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R E V I E W

Open Access

Diagnosis and treatment of acute

appendicitis: 2020 update of the WSES

Jerusalem guidelines

Salomone Di Saverio

1,2*

, Mauro Podda

3

, Belinda De Simone

4

, Marco Ceresoli

5

, Goran Augustin

6

, Alice Gori

7

,

Marja Boermeester

8

, Massimo Sartelli

9

, Federico Coccolini

10

, Antonio Tarasconi

4

, Nicola de

’ Angelis

11

,

Dieter G. Weber

12

, Matti Tolonen

13

, Arianna Birindelli

14

, Walter Biffl

15

, Ernest E. Moore

16

, Michael Kelly

17

,

Kjetil Soreide

18

, Jeffry Kashuk

19

, Richard Ten Broek

20

, Carlos Augusto Gomes

21

, Michael Sugrue

22

,

Richard Justin Davies

1

, Dimitrios Damaskos

23

, Ari Leppäniemi

13

, Andrew Kirkpatrick

24

, Andrew B. Peitzman

25

,

Gustavo P. Fraga

26

, Ronald V. Maier

27

, Raul Coimbra

28

, Massimo Chiarugi

10

, Gabriele Sganga

29

, Adolfo Pisanu

3

,

Gian Luigi de

’ Angelis

30

, Edward Tan

20

, Harry Van Goor

20

, Francesco Pata

31

, Isidoro Di Carlo

32

, Osvaldo Chiara

33

,

Andrey Litvin

34

, Fabio C. Campanile

35

, Boris Sakakushev

36

, Gia Tomadze

37

, Zaza Demetrashvili

37

, Rifat Latifi

38

,

Fakri Abu-Zidan

39

, Oreste Romeo

40

, Helmut Segovia-Lohse

41

, Gianluca Baiocchi

42

, David Costa

43

, Sandro Rizoli

44

,

Zsolt J. Balogh

45

, Cino Bendinelli

45

, Thomas Scalea

46

, Rao Ivatury

47

, George Velmahos

48

, Roland Andersson

49

,

Yoram Kluger

50

, Luca Ansaloni

51

and Fausto Catena

4

Abstract

Background and aims: Acute 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-non-operative scoring, and peri-operative antibiotic therapy.

(Continued on next page)

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visithttp://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence:salo75@inwind.it;salomone.disaverio@gmail.com 1Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK

2Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy

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(Continued from previous page)

Methods: This 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.

Conclusions: The 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.

Keywords: Acute appendicitis, Appendicitis guidelines, Jerusalem guidelines, Consensus conference, Alvarado score, Appendicitis diagnosis score, Adult Appendicitis Score, Imaging, CT scan appendicitis, Non-operative management, Antibiotics, Complicated appendicitis, Appendectomy, Laparoscopic appendectomy, Diagnostic laparoscopy, Phlegmon, Appendiceal abscess

Background

Acute abdominal pain accounts for 7–10% of all emer-gency department accesses [1]. 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 ad-mitted to the hospital with an acute abdomen.

The incidence of AA has been declining steadily since the late 1940s. In developed countries, AA occurs at a rate of 5.7–50 patients per 100,000 inhabitants per year, with a peak between the ages of 10 and 30 [2,3].

Geographical differences are reported, with a lifetime risk for AA of 9% in the USA, 8% in Europe, and 2% in Africa [4]. Moreover, there is great variation in the pres-entation, severity of the disease, radiological workup, and surgical management of patients having AA that is related to country income [5].

The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40– 57%) and in patients older than 50 years (55–70%) [6].

Appendiceal perforation is associated with increased morbidity and mortality compared with non-perforating AA. The mortality risk of acute but not gangrenous AA is less than 0.1%, but the risk rises to 0.6% in gangrenous AA. On the other hand, perforated AA carries a higher mortality rate of around 5%. Currently, growing evidence suggests that perforation is not necessarily the inevitable result of appendiceal obstruction, and an increasing amount of evidence now suggests not only that not all patients with AA will progress to perforation, but even that resolution may be a common event [7].

The clinical diagnosis of AA is often challenging and involves a synthesis of clinical, laboratory, and radio-logical findings. The diagnostic workup could be

improved by using clinical scoring systems that involve

physical examination findings and inflammatory

markers. Many simple and user-friendly scoring systems have been used as a structured algorithm in order to aid in predicting the risk of AA, but none has been widely accepted [8–10]. The role of diagnostic imaging, such as ultrasound (US), computed tomography (CT), or mag-netic resonance imaging (MRI), is another major contro-versy [11,12].

Since surgeons started performing appendectomies in the nineteenth century, surgery has been the most widely accepted treatment, with more than 300,000 ap-pendectomies performed annually in the USA [13]. Current evidence shows laparoscopic appendectomy (LA) to be the most effective surgical treatment, being associated with a lower incidence of wound infection and post-intervention morbidity, shorter hospital stay, and better quality of life scores when compared to open appendectomy (OA) [14,15].

Despite all the improvements in the diagnostic process, the crucial decision as to whether to operate or not remains challenging. Over the past 20 years, there has been renewed interest in the non-operative manage-ment of uncomplicated AA, probably due to a more reli-able analysis of postoperative complications and costs of surgical interventions, which are mostly related to the continuously increasing use of minimally invasive tech-niques [16–18].

The most common postoperative complications, such as wound infection, intra-abdominal abscess, and ileus, vary in frequency between OA (overall complication rate of 11.1%) and LA (8.7%) [19].

In August 2013, the Organizational Board of the 2nd World Congress of the World Society of Emergency

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Surgery (WSES) endorsed its president to organize the first Consensus Conference on AA, in order to develop the WSES Guidelines on this topic. The Consensus Con-ference on AA was held in Jerusalem, Israel, on July 6, 2015, during the 3rd World Congress of the WSES, fol-lowing which, the WSES Jerusalem guidelines for diag-nosis and treatment of AA were published [20].

Over the last 4 years, major issues still open to debate in the management of AA have been reported concern-ing the timconcern-ing of appendectomy, the safety of in-hospital delay, and the indications to interval appendectomy fol-lowing the resolution of AA with antibiotics [21–24]. Therefore, the board of the WSES decided to convene an update of the 2016 Jerusalem guidelines.

Materials and methods

These updated consensus guidelines were written under the auspices of the WSES by the acute appendicitis working group.

The coordinating researcher (S. Di Saverio) invited six experienced surgeons (G. Augustin, A. Birindelli, B. De Simone, M. Podda, M. Sartelli, and M. Ceresoli) with high-level experience in the management of AA to serve as experts in this 2020 update of the WSES Jerusalem guidelines. The experts reviewed and updated the ori-ginal list of key questions on the diagnosis and treatment of AA addressed in the previous version of the guide-lines. The subject of AA was divided into seven main topics: (1) diagnosis, (2) non-operative management of 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) antibiotic prophylaxis and postoperative antibiotic treatment.

Both adults and pediatric populations were considered and specific statements and recommendations were made for each of two groups. Pediatric patients were de-fined as including children and adolescents aged be-tween 1 and 16 years old. Infants were excluded from this review.

Based upon the list of topics, research questions (Pa-tients/Population, Intervention/Exposure, Comparison, Outcome (PICO)) were formulated, reviewed, and adopted as guidance to conduct an exploratory literature search (Table1).

The searches were conducted in cooperation with a medical information specialist from the University of Bologna (A. Gori). A computerized search of different databases (MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials), and new citations were included for the period April 2015 to June 2019. No search restrictions were imposed. Search syntaxes have been reported in (Supplemetary material file1).

The search results were selected and categorized to allow comprehensive published abstract of randomized clinical trials, non-randomized studies, consensus con-ferences, congress reports, guidelines, government publi-cations, systematic reviews, and meta-analyses.

In the 2016 Jerusalem guidelines, the Oxford classifica-tion was used to grade the evidence level (EL) and the grade of recommendation (GoR) for each statement. In this updated document, quality of evidence and strength of recommendations have been evaluated according to the Grading of Recommendations, Assessment, Develop-ment and Evaluation (GRADE) system.

The GRADE system is a hierarchical, evidence-based tool, which systematically evaluates the available litera-ture and focuses on the level of evidence based upon the types of studies included. The quality of evidence (QoE) can be marked as high, moderate, low, or very low. This could be either downgraded in case of significant bias or upgraded when multiple high-quality studies showed consistent results. The highest quality of evidence stud-ies (systematic reviews with meta-analysis of randomized controlled trials) was assessed first. If the meta-analysis was of sufficient quality, it was used to answer the re-search question. If no meta-analysis of sufficient quality was found, randomized controlled trials (RCTs) and non-randomized cohort studies (n-RCS) were evaluated. The strength of the recommendation (SoR) was based on the level of evidence and qualified as weak or strong (Table2) [25–28].

The first draft of the updated statements and recom-mendations was commented on by the steering group of the guidelines and the board of governors of the WSES during the 6th WSES congress held in Nijmegen, Hol-land (26–28 June 2019). Amendments were made based upon the comments, from which a second draft of the consensus document was generated. All finalized state-ments and recommendations with QoE and SoR were entered into a web survey and distributed to all the au-thors and the board of governor’s members of the WSES by e-mail. The web survey was open from December 1, 2019, until December 15, 2019. The authors were asked to anonymously vote on each statement and recommen-dation and indicate if they agreed, (≥ 70% “yes” was cate-gorized as agreement), leading to the final version of the document.

Results

The literature search yielded 984 articles. The titles, ab-stracts, and full text were reviewed. In total, 157 articles were selected and reviewed in detail to define 48 state-ments and 51 recommendations addressing seven topics and 30 research questions. A summary of the updated 2020 guidelines statements and recommendations has been reported in Table3.

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Table 1 Research topics and key questions Top ic Key que stions 1. Diagnosis Q.1.1: What is the value of clinical sco ring syst ems in the manageme nt of adu lt patien ts with suspected app endic itis? Can they be used as a basis for a struc tured manageme nt? Q.1.2: In pediatric pat ients with suspe cted acute appendicitis cou ld the diagn osis be based onl y o n clinical scores? Q.1.3: What is the role of serum biomarkers in eva luating adu lt pat ients pre sentin g with clinical feature s evocat ive of acut e app endicit is? Q.1.4: What is the role of serum biomarkers in eva luating pediatric patie nts prese nting clinical feat ures highly suggestive o f acute appendicitis? Q.1.5: What is the optim um pathway for imaging in adult pat ients with suspe cted acute appendicitis? Q.1.6: What is the optim um pathway for imaging in pediatric patie nts with suspected acute app end icitis? 2. Non-ope rative m anage ment of unco mplicat ed acute app endicitis Q.2.1: Is non-ope rative manage ment wit h o r wit hout antibiotics a safe an d effect ive treatme nt opt ion for adu lt pat ients with unc omplicat ed acute appendicitis? Q.2.2: Is non-ope rative manage ment wit h o r wit hout antibiotics a safe an d effect ive treatme nt opt ion for pediatric pat ients with unco mpli-cated acute appendicitis? Q.2.3: What is the best non-operative manageme nt of pat ients with unc omplicat ed acute appendicitis? 3. Timing of appe ndecto my and in-h ospital del ay Q.3.1: D oes in-hosp ital de lay increase the rate of compl ications or perforation for adu lt patien ts with uncomp licated acu te app end icitis? Q.3.2: D oes in-hosp ital de lay increase the rate of compl ications or perforation for pe diatri c patien ts wit h unc omp licated acut e app endic itis? 4. Surgica l trea tment Q.4.1: D oes laparo scopic appendectomy confe r super ior outcom es compared with ope n app end ectomy for adult patie nts with acut e appendicitis? Q.4.2: D oes laparo scopic appendectomy confe r super ior outcom es compared with ope n app end ectomy for pediatric patie nts with acute appendicitis? Q.4.3: D oes laparo scopic single-inc ision sur gery confe r any advantage over the thre e-trocar techni que in pe rforming lap arosco pic app endec -tomy for adult patie nts with acute appendicitis? Q.4.4: D oes laparo scopic single-inc ision sur gery confe r any advantage over the thre e-trocar techni que in pe rforming lap arosco pic app endec -tomy for pediatri c patien ts wit h acute app end icitis? Q.4.5: Is out patie nt lap aroscopi c appendectom y safe and feas ible for pat ients with unc omplicat ed acute appendicitis? Q.4.6: Is lap arosco pic app end ectomy indi cated over ope n appendectom y in spe cific patie nt groups? Q.4.7: D oes aspiration alon e confe r clinical advantag es ov er lavage and asp iration for pat ients with com plicated acut e appendicitis? Q.4.8: D oes the type of me soappendix disse ction te chnique (endoc lip, end oloop, el ectro coagul ation, H armonic Scalpel, or LigaSure) produ ce different cl inical out comes for pat ients with acut e app endic itis undergoing appendectom y? Q.4.9: D oes the type of stum p clo sure te chnique (sta pler or end oloop, ligation or invag ination of the stump) produ ce diff erent clinical outcom es for patien ts with acute appendicitis unde rgoing app end ectomy ? Q.4.10: Is the use of abd omina l drai ns recom me nded after appendectom y for compl icated acute appendicitis in adu lt pat ients? Q.4.11: Is the use of abd omina l drai ns recom me nded after appendectom y for compl icated acute appendicitis in pediatric pat ients? Q.4.12: What are the be st method s to reduce the risk of SSI in ope n app endectom ies with contam inated /dirty wo unds? 5. Intra-oper ative gra ding of acu te app endicitis Q.5.1: What is the value of scoring systems for intra-o perative grad ing of acute appendicitis? Q.5.2: Shou ld the mac roscopically normal app end ix be remo ved during laparosco py for acut e right iliac fossa pain whe n no othe r exp lanatory pathology is fou nd? 6. Manage ment of perfora ted app endicitis wit h phlegmo n or abscess Q.6.1: Is earl y appendectom y an appro priate treatme nt com pared wit h delayed app endectom y for pat ients with pe rforated acute appendicitis with phlegm on or abscess ? Q.6.2: Is inte rval appendectom y always indi cated for patie nts with acut e appendicitis followin g succ essful NOM? 7. Periopera tive antib iotic therapy Q.7.1: Is pre ope rative antibiotic therapy recom mende d for patients with acu te app end icitis? Q.7.2: Are postope rative antibiotics alw ays indicated in adult pat ients followi ng appendectomy ? Q.7.3: Are postope rative antibiotics alw ays indicated in pediatric patie nts followi ng app end ectomy ?

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Table 2 GRADE Quality of evidence and strength of recommendations Qual ity of evide nce and streng th of recom mendat ion Clar ity of bal ance betwee n desirable and undesi rable effects Met hodolog ical qua lity of sup porting eviden ce Implication s High-quality evi dence, stron g recom mendat ion Desirab le effect s clear ly outwe igh unde sirable effect s or vice versa Consi stent evide nce from well-perfor med RCTs or except ion-ally st rong eviden ce from unbi ased observationa l studies Recom mendation can apply to most pat ients in mos t circumstances. Fu rther research is unlikely to change our confid ence in the esti mate effect Mod erate quality evide nce, stro ng recom mendat ion Desirab le effect s clear ly outwe igh unde sirable effect s or vice versa Evide nce from RCTs with impo rtant lim itations (incons isten t resul ts, method ologi cal flaws, indirect ness, im precisi on) or except ionally strong eviden ce from unbi ased observationa l studies Recom mendation can apply to most pat ients in mos t circumstances. Fu rther research (if performed) is like ly to have an im portan t impact on our conf idenc e in the estimat e of effec t and may chang e the es timate Low-q uality eviden ce, stron g recom mendat ion Desirab le effect s clear ly outwe igh unde sirable effect s or vice versa Evide nce for at least one critical out come from obse rvational studies, RCTs with se rious flaws or indirec t eviden ce Recom mendation may chang e whe n highe r qua lity evide nce becomes availab le. Furthe r res earch (if performed) is likely to have an impo rtant im pact on our conf idence in the estimat e of eff ect and is likely to chang e the es timate Very low-q ualit y evi-den ce, stron g recom -mendat ion (rarely app licable) Desirab le effect s clear ly outwe igh unde sirable effect s or vice versa Evide nce for at least one critical out come from unsy stemat ic clinical observations or very indirect evi dence Recom mendation may chang e whe n highe r qua lity evide nce becomes availab le; any es timate of effect for at least one critical outcom e is very uncert ain High-quality evi dence, weak reco mmend ation Desirab le effect s clo sely balance d with undesi rable effects Consi stent evide nce from well-perfor med RCTs or except ion-ally st rong eviden ce from unbi ased observationa l studies The best action may differ de pending on circ umstances or patien ts or societal valu es. Furthe r res earch is unlikely to chang e our confidenc e in the estimate effect Mod erate quality evide nce, we ak recom mendat ion Desirab le effect s clo sely balance d with undesi rable effects Evide nce from RCTs with impo rtant lim itations (incons isten t resul ts, method ologi cal flaws, indirect ness, im precisi on) or except ionally strong eviden ce from unbi ased observationa l studies Alter native app roac hes likely to be better for some pat ients under som e circumstances. Fu rther research (if performed) is likely to ha ve an import ant im pact on our confid ence in the estimat e of effec t and may chang e the es timate Low-q uality eviden ce, weak reco mmend ation Uncert ainty in the esti mates of de sirable effect s, harms , and burden; desirable effects, ha rms, an d burden may be closely bal anced Evide nce for at least one critical out come from obse rvational studies, RCTs with se rious flaws or indirec t eviden ce Other alternatives may be eq ually reason able. Furthe r research is very likely to have an import ant im pact on our confid ence in the esti mate of eff ect and is likely to chang e the estimat e Very low-q ualit y evi-den ce, weak recom mendat ion Majo r unc ertainty in the estimat es of desirable effect s, harms, and bur den ; desirable eff ects may or may not be bal anced with undesi rable effect s Evide nce for at least one critical out come from unsy stemat ic clinical observations or very indirect evi dence Other alternatives may be eq ually reason able. Any es timate of effec t, for at least one critical outcom e, is very unc ertain

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Table 3 Summary of the updated 2020 guidelines statements and recommendations Top ic Statement Recomm end ation 1. Diagnosis Statement 1.1 Establi shing the dia gnosis of acut e app endicit is based on cl inical presen tation an d phy sical exami natio n may be chal lenging . As the value of individ ual clinical variables to determ ine the like lihood of acute appendicitis in a patient is low, a tai lored individ ualized app roach is rec ommend ed, depen ding on disease proba bilit y, se x, and age of the patie nt. Recommend ation 1.1 We reco mmend to adopt a tai lored individ ualized diagnost ic approach for strat ifying the risk and disea se proba bility and planning an appropriate stepwis e diagno stic pathway in patie nts with suspected acu te appendicitis, depe nding on age , sex and clinical sig ns and symp toms of the patien t [QoE: Mod erate ; Stren gth of reco mmend ation: Strong; 1B]. Statement 1.2 Clinical scores alone , e.g. Alva rado score, AIR score, and the new Adult App endicit is Score are suff iciently sensitive to exclude acut e app endicit is, accurately iden tifying low-r isk pat ients and decreasing the nee d for imaging an d the negati ve appendectom y rates in such patien ts. Recommend ation 1.2 .1 We reco mmend the use of cl inical scores to excl ude acute appendicitis an d ident ify interm ediate-risk pat ients nee ding of im aging diagnost ics [QoE : High; Stre ngth of reco mmend ation : Strong; 1A]. Re commenda-tion 1.2.2 We sug gest not making the diagno sis of acut e appendicitis in pre gnant patien ts on symptom s and signs only. Laboratory tests an d inflam matory se rum parame ters shoul d always be req uested [QoE: Ve ry Lo w; Stre ngt h of recom men da-tion: Weak; 2C]. Statement 1.3 The Alvarado score is not sufficiently specific in diagno sing acut e appendicitis in adult s, seems unreliable in differ entiating compl icated from uncomp licated acut e app end icitis in elderly patie nts and is less sen sitive in patients with HIV . Recommend ation 1.3 We sugge st again st the use of Alva rado score to positi vely confirm the clinical suspici on of acut e app endicit is in adu lts [QoE: Mod erate; Stren gth of recom men dation: We ak; 2B ]. Statement 1.4 The AIR score an d the AAS sco re seem curre ntly to be the be st performing clinical pre diction sco res and ha ve the highest dis criminating powe r in adu lts with sus pecte d acut e app endicit is. The AIR an d AAS sco res decrease negative appendectom y rates in low-r isk groups and reduce the need for imaging studies and hospi tal adm issions in bot h low an d interm ediate-risk gro ups. Recommend ation 1.4 We reco mmend the use of AIR sc ore and AAS score as clinical pre dictors of acut e app endicit is [QoE: Hig h; Stre ngt h of recom mendat ion: Strong; 1A]. Statement 1.5 In pe diatric pat ients with suspe cted acut e appendicitis, the Alvarado score and Pe diatric App end icitis Score are useful tools in excl uding acute appendicitis. Recommend ation 1.5 In pediatric patie nts with suspected acu te app end icitis, we suggest agai nst making a dia gnosis based on cl inical sco res alone [QoE: Low; Stren gth of recom men dation: We ak: 2C]. Statement 1.6 Bioche mical markers repres ent a prom ising reliab le diagnost ic tool for the ident ificat ion of both neg ative cas es or com plica ted acut e app endic itis in adults. Ho wever, furt her high-q uality eviden ce is nee ded [QoE: Lo w; No recom mendation ]. Statement 1.7 White blood cell count, the differ ential wit h the calculation of the absolute neutrop hil cou nt, and the CRP are usef ul lab tests in pre dicting acute appendicitis in children; moreo ver, CRP le vel on admission ≥ 10 mg /L and leucocyt osis ≥ 16,0 00/mL are stron g pre dictive facto rs for app end icitis in pediatric patients . Recommend ation 1.6 .1 In evaluating children with sus pected app endicit is, we recom mend to req uest routine ly laboratory test s and serum inflam matory biomarkers [QoE : Very Lo w; Stren gth of reco mmend ation: Strong: 1D]. Recommend ation 1.6 .2 In pediatric patie nts with suspected acute app end icitis, we suggest adopting bot h biomark er tests an d sco res in or der to predict the severity of the inf lammation and the need for imaging investigation [QoE : Very Low; Stre ngth of reco mmend ation : Weak : 2D]. Statement 1.8 Combinat ion of US an d clinical (e.g. AIR, AAS scores ) parame ters forming com bined clinico-radiol ogical sco res may sig nificantly improve dia gnost ic sensitivity and specif icity and event ually replace the need for a C T scan in adult patients with sus pecte d acut e app endicit is. Recommend ation 1.7 We reco mmend the ro utine use of a combi nation of clinical parameters and US to im prove diagn ostic sensitivity an d spec ificity an d reduce the need for CT scan in the diagnosis o f acute appendicitis. The use of imaging dia gnostics is recom men ded in patie nts with suspected app end icitis afte r an initial asses sment and risk strat ificat ion using cl inical scores [QoE : Mod erate; Stren gth of recom men dation: Stro ng; 1B]. Statement 1.9 Interme diate -risk class ification iden tifies patien ts likely to be nefit from observation an d system atic dia gnostic imaging. Recommend ation 1.8 We sugge st proceedi ng with timely and system atic diagnost ic imaging in patien ts with interme diate -risk of acut e app end icitis [QoE: Moderate; Stre ngth of recom mendat ion: Weak ; 2B]. Statement 1.10 Patien ts with strong signs and sy mptom s and high-risk of Recommend ation 1.9 We sugge st that cross-s ectional imaging (i.e ., CT sc an) in

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Table 3 Summary of the updated 2020 guidelines statements and recommendations (Continued) Top ic Statement Recomm end ation appendicitis accord ing to AIR sco re/Alvarado sco re/AAS score and you nger than 40 years may not requi re cross-s ection al pre-o perative im aging (i.e., CT scan ). high-risk patie nts youn ger than 40 years old (with AIR score 9– 12 and Alvarado score 9– 10 an d AAS ≥ 16) may be avoid ed before procee ding to dia gnostic +/ − therapeutic lap arosco py [QoE: Mod erate ; Stren gth of recom men dation: Weak; 2B ]. Statement 1.11 POC US (Point -of-care Ultrasound) is a reliab le initial invest igation with satisfactory sen sitivity an d spec ificity in diagn osing acut e app endicit is, eas ing swift de cision-making by the em ergency physicians or sur geons. POCUS, if per-forme d b y an exper ienced ope rator, sho uld be conside red the most appropriate first-line diagno stic tool in both adu lts an d children. Recommend ation 1.1 0 We rec ommend POCUS as the mos t app ropriate first-li ne diagnost ic tool in bo th adults an d children, if an im aging investigation is indicated based on cl inical asses sment [QoE : Mod erate; Stre ngt h of recom mendat ion: Strong; 1B]. Statement 1.12 When it is indi cated, cont rast-e nhan ced low-d ose CT scan shoul d be preferre d over contrast-enhan ced stan dard-dose C T sc an. Diag nostic accu racy of contrast-enh anced low-dose CT is not inf erior to stan dard CT in diagno sing AA or distinguishing betw een unco mplicated an d com plicated acut e appendicitis and enab les significan t radiation dose reduction. Recommend ation 1.1 1 We rec ommend the use of contrast-enhan ced low-d ose CT scan over cont rast-enhanced standard-d ose CT scan for adolescent s an d youn g adults with suspected acu te app end icitis and negati ve US fin dings [QoE: Hig h; Stren gth of recom men dation: Stro ng; 1A]. Statement 1.13 In patients with nor mal invest igations an d symp toms unlikely to be acute appendicitis but which do not settle, cross-sec tional imaging is reco m-mende d before sur gery. Laparoscopy is reco mmend ed to es tablish/exc lude the diagnosis o f acute appendicitis and event ually treat the dis ease. Recommend ation 1.1 2 We rec ommend cross-sectional imaging b e fore sur gery for patie nts with normal inve stiga tions but non-reso lving right iliac fossa pain. After negati ve imaging, initial non-ope rative treat ment is appropriate. Ho wever, in patien ts with progr es sive or pe rsistent pai n, exp lorative laparo scopy is recom -mende d to establish/exclu de the diagno sis of acute appendicitis or alternative diagnose s [QoE : High; Stren gth of reco mmend ation: Strong; 1A]. Statement 1.14 MRI is sensitive and highl y specific for the dia gnosi s o f acu te appendicitis dur ing pre gnancy. Howe ver, a neg ative or inc oncl usive MRI does not exclude app endic itis and surgery sho uld be still conside red if high clinical suspicio n. Recommend ation 1.1 3.1 We suggest grad ed compre ssion trans-abdom inal ultra-sound as the preferred initial im aging method for suspected acu te app end icitis during pregnanc y [QoE: Very Low; Stre ngth of Recomm end ation : Weak; 2C]. Rec-ommend ation 1.13 .2 We sug gest MRI in pre gnant patie nts with suspected ap-pendicitis, if this resource is available, afte r incon clusive US [QoE : Mod erate; Stren gth of recom men dation: We ak; 2B ]. Statement 1.15 The use of US in children is accu rate and safe in terms of perforation rates, emer gen cy de partm ent re-visits, and neg ative appendectomy rates. CT use may be de creased by usi ng app ropri ate cl inical and/ or staged algo-rithm wit h U S/MRI. MRI ha s at le ast the same se nsitivity and spe cificity as CT and, although higher cos ts, shoul d b e pre ferred over CT as second -line imaging in children. Recommend ation 1.1 4.1 In pe diatric pat ients with suspe cted appendicitis, w e suggest the use of US as first-li ne imaging. In pediatric patie nts with inco nclusive US, we suggest choos ing the second -line imaging techni que based on local avail-ability and exper tise, as there are curre ntly no st rong data to sugge st a be st dia g-nostic pat hway due to a variety of opt ions and depe ndence on local res ources [QoE: Mod erate ; Stren gth of reco mmend ation: Weak: 2B]. Recom mendat ion 1.14.2 Since in pediatric patie nts with equiv ocal CT finding the pre valence o f tru e acute appendicitis is not neg ligible, w e sugge st against the ro utine use of CT as first-lin e imaging in chi ldren with right ili ac fossa pai n [QoE: Mod erate ; Stre ngth of recom mendat ion: Weak ; 2B]. 2. Non-ope rative m anage -ment of unco mplic ated acute app endicitis. Statement 2.1 The antibiotic-first strategy can be cons idere d safe an d effec tive in selecte d pat ients with unc omplicat ed acute appendicitis. Patien ts who wish to avoid surge ry must be aware of a ris k o f recurrence of up to 39% after 5 years. Most rece nt dat a from me ta-analy ses of RCTs showe d that NOM with an tibiotics achieves a sign ificantly lower overa ll compl ication rate at 5 years and short er sick leave com pared to surge ry. Recommend ation 2.1 .1 We reco mmend dis cussing NOM with antibiotics as a safe alternative to surge ry in se lected patie nts with unco mplicat ed acute appendicitis an d abs ence of appendicolith, advising of the possibility of failure and mi sdiagnosing com plica ted app endic itis [QoE: H igh; Strengt h o f Recomm end ation: Strong; 1A]. Recom mendat ion 2.1.2 We sugge st against treating acute appendicitis non-ope rative ly dur ing pre gnanc y until furt her high-level evide nce is available [QoE: Ve ry Low; Stre ngth of Recomm end ation: Weak; 2C]. Statement 2.2 NOM for unco mplicat ed acute appendicitis in children is feasible, safe and effect ive as initial treat ment. Howe ver, failure rate inc reases in the presen ce of appendicolith, and sur gery is reco mmend ed in such cas es. Recommend ation 2.2 We sugge st discuss ing NOM with anti biotics as a saf e and effect ive alt ernative to sur gery in children wit h unc omp licated acut e app endic itis in the abs ence of an appendicolith , advising of the possibility of failure and misdiagno sing compl icated app end icitis [QoE : Moderate; Stre ngth of

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Table 3 Summary of the updated 2020 guidelines statements and recommendations (Continued) Top ic Statement Recomm end ation recom mendat ion: Weak ; 2B]. Statement 2.3 Current evi dence support s initial intr avenou s anti biotics with subsequ ent conversion to or al antibiotics unt il further evide nce from ongoing RCT is available. Recommend ation 2.3 In the case of NOM, we rec ommend initial intravenous antibiotics with a subsequ ent switch to or al antibiotics bas ed on patie nt's clinical condit ions [QoE : Mod erate; Stre ngt h of recom mendat ion: Stro ng; 1B]. Statement 2.4 Uncompl icated acute appendicitis may safe ly resolve spontane ously with similar treatme nt failu re rates, short er lengt h o f stay an d costs compared with antibiotics . Howe ver, the re is still limite d dat a for the panel to expre ss in fav or of or against the sy mptom atic treat ment with out antibiotics [QoE: Moderate; No recom mendat ion]. 3. Timing of appe ndecto my and in-hospit al delay Statement 3.1 Short, in-hosp ital sur gical de lay up to 24 h is safe in unc omp licated acute appendicitis an d doe s not increase compl ication s and/ or perforation rate in adults. Su rgery for unc omp licated acut e app endicit is can be pla nned for the next available list min imizing delay whe rever poss ible (b etter pat ient com fort, etc.) . Short, in-h ospital delay with obse rvation and repeated trans -abdo minal US in pregnant pat ients with eq uivocal app endic itis is acce ptable and doe s not seem to increase the risk of mat ernal and fetal adve rse outcom es. Recommend ation 3.1 We reco mmend pla nning laparosc opic appendectomy for the next available operating list within 24 h in case of unc omp licated acut e appendicitis, min imizing the de lay whereve r poss ible [QoE : Mod erate; Stre ngt h o f recom mendat ion: Stron g; 1B]. Statement 3.2 Delaying app endectom y for unc omplicat ed acut e appendicitis for up to 24 h after admission doe s not app ear to be a risk fact or for compl icated appendicitis, postope rative sur gical site inf ection or morb idity. Conve rsely , appendectomie s p e rformed after 24 h from adm ission are related to an inc reased risk of adve rse outcom es. Recommend ation 3.2 We reco mmend agai nst delaying app endectom y for acut e appendicitis nee ding surge ry beyond 24 h from the adm ission [QoE: Mod erate ; Stren gth of recom men dation: Stro ng; 1B]. Statement 3.3 Append ectomy performed with in the first 24 h from presen tation in the case of unco mplicat ed appendicitis is not ass ociated with an increased ris k of perforation or adve rse outcom es. Ear ly app end ectomy is the be st managemen t in com plicated app endicit is. Recommend ation 3.3 We sugge st again st de laying app end ectomy for pediatric patien ts with unc omp licated acut e app endic itis needi ng sur gery be yond 24 h from the admission. Early app endectom y within 8 h should be performed in cas e of compl icated appendicitis [QoE : Low; Stre ngt h o f Recomm end ation : Weak ; 2C]. 4. Surgica l trea tment Statement 4.1 Laparoscopic appendectom y offers significan t advantages over open app endec tomy in term s of le ss pain, lower inciden ce of surgical site infection , decreased leng th of hos pital stay , earlier return to work , overa ll costs , and be tter qua lity of life scores . Recommend ation 4.1 We reco mmend lap aroscopi c app endectom y as the preferre d app roach ov er open app end ectomy for both unc omplicat ed and compl icated acut e app end icitis, where laparosco pic eq uipmen t and exp ertise are available [QoE: Hig h; St rength of recom men dation: Stro ng; 1A]. Statement 4.2 Laparoscopic appendectom y is associ ated with lowe r postope rative pain, lower inc idence of SSI an d highe r qua lity of life in children. Recommend ation 4.2 We reco mmend lap aroscopi c app endectom y shoul d be preferre d over open app endectom y in children whe re lap aroscopi c equip ment and exp ertise are available [QoE: Mod erate ; Stre ngth of reco mmend ation : Strong; 1B]. Statement 4.3 Single-incision laparo scopic appendectom y is basically feas ible, safe, and as effect ive as conven tional three-port laparo scopic appendectom y, op-erative times are longer, requires highe r doses of analg esia, and is associated with a highe r incidenc e of wo und infect ion. Recommend ation 4.3 We reco mmend conve ntiona l thre e-port lap arosco pic ap-pende ctomy over sing le-incision laparo scopic appendectomy , as the convent ional laparosc opic app roac h is associ ated with short er ope rative ti mes, less posto pera-tive pai n, and lower inciden ce of wound inf ection [QoE : High; Stre ngth of reco m-mendat ion: Stron g; 1A]. Statement 4.4 In chi ldren with acute appendicitis, the sing le inc ision / transum bilical extrac orpore al laparo scopic-assisted te chnique is as safe as the lap -aroscopi c three-port techni que. Recommend ation 4.4 In pediatric patie nts with acut e appendicitis and fav orable anatomy , w e sugge st performing single inc ision/t ransumb ilical extracorporeal laparosc opic ass isted appendectom y o r traditional three-port laparo scopic ap-pende ctomy based on loc al skil ls and experti se [QoE: Low; Strengt h of recom men-dation: We ak; 2C]. Statement 4.5 Outpatie nt lap aroscopi c app endectom y for unc omplicat ed acut e appendicitis is feas ible and safe without any differenc e in morbidity and Recommend ation 4.5 We sugge st the adoption of out patie nt laparo scopic appendectomy for unco mplicated appendicitis, provi ded that an amb ulatory

