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      Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

      review-article

      , 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 4 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 1 , 23 , 13 , 24 , 25 , 26 , 27 , 28 , 10 , 29 , 3 , 30 , 20 , 20 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 4

      World Journal of Emergency Surgery : WJES

      BioMed Central

      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

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          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-operative scoring, and peri-operative antibiotic therapy.

          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.

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          Most cited references 231

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          The epidemiology of appendicitis and appendectomy in the United States.

          To describe the epidemiology of appendicitis and appendectomy in the United States, the authors analyzed National Hospital Discharge Survey data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in the United States during this period, accounting for an estimated 1 million hospital days per year. The highest incidence of primary positive appendectomy (appendicitis) was found in persons aged 10-19 years (23.3 per 10,000 population per year); males had higher rates of appendicitis than females for all age groups (overall rate ratio, 1.4:1). Racial, geographic, and seasonal differences were also noted. Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months. The highest rate of incidental appendectomy was found in women aged 35-44 years (43.8 per 10,000 population per year), 12.1 times higher than the rate for men of the same age. Between 1970 and 1984, the incidence of appendicitis decreased by 14.6%; reasons for this decline are unknown. A life table model suggests that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Overall, an estimated 36 incidental procedures are performed to prevent one case of appendicitis; for the elderly, the preventive value of an incidental procedure is considerably lower.
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            A practical score for the early diagnosis of acute appendicitis.

            We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.
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              Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.

              Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
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                Author and article information

                Contributors
                salo75@inwind.it , salomone.disaverio@gmail.com
                Journal
                World J Emerg Surg
                World J Emerg Surg
                World Journal of Emergency Surgery : WJES
                BioMed Central (London )
                1749-7922
                15 April 2020
                15 April 2020
                2020
                : 15
                Affiliations
                [1 ]GRID grid.120073.7, ISNI 0000 0004 0622 5016, Cambridge Colorectal Unit, , Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, ; Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ UK
                [2 ]Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
                [3 ]GRID grid.7763.5, ISNI 0000 0004 1755 3242, Department of General and Emergency Surgery, , Cagliari University Hospital, ; Cagliari, Italy
                [4 ]GRID grid.411482.a, Emergency and Trauma Surgery Department, , Maggiore Hospital of Parma, ; Parma, Italy
                [5 ]GRID grid.7563.7, ISNI 0000 0001 2174 1754, Emergency and General Surgery Department, , University of Milan-Bicocca, ; Milan, Italy
                [6 ]GRID grid.412688.1, ISNI 0000 0004 0397 9648, Department of Surgery, , University Hospital Centre of Zagreb, ; Zagreb, Croatia
                [7 ]GRID grid.416290.8, ISNI 0000 0004 1759 7093, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, ; Bologna, Italy
                [8 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Surgery, , University of Amsterdam, ; Amsterdam, The Netherlands
                [9 ]Macerata Hospital, Macerata, Italy
                [10 ]GRID grid.144189.1, ISNI 0000 0004 1756 8209, General, Emergency and Trauma Surgery, , Pisa University Hospital, ; Pisa, Italy
                [11 ]GRID grid.412116.1, ISNI 0000 0001 2292 1474, Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, , Henri Mondor University Hospital, ; Paris, France
                [12 ]GRID grid.1012.2, ISNI 0000 0004 1936 7910, Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, ; Perth, Australia
                [13 ]GRID grid.7737.4, ISNI 0000 0004 0410 2071, Department of Abdominal Surgery, Abdominal Center, , University of Helsinki and Helsinki University Central Hospital, ; Helsinki, Finland
                [14 ]Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
                [15 ]GRID grid.410445.0, ISNI 0000 0001 2188 0957, Queen’s Medical Center, , University of Hawaii, ; Honolulu, HI USA
                [16 ]GRID grid.239638.5, ISNI 0000 0001 0369 638X, Denver Health System – Denver Health Medical Center, ; Denver, USA
                [17 ]GRID grid.413314.0, ISNI 0000 0000 9984 5644, Acute Surgical Unit, , Canberra Hospital, ; ACT, Canberra, Australia
                [18 ]GRID grid.412835.9, ISNI 0000 0004 0627 2891, Department of Gastrointestinal Surgery, , Stavanger University Hospital, ; Stavanger, Norway
                [19 ]GRID grid.9619.7, ISNI 0000 0004 1937 0538, Department of Surgery, , University of Jerusalem, ; Jerusalem, Israel
                [20 ]GRID grid.10417.33, ISNI 0000 0004 0444 9382, Department of Surgery, , Radboud University Medical Center, ; Nijmegen, The Netherlands
                [21 ]Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
                [22 ]Letterkenny Hospital, Donegal, Ireland
                [23 ]GRID grid.418716.d, ISNI 0000 0001 0709 1919, Department of Upper GI Surgery, , Royal Infirmary of Edinburgh, ; Edinburgh, Scotland, UK
                [24 ]GRID grid.414959.4, ISNI 0000 0004 0469 2139, General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, , Foothills Medical Centre, ; Calgary, Alberta Canada
                [25 ]Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
                [26 ]GRID grid.411087.b, ISNI 0000 0001 0723 2494, Faculdade de Ciências Médicas (FCM) – Unