and the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), with the most commonly used being the Alvarado Score (also known as MANTRELS) and the Pediatric Appendicitis Score (PAS) [53][54][55][56][57][58][59][60][61][62][63]. Of the clinical scoring systems used to aid in diagnosis of acute appendicitis, the Alvarado and Appendicitis Inflammatory Response scores have been the longest standing and most thoroughly evaluated [2,60,[63][64][65]. According to the World Society of Emergency Surgery's recent Jerusalem guidelines for diagnosis of acute appendicitis, Alvarado or AIR scores can be used to triage patients into further treatment categories [66].…”

“…However, these scoring systems have only been validated by level 2 and 3 evidence and are plagued by inadequate or inconsistent definitions for clinical variables [67]. Moreover, no data exist that demonstrates improvement in outcomes after implementation of any of the scoring systems [2,[68][69][70].…”

“…Acute appendicitis has a higher lifetime risk in males than females (8.6% vs. 6.7%), yet treatment with appendectomy is actually higher in women than in men (23% vs. 12%) [2,3]. Moreover, if treated without surgery at initial presentation, recurrence is higher for males [4].…”

“…Appendicitis in pregnancy is the most common cause of surgical intervention for an acute abdomen, followed by cholecystectomy, pancreatitis and bowel obstruction [5][6][7][8]. Non-obstetric surgery in pregnancy, for any gestational age, for a variety of indications, is performed for 1-2% of all pregnancies [2].…”

Management of Intra-Abdominal Infections

“…Recent WSES guidelines for diagnosis and treatment of acute appendicitis stated that laparoscopic appendectomy (LA) is the first choice where laparoscopic equipment and skills are available [96]. In the Sauerland et al review, wound infections were less likely after LA than after open appendectomy (OA) (OR 0.43; CI 0.34-0.54); however, the incidence of intra-abdominal abscesses was increased (OR 1.87; CI 1.19-2.93) [97].…”