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Table 3 Summary of the updated 2020 guidelines statements and recommendations (Continued) Top ic Statement Recomm end ation readmission rates. It is associ ated with pot ential be nefits of earlier recove ry after surgery and lowe r hos pital and social cos ts. pathway with we ll-defined ERAS protocol s and patie nt information/c onsent are lo-cally established [QoE: Mod erate ; Stren gth of reco mmend ation: Weak; 2B]. Statement 4.6 Laparoscopic appendectom y seems to show releva nt advantag es compared to ope n app endectom y in obese adu lt patients , older patie nts, an d patients with com orbidit ies. Laparoscopic app endectom y is asso ciated with reduced mort ality, red uced overa ll morb idity, reduc ed superfi cial wound infection s, shorter operating time s and postope rative le ngth of hos pital stay in such pat ients . Recommend ation 4.6 We sugge st laparosc opic appendectomy in obe se patien ts, older patien ts an d patie nts with high peri-an d posto perative risk facto rs [QoE: Moderate; Stre ngth of recom mendat ion: Weak ; 2B]. Statement 4.7 Laparoscopic appendectom y during pregnanc y is safe in term s o f risk of feta l loss an d preterm delivery an d it is preferab le to open sur gery as associated to sho rter le ngth of hospital stay and lowe r inc idenc e o f sur gical site infection . Recommend ation 4.7 We sugge st laparosc opic appendectomy should be preferre d to o p e n app endectom y in pregnant patients whe n surge ry is indicated. Laparoscopy is techni cally safe an d feas ible dur ing pregn ancy wh ere exp ertise of laparosc opy is available [QoE: Moderate; Stre ngth of recom mendation : Weak ; 2B]. Statement 4.8 Periton eal irrigation doe s not have an y advantage ov er suction alone in compl icated app end icitis in both adu lts an d chi ldren. The pe rformanc e of irrigat ion dur ing lap arosco pic app end ectomy doe s not seem to prevent the develo pment of IAA and wo und infect ions in neith er adult s nor pe diatric pat ients. Recommend ation 4.8 We reco mmend pe rforming suct ion alone in compl icated appendicitis pat ients with intr a-abdominal col lections undergoing laparosc opic appendectomy [QoE: Mod erate ; Stren gth of recom me ndation: Strong; 1B]. Statement 4.9 There are no clinical diff erenc es in out comes, length of hospital stay and compl ication s rates be tween the diff erent techni ques describ ed for mesente ry dissection (mon opolar el ectro coagulation, bip olar ene rgy, me tal cl ips, endolo ops, LigaSure, Harm onic Scal pel, etc.) . Recommend ation 4.9 We sugge st the use of monopol ar electr ocoagulation an d bipolar energy as the y are the mos t cost-ef fective techni ques, whereas othe r en-ergy de vices can be used depen ding on the intr a-operat ive judgm ent of the sur-geon an d reso urces available [QoE: Mod erate ; Stre ngth of reco mmend ation : Weak ; 2B]. Statement 4.10 There are no clinical advantages in the use of endost aplers ov er endolo ops for stum p cl osure for both adu lts an d chi ldren in ei ther simple or compl icated app end icitis, except for a lowe r inc idence of wound infect ion wh en using end ost aplers in children with unc omplicat ed appendicit is. Polym eric cl ips may be the cheapest and easie st me thod (w ith shorter operative times) for st ump closure in unc omp licated app endicit is. Recommend ation 4.1 0 We rec ommend the use of endolo ops/sutu re ligat ion or polym eric clips for st ump cl osure for both adu lts an d chi ldren in ei ther uncomp licated or com plicated appendicit is, whe reas end ostaplers may be used when de aling with compl icated cases depe nding on the intr a-operat ive judgm ent of the surge on and resources availab le [QoE: Mod erate ; Stren gth of reco mmend a-tion: Strong; 1B]. Statement 4.11 Simp le ligation shoul d be pre ferred to stum p inve rsion, eithe r in open or lap aroscopi c surge ry, as the majo r morb idity and inf ectious com plica tions are similar. Simple ligat ion is asso ciated with sho rter ope rative ti mes, less postope rative ileus and quic ker recove ry. Recommend ation 4.1 1 We rec ommend simple lig ation over stump inversi on either in open and laparo scopic appendectom y [QoE: Hig h; Stre ngt h o f recom mendat ion: Stron g; 1A]. Statement 4.12 In adult patie nts, the use of drai ns afte r appendectomy for perforated app endic itis and abscess /peritonitis should be disc ouraged . Drains are of no be nefit in pre venting intr a-abdominal abscess an d lead to lon ger lengt h o f hospitalization and there is als o low-quality evide nce of inc reased 30-day morb id-ity and mortality rates in pat ients in the drain group. Recommend ation 4.1 2 We rec ommend against the use of drai ns fol lowin g appendectomy for compl icated appendicitis in adult pat ients [QoE: Moderate; Stren gth of recom men dation: Stro ng; 1B]. Statement 4.13 The prophy lactic use of abd omina l drain age after laparo scopic appendectomy for perforated app end icitis in children doe s not prevent postope rative compl icatio ns and may be asso ciated with neg ative out comes . Recommend ation 4.1 3 We sug gest agai nst the prophylactic use of abdominal drainage afte r laparosco pic app end ectomy for compl icated app end icitis in children [QoE: Low; Stre ngth of recom mendation : Weak ; 2C]. Statement 4.14 The use of wound ring prot ectors shows som e evi dence of surgical site infection red uction in ope n appendectomy , espe cially in case of compl icated app end icitis with cont aminated/dirty wound s. Recommend ation 4.1 4 We rec ommend wound ring protect ors in ope n appendectomy to decrease the ris k o f SSI [QoE: Mod erate ; Stren gth of recom mendat ion: Stron g; 1B]. Statement 4.15 Delayed primary skin closure increases the lengt h o f hospi tal stay and ov erall cos ts in ope n appendectom ies with cont amin ated/di rty wound s and does not red uce the ris k of SSI. Subc uticular sutu re seem s preferab le in open Recommend ation 4.1 5 We rec ommend primary skin closure with a uniq ue absorbable intrade rmal sutu re for ope n appendectom y wound s [QoE: Moderate; Stren gth of recom men dation: We ak; 2B ].

