Acute Appendicitis

- Recommendations

1.    Clinical scores for acute appendicitis

·   We recommend to adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diagnostic pathway in patients with suspected acute appendicitis, depending on age, sex, and clinical signs and symptoms of the patient, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·  We recommend the use of clinical scores, (Alvarado score and the new Adult Appendicitis Score) to exclude acute appendicitis and identify intermediate-risk patients needing of imaging diagnostics, (Strong recommendation, high certainty evidence, ⁽⁴⁾).

2.   What is the role of serum biomarkers in evaluating patients presenting with clinical features evocative of acute appendicitis:

·  We recommend the use of biochemical markers as a diagnostic tool for the identification of both negative cases and complicated acute appendicitis in adults, (good practice statement, low certainty evidence ⁽⁶⁾).

3.    Should abdominal CT versus ultrasonography  be used for diagnosing acute appendicitis?

·    We recommend POCUS (point of care ultrasound)  as the most appropriate first-line diagnostic tool in both adults and children, if an imaging investigation is indicated based on clinical assessment, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾).

·   We recommend the routine use of a combination of clinical parameters and US to improve diagnostic sensitivity and specificity and reduce the need for CT scan in the diagnosis of acute appendicitis, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾).

4.    Unresolved  RT iliac fossa pain:

·  We recommend CT before surgery for patients with normal investigations but non-resolving right iliac fossa pain, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·  After negative imaging, initial non-operative treatment may be recommended, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

·   Explorative laparoscopy is recommended to establish/exclude the diagnosis of acute appendicitis or alternative diagnoses, in patients with progressive or persistent pain,  (Strong recommendation, high certainty evidence, ⁽⁴⁾).

5.    Acute appendicitis with pregnancy:

·   We suggest graded compression trans-abdominal ultrasound as the preferred initial imaging method for suspected acute appendicitis during pregnancy, (conditional recommendation, very low certainty evidence, ⁽⁶⁾).

·  We suggest MRI in pregnant patients with suspected appendicitis, if this resource is available, after inconclusive US, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

6.    Should adult patients with acute, uncomplicated appendicitis be managed nonoperatively versus operatively?

·  We recommend discussing NOM with antibiotics as a safe alternative to surgery in selected patients with uncomplicated acute appendicitis and absence of appendicolith, advising of the possibility of failure and misdiagnosing complicated appendicitis, (conditional recommendation, high certainty evidence, ⁽⁴⁾).

· We suggest against treating acute appendicitis non-operatively during pregnancy until further high-level evidence is available, (conditional recommendation, very low certainty evidence, ⁽⁴⁾).

·  In the case of NOM, we recommend initial intravenous antibiotics with a subsequent switch to oral antibiotics based on patient's clinical conditions, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

7.    Should adult with acute, uncomplicated appendicitis undergo delayed (> 12 h) or immediate operation (< 12 h)?

·   We recommend planning open or laparoscopic appendectomy for the next available operating list within 24 h in case of uncomplicated acute appendicitis, minimizing the delay wherever possible, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·  We recommend against delaying appendectomy for acute appendicitis needing surgery beyond 24 h from the admission, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

8.    Does laparoscopic appendectomy confer superior outcomes compared with open appendectomy for adult patients with acute appendicitis

·   We recommend laparoscopic appendectomy as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available, (Strong recommendation, high certainty evidence, ⁽⁴⁾).

·  We recommend laparoscopic appendectomy in obese patients, older patients, and patients with high peri- and postoperative risk factors, (conditional recommendation, moderate certainty evidence, ⁽⁴⁾).

·  We suggest laparoscopic appendectomy in pregnant patients in the first and second trimesters instead of open appendectomy when surgery is indicated, (conditional recommendation, moderate certainty evidence, ⁽⁴⁾).

9.    What are the best methods to reduce the risk of SSI in open appendectomies with contaminated/dirty wounds?

·  We recommend protection of the edges of the wound by ring protectors in open appendectomy to decrease the risk of SSI, (Strong recommendation, moderate certainty evidence ⁽⁶⁾).

·  We recommend primary skin closure with a unique absorbable intradermal suture for open appendectomy wounds, (conditional recommendation, moderate certainty evidence ⁽⁶⁾).

10.   In patients undergoing appendectomy for perforated appendicitis, should suction and lavage versus suction alone be used?

·  We recommend performing suction alone in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾).

11.  Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found?

·   We suggest appendix removal if the appendix appears “normal” during surgery and no other disease is found in symptomatic patients, (conditional recommendation, low certainty evidence, ⁽⁶⁾).

12.   Management of perforated appendicitis with phlegmon or abscess

·   We suggest the open or laparoscopic approach as treatment of choice for patients with complicated appendicitis with phlegmon or abscess, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

13.   Is histopathology is needed

·   We recommend routine histopathology after appendectomy, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).