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Table 3 Summary of the updated 2020 guidelines statements and recommendations (Continued) Top ic Statement Recomm end ation appendectomy for acut e appendicitis as it is asso ciated with lowe r ris k o f compl ications (surgic al site infec tion/abscess and se roma) and lowe r cos ts. 5. Intra-oper ative gra ding of acute app endicitis Statement 5.1 The incidenc e of unexpec ted findings in app end ectomy specim ens is low. The intr a-operat ive diagnosis alone is insufficient for iden tifying unexpe cted disease. From the curre ntly availab le eviden ce, routine histopatholog y is necessary. Recommend ation 5.1 We reco mmend ro utine histopatholog y afte r appendectomy [QoE: Mod erate ; Stren gth of recom me ndation: Strong; 1B]. Statement 5.2 Operative finding s and intra-ope rative grad ing se em to corr elate better than histopatholog y with morb idity, ov erall out comes , and cos ts, bot h in adults and chi ldren. Intr a-ope rative grad ing system s can help the identif ication of homoge neous groups of patie nts, de term ining opt imal post operative manage-ment acco rding to the grad e of the dis ease an d ultimat ely im prove the utiliz ation of resourc es. Recommend ation 5.2 We sugge st the routine adoption of an intr a-operat ive grading system for acu te app end icitis (e.g., WSE S 2015 grad ing sco re or AAST EGS grading score) based on clinical, imaging an d ope rative fin dings [QoE : Mod erate; Stren gth of recom men dation: We ak; 2B ]. Statement 5.3 Surgeo n’ s macroscopic judgm ent of earl y grades of acute appendicitis is inac curate and high ly variable. The variability in the intr a-operat ive classification of app endic itis influences the deci sion to prescrib e postope rative an -tibiotics and sho uld be therefore pre vente d/avoided. Recommend ation 5.3 We sugge st appendix rem oval if the app endix appears “normal ” dur ing sur gery and no othe r dis ease is fou nd in symp tomat ic pat ients [QoE: Lo w; Stren gth of recom men dation: We ak; 2C]. 6. Manage ment of perfora ted appe ndicitis wit h phlegmo n or abscess Statement 6.1 Non-op erative manageme nt is a reason able first -line treatmen t for appendicitis with phle gmo n o r abs cess. Percut aneous drain age as an adjunc t to antibiotics, if acce ssible, cou ld be ben eficial, alth ough the re is a lack of evi dence for its use on a rout ine basis. Laparoscopic surge ry in exper ienced hands is a safe and feas ible fi rst-line treatme nt for app end iceal abscess , being associ ated with fewer readmissions and fewe r add itional interven tions than conservative treat -ment, with a comparable hospital stay . Recommend ation 6.1 We sugge st non-operative managemen t with antibiotics and — if available — percutaneou s drain age for compl icated appendicitis with pe ri-appendicular abs cess, in setting s w h ere lap arosco pic exp ertise is not available [QoE: Mod erate ; Stren gth of reco mmend ation: Weak; 2B]. Statement 6.2 Operative managemen t o f acut e app endic itis with phlegm on or abscess is a safe alt ernative to non-ope rative manage ment in exper ience d han ds, and may be ass ociated with shorter LOS, reduced nee d for readmissions an d fewer addit ional interve ntions than cons ervative treatmen t. Recommend ation 6.2 We sugge st the laparo scopic approach as treat ment of choice for pat ients with com plicated appendicitis with phlegmo n o r abscess where advanced lap aroscopi c exper tise is available, with a low thresho ld for conversion. [QoE : Mod erate; Strengt h o f recom men dation: We ak; 2B ]. Statement 6.3 The reported rate of recurrence afte r non-sur gical treat ment for perforated AA and ph legmo n ranges from 12% to 24 %. Interval appendectomy and rep eated NOM in case of recurrence of app endiceal phle gmo n are associ ated with similar morb idity. Howe ver, elective interval appendectom y is related to add -itional ope rative costs to pre vent recurrenc e in only one of eigh t patien ts, such as not to justify the routine pe rformanc e of app end ectomy . Recommend ation 6.3 We reco mmend agai nst routine interval app endectom y after NOM for com plicated appendicitis in you ng adu lts (< 40 years old) and children. Interval app endectom y is recom men ded for thos e patien ts with recurrent sy mptom s [QoE: Moderate; Stre ngth of recom mendation : Strong; 1B]. Statement 6.4 The incidenc e o f appendicular neopl asms is high (3 –17% ) in adu lt patients ≥ 40 years old) with com plicate d app endicit is. Recommend ation 6.4 We sugge st both col onic screen ing with col onosc opy and interval full -dose contrast-enhan ced CT scan for patien ts with app end icitis treat ed non-o peratively if ≥ 40 years old [QoE: Low; Stre ngth of reco mmend ation : Weak; 2C]. 7. Periopera tive antib iotic therapy Statement 7.1 A sing le dose of broad -spectrum anti biotics giv en pre operatively (from 0 to 60 min before the sur gical skin inc ision) has be en shown to be eff ective in de creasing wound inf ection an d posto perative intr a-abdominal abscess , regard-less of the de gree of inflammatio n o f the remove d appendix. Recommend ation 7.1 We reco mmend a single pre operative dose of broad -spectrum antibiotics in patien ts wit h acute app end icitis unde rgoing app endec-tomy. We recom mend again st postoperat ive antibiotics for pat ients with unc om-plicated appendicitis [QoE: Hig h; Stre ngth of recom mendat ion: Stron g; 1A]. Statement 7.2 In pat ients with com plicated acute appendicitis, posto perative broad-spectrum antibiotics are sugge sted, especi ally if compl ete sour ce cont rol has not been achieved. For adu lt pat ients de emed to req uire the m, discontinu -ation of an tibiotics after 24 h seem s safe an d is ass ociated with shorter lengt h of Recommend ation 7.2 We reco mmend agai nst prolong ing an tibiotics longer than 3– 5 day s posto peratively in case of compl icated appendicitis with ade quate source-c ontrol [QoE : Hig h; Stre ngth of recom mendat ion: Stron g; 1A].

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Table 3 Summary of the updated 2020 guidelines statements and recommendations (Continued) Top ic Statement Recomm end ation hospital stay and lowe r cos ts. In patie nts with intra-abdom inal infect ions who had undergone an adequate sour ce control, the out comes afte r fixe d-d uration anti-biotic therapy (approxim ately 3– 5 day s) are similar to thos e afte r a longe r cou rse of antibiotics . Statement 7.3 Admini sterin g posto perative an tibiotics orally in children with compl icated app end icitis for pe riods short er than 7 days post operatively seem s to be safe and it is not ass ociated with increased risk of com plica tions. Ear ly transition to oral anti biotics is safe, eff ective , and cost-ef ficient in the tre atmen t of compl icated app end icitis in the child. Recommend ation 7.3 We reco mmend earl y switch (after 48 h) to or al administration of postope rative anti biotics in children wit h complic ated appendicitis, with an overa ll lengt h o f therapy short er than 7 days [QoE: Moderate; Stre ngth of recom mendat ion: Stron g; 1B]. Statement 7.4 Postoperat ive antibiotics afte r app end ectomy for uncomp licated acute appendicitis in children se ems to have no role in red ucing the rate of surgical site infection . Recommend ation 7.4 In pediatric patie nts ope rated for unc omp licated acut e appendicitis, w e sugge st against usin g posto perative antibiotic the rapy [QoE : Low; Stren gth of recom men dation: We ak; 2C].

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Topic 1: Diagnosis

Q.1.1: What is the value of clinical scoring systems in the management of adult patients with suspected appendicitis? Can they be used as basis for a structured management?

Risk stratification of patients with suspected AA by clin-ical scoring systems could guide decision-making to re-duce admissions, optimize the utility of diagnostic imaging, and prevent negative surgical explorations. Clinical scores alone seem sufficiently sensitive to iden-tify low-risk patients and decrease the need for imaging and negative surgical explorations (such as diagnostic laparoscopy) in patients with suspected AA.

The RCT by Andersson et al. demonstrated that, in low-risk patients, the use of an AIR (Appendicitis Inflammatory Response) scobased algorithm re-sulted in less imaging (19.2% vs 34.5%, P < 0.001), fewer admissions (29.5% vs 42.8%, P < 0.001), fewer negative explorations (1.6% vs 3.2%, P = 0.030), and fewer surgical operations for non-perforated AA (6.8% vs 9.7%, P = 0.034). Intermediate-risk patients randomized to the imaging and observation strat-egies had the same proportion of negative appendec-tomies (6.4% vs 6.7%, P = 0.884), number of hospital admissions, rates of perforation, and length of hos-pital stay, but routine imaging was associated with an increased proportion of patients treated for AA (53.4% vs 46.3%, P = 0.020) [29].

Among the many available clinical prediction models for the diagnosis of AA, the AIR score appears to be the best performer and most pragmatic. The review by Kularatna et al. recently summarized the results from validation studies, showing that the overall best per-former in terms of sensitivity (92%) and specificity (63%) is the AIR score [30].

Although the Alvarado score is not sufficiently specific in diagnosing AA, a cutoff score of < 5 is sufficiently sensitive to exclude AA (sensitivity of 99%). The Alvar-ado score could, therefore, be used to reduce emergency department length of stay and radiation exposure in pa-tients with suspected AA. This is confirmed by a large retrospective cohort study that found 100% of males with Alvarado score of 9 or greater, and 100% of females with an Alvarado score of 10 had AA confirmed by sur-gical pathology. Conversely, 5% or less of female patients with an Alvarado score of 2 or less and 0% of male pa-tients with an Alvarado score of 1 or less were diagnosed with AA at surgery [31].

However, the Alvarado score is not able to differenti-ate complicdifferenti-ated from uncomplicdifferenti-ated AA in elderly pa-tients and seems less sensitive in HIV+ papa-tients [32,33].

The RIPASA (Raja Isteri Pengiran Anak Saleha Appen-dicitis) score has shown to achieve better sensitivity and specificity than the Alvarado score in Asian and Middle Eastern population. Malik et al. recently published the

first study evaluating the utility of the RIPASA score in predicting AA in a Western population. At a value of 7.5 (a cut of score suggestive of AA in the Eastern popula-tion), the RIPASA demonstrated reasonable sensitivity (85.39%), specificity (69.86%), positive predictive value (84.06%), negative predictive value (72.86%), and diag-nostic accuracy (80%) in Irish patients with suspected AA and was more accurate than the Alvarado score [34]. The Adult Appendicitis Score (AAS) stratifies patients into three groups: high, intermediate, and low risk of AA. The score has been shown to be a reliable tool for stratification of patients into selective imaging, which re-sults in a low negative appendectomy rate. In a prospect-ive study enrolling 829 adults presenting with clinical suspicion of AA, 58% of patients with histologically con-firmed AA had score value at least 16 and were classified as high probability group with 93% specificity. Patients with a score below 11 were classified as low probability of AA. Only 4% of patients with AA had a score below 11, and none of them had complicated AA. In contrast, 54% of non-AA patients had a score below 11. The area under ROC curve was significantly larger with the new score 0.882 compared with AUC of Alvarado score 0.790 and AIR score 0.810 [11].

In the validation study by Sammalkorpi et al., the AAS score stratified 49% of all AA patients into a high-risk group with the specificity of 93.3%, whereas in the low-risk group the prevalence of AA was 7%. The same study group demonstrated that diagnostic imaging has limited value in patients with a low probability of AA according to the AAS [35].

Tan et al. recently performed a prospective data col-lection on 350 consecutive patients with suspected AA for whom the Alvarado score for each patient was scored at admission and correlated with eventual hist-ology and CT findings. The positive likelihood ratio of disease was significantly greater than 1 only in patients with an Alvarado score of 4 and above. An Alvarado score of 7 and above in males and 9 and above in fe-males had a positive likelihood ratio comparable to that of CT scan [36].

Nearly all clinical signs and symptoms, as isolated pa-rameters, do not significantly discriminate between those pregnant women with and without AA [37–39].

Of 15 validated risk prediction models taken into con-sideration in a recently published study enrolling 5345 patients with right iliac fossa pain across 154 UK hospi-tals, the AAS performed best for women (cutoff score 8 or less, specificity 63.1%, failure rate 3.7%), whereas the AIR score performed best for men (cutoff score 2 or less, specificity 24.7%, failure rate 2.4%) [40].

The Alvarado score can be higher in pregnant women due to the higher WBC values and the frequency of nau-sea and vomiting, especially during the first trimester,

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implicating lower accuracy compared to the non-pregnant population. Studies show Alvarado score (cut-off 7 points) sensitivity of 78.9% and specificity of 80.0% in pregnant patients [41, 42]. The RIPASA score has a specificity (cutoff 7.5 points) of 96%, but the score should be validated in larger studies. There are no stud-ies of the Alvarado score discriminating between un-complicated and un-complicated AA during pregnancy.

The preoperative distinction between uncomplicated and complicated AA is challenging. Recently, prediction models based on temperature, CRP, presence of free fluids on ultrasound, and diameter of the appendix have been shown to be useful for the identification of “high-risk” patients for complicated AA. Atema et al. found that, with the use of scoring systems combining clinical and imaging features, 95% of the patients deemed to have uncomplicated AA were correctly identified [43].

Statement 1.1 Establishing the diagnosis of acute ap-pendicitis based on clinical presentation and physical examination may be challenging. As the value of individ-ual clinical variables to determine the likelihood of acute appendicitis in a patient is low, a tailored individualized approach is recommended, depending on disease prob-ability, sex, and age of the patient. Recommendation 1.1 We recommend to adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diag-nostic pathway in patients with suspected acute appendi-citis, depending on age, sex, and clinical signs and symptoms of the patient [QoE: Moderate; Strength of recommendation: Strong; 1B].

Statement 1.2 Clinical scores alone, e.g., Alvarado score, AIR score, and the new Adult Appendicitis Score are sufficiently sensitive to exclude acute ap-pendicitis, accurately identifying low-risk patients and decreasing the need for imaging and the nega-tive appendectomy rates in such patients. Recom-mendation 1.2.1 We recommend the use of clinical scores to exclude acute appendicitis and identify intermediate-risk patients needing of imaging diag-nostics [QoE: High; Strength of recommendation: Strong; 1A]. Recommendation 1.2.2 We suggest not making the diagnosis of acute appendicitis in preg-nant patients on symptoms and signs only. Labora-tory tests and inflammaLabora-tory serum parameters (e.g., CRP) should always be requested [QoE: Very Low; Strength of recommendation: Weak; 2C].

Statement 1.3 The Alvarado score is not sufficiently specific in diagnosing acute appendicitis in adults, seems unreliable in differentiating complicated from uncompli-cated acute appendicitis in elderly patients, and is less sensitive in patients with HIV. Recommendation 1.3 We suggest against the use of Alvarado score to posi-tively confirm the clinical suspicion of acute appendicitis

in adults [QoE: Moderate; Strength of recommendation: Weak; 2B].

Statement 1.4 The AIR score and the AAS score seem currently to be the best performing clinical prediction scores and have the highest discriminating power in adults with suspected acute appendicitis. The AIR and AAS scores decrease negative appendectomy rates in low-risk groups and reduce the need for imaging studies and hospital admissions in both low- and intermediate-risk groups. Recommendation 1.4 We recommend the use of AIR score and AAS score as clinical predictors of acute appendicitis [QoE: High; Strength of recommenda-tion: Strong; 1A].

Q.1.2: In pediatric patients with suspected acute

appendicitis could the diagnosis be based only on clinical scores?

AA is the most common surgical emergency in children, but early diagnosis of AA remains challenging due to atypical clinical features and the difficulty of obtaining a reliable history and physical examination. Several clinical scoring systems have been developed, the two most popular for use in children being the Alvarado score and Samuel’s Pediatric Appendicitis Score (PAS).

PAS includes similar clinical findings to the Alvarado score in addition to a sign more relevant in children: right lower quadrant pain with coughing, hopping, or percussion. Several studies comparing the PAS with the Alvarado score have validated its use in pediatric pa-tients. However, in a systematic review by Kulik et al. both scores failed to meet the performance benchmarks of CRP (C-reactive protein). On average, the PAS would over-diagnose AA by 35%, and the Alvarado score would do so by 32% [44].

If we consider patients of preschool age, AA often pre-sents with atypical features, more rapid progression, and higher incidence of complications. This age group is more likely to have lower PAS and Alvarado score than those of school-aged children [45]. This is the reason why Macco et al. retrospectively analyzed data from 747 children (mean age of 11 years) suspected of AA to evaluate the predictive value of the Alvarado score and PAS compared with the AIR score, which includes fewer symptoms than the Alvarado score and PAS, but adds the CRP value and allows for different severity levels of rebound pain, leukocytosis, CRP, and polymorphonu-cleocytes. The study showed that the AIR had the high-est discriminating power and outperformed the other two scores in predicting AA in children [46].

The use of PAS seems to be useful to rule out or in AA in pediatric female patients. A retrospective observa-tional study demonstrated that at a cutoff of ≥ 8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients, although the specificities

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did not differ at a cutoff of≥ 7. At both cutoffs, the posi-tive predicposi-tive values were poor in both groups. At a cutoff of ≥ 3, the PAS showed similar sensitivities in both groups [47].

Recently, the new Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte and neutrophil counts, CRP, and calprotectin levels has been shown to accurately predict which children are at low risk of AA and could be safely managed with close ob-servation. A PALabS ≤ 6 has a sensitivity of 99.2%, a negative predictive value of 97.6%, and a negative likeli-hood ratio of 0.03 [48].

The preoperative clinical scoring system to distinguish perforation risk with pediatric AA proposed by Bonadio et al., based on the duration of symptoms (> 1 day), fever (> 38.0 C), and WBC absolute count (> 13,000/mm3), re-sulted in a multivariate ROC curve of 89% for perfor-ation (P < 0.001), and the risk for perforperfor-ation was additive with each additional predictive variable exceed-ing its threshold value, linearly increasexceed-ing from 7% with no variable present to 85% when all 3 variables are present [49].

In assessing if the clinical scores can predict disease severity and the occurrence of complications, a retro-spective study on the Alvarado score validity in pediatric patients showed that a higher median score was found in patients who suffered postoperative complications. The eight items in the scoring system were analyzed for their sensitivities. Fever, right lower quadrant tenderness, and neutrophilia were found to be the three most sensi-tive markers in predicting complicated AA (88.6%, 82.3%, and 79.7%). On the other hand, rebound tender-ness was found to have the highest positive predictive value (65%) among the eight items to predict compli-cated AA [50].

Statement 1.5 In pediatric patients with suspected acute appendicitis, the Alvarado score and Pediatric Ap-pendicitis Score are useful tools in excluding acute ap-pendicitis. Recommendation 1.5 In pediatric patients with suspected acute appendicitis, we suggest against making a diagnosis based on clinical scores alone [QoE: Low; Strength of recommendation: Weak: 2C].

Q.1.3: What is the role of serum biomarkers in evaluating adult patients presenting with clinical features evocative of acute appendicitis?

The diagnostic accuracy of several biomarker panels has been prospectively validated, showing high sensitivity and negative predictive values for AA in large cohorts of patients with right iliac fossa pain, thereby potentially re-ducing the dependence on CT for the evaluation of pos-sible AA [51].

The diagnostic value of baseline and early change of CRP concentrations has been evaluated separately or in

combination with the modified Alvarado score in pa-tients with clinically suspected AA in the prospective ob-servational study by Msolli et al. Early change of CRP had a moderate diagnostic value in patients with sus-pected AA, and even combining CRP values to the modified Alvarado score did not improve diagnostic ac-curacy [52]. Recently, ischemia-modified albumin (IMA) levels have been used to determine the prediction of se-verity in AA patients. Kilic et al. found a strong positive correlation between IMA levels and CT findings in dis-tinguishing gangrenous/perforated AA from uncompli-cated AA [53]. A combination of clinical parameters, laboratory tests, and US may significantly improve diag-nostic sensitivity and specificity and eventually replace the need for CT scan in both adults and children [54].

Statement 1.6 Biochemical markers represent a prom-ising reliable diagnostic tool for the identification of both negative cases or complicated acute appendicitis in adults. However, further high-quality evidence is needed [QoE: Low; No recommendation].

Q.1.4: What is the role of serum biomarkers in evaluating pediatric patients presenting clinical features highly suggestive of acute appendicitis?

In pediatric patients, routine diagnostic laboratory workup for suspected AA should include WBC, the dif-ferential with the calculation of the absolute neutrophil count (ANC), CRP, and urinalysis.

Although not widely available, the addition of procalci-tonin and calprotectin to the above tests may signifi-cantly improve diagnostic discrimination [55].

Biomarkers have also been shown to be useful when used in association with the systematic adoption of scor-ing systems, as the addition of negative biomarker test results to patients with a moderate risk of AA based on the Pediatric Appendicitis Score (PAS) can safely reclas-sify many patients to a low-risk group. This may allow surgeons to provide more conservative management in patients with suspected AA and decrease unnecessary resource utilization [56].

Zouari et al. highlighted the value of CRP ≥ 10

mg/L as a strong predictor of AA in children < 6 years old [57].

Yu et al. reported that PCT had little value in diagnos-ing AA, with lower diagnostic accuracy than CRP and WBC, but a greater diagnostic value in identifying com-plicated AA [58]. In a recent meta-analysis, it was con-firmed that PCT was more accurate in diagnosing complicated AA, with a pooled sensitivity of 0.89 (95% CI 0.84–0.93), specificity of 0.90 (95% CI 0.86–0.94), and diagnostic odds ratio of 76.73 (95% CI 21.6–272.9) [59].

Zani et al. retrospectively analyzed data from 1197 children admitted for AA and reported that patients with complicated AA had higher CRP and WBC levels

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than normal patients and those with uncomplicated AA. The authors found a CRP > 40 mg/L in 58% of patients with complicated AA and 37% of patients with uncom-plicated AA, and WBC > 15 × 109/L in 58% of patients with complicated AA and 43% of patients with uncom-plicated AA [60].

One recent study identified a panel of biomarkers, the APPY1 test, consisting of WBC, CRP, and myeloid-related protein 8/14 levels that have the potential to identify, with great accuracy, children and adolescents with abdominal pain who are at low risk for AA. The biomarker panel exhibited a sensitivity of 97.1%, a nega-tive predicnega-tive value of 97.4%, and a neganega-tive likelihood ratio of 0.08, with a specificity of 37.9% for AA [51].

Benito et al. prospectively evaluated the usefulness of WBC and ANC and other inflammatory markers such as CRP, procalcitonin, calprotectin, and the APPY1 test panel of biomarkers, to identify children with abdominal pain at low risk for AA. The APPY1 test panel showed the highest discriminatory power, with a sensitivity of 97.8, negative predictive value of 95.1, negative likeli-hood ratio of 0.06, and specificity of 40.6. In the multi-variate analysis, only the APPY1 test and ANC > 7500/ mL were significant risk factors for AA [55].

More recently the Appendictis-PEdiatric score (APPE) was developed with the aim of identifying the risk of AA. Patients with an APPE score≤ 8 were at low risk of AA (sensitivity 94%); those with a score ≥ 15 were at high risk for AA (specificity 93%). Those between 8 and 15 were defined at intermediate-risk [61].

A number of prospective studies of children were con-ducted to find urinary biomarkers for AA, such as leucine-rich α-2-glycoprotein (LRG), not to be used alone but combined with PAS and routine blood tests. LRG in conjunction with PAS showed 95% sensitivity, 90% specificity, 91% positive predictive value, and 95% negative predictive value for AA in children [62].

Among the new laboratory biomarkers developed, the

Appendicitis Urinary Biomarker (AuB—leucine-rich

alpha-2-glycoprotein) appears promising as a diagnostic tool for excluding AA in children, without the need for blood sampling (negative predictive value 97.6%) [63].

Statement 1.7 White blood cell count, the differential with the calculation of the absolute neutrophil count, and the CRP are useful lab tests in predicting acute ap-pendicitis in children; moreover, CRP level on admission ≥ 10 mg/L and leucocytosis ≥ 16,000/mL are strong pre-dictive factors for appendicitis in pediatric patients.

Rec-ommendation 1.6.1 In evaluating children with

suspected appendicitis, we recommend to request rou-tinely laboratory tests and serum inflammatory bio-markers [QoE: Very Low; Strength of recommendation: Strong: 1D]. Recommendation 1.6.2 In pediatric pa-tients 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 [QoE: Very Low; Strength of rec-ommendation: Weak: 2D].

Q.1.5: What is the optimum pathway for imaging in adult patients with suspected acute appendicitis?

Estimating pre-image likelihood of AA is important in tailoring the diagnostic workup and using scoring sys-tems to guide imaging can be helpful: low-risk adult pa-tients according to the AIR/Alvarado scores could be discharged with appropriate safety netting, whereas high-risk patients are likely to require surgery rather than diagnostic imaging. Intermediate-risk patients are likely to benefit from systematic diagnostic imaging [64]. A positive US would lead to a discussion of appendec-tomy and a negative test to either CT or further clinical observation with repeated US. A conditional CT strat-egy, where CT is performed after the negative US, is preferable, as it reduces the number of CT scans by 50% and will correctly identify as many patients with AA as an immediate CT strategy.

Point-of-care ultrasonography (POCUS) has proven to be a valuable diagnostic tool in diagnosing AA and has a positive impact on clinical decision-making. Overall sen-sitivity and specificity of US is 76% and 95% and for CT is 99% and 84% respectively [65].

The meta-analysis by Matthew Fields et al. found that the sensitivity and specificity for POCUS in diagnosing AA were 91% and 97%, respectively. The positive and negative predictive values were 91% and 94%, respect-ively [66]. US reliability for the diagnosis of AA can be improved through standardized results reporting. In the study by Sola et al., following the adoption of a diagnos-tic algorithm that prioritized US over CT and

encom-passed standardized templates, the frequency of

indeterminate results decreased from 44.3% to 13.1% and positive results increased from 46.4% to 66.1% in pa-tients with AA [67].

Recent studies from the Finnish group led by Salminen demonstrated that the diagnostic accuracy of contrast-enhanced low-dose CT is not inferior to standard CT in diagnosing AA or distinguishing between uncomplicated and complicated AA, enabling significant radiation dose reduction. The OPTICAP randomized trial has shown that a low-dose protocol using intravenous contrast media was not inferior to the standard protocol in terms of diagnostic accuracy (79% accurate diagnosis in low-dose and 80% in standard CT by a primary radiologist) and accuracy to categorize AA severity (79% for both protocols). However, the mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively) [12]. The radiation dose of appendiceal CT for adolescents and young adults

Figura

Fig. 1 Practical WSES algorithm for diagnosis and treatment of adult patients with suspected acute appendicitis
Fig. 2 Practical WSES algorithm for diagnosis and treatment of pediatric patients with suspected acute appendicitis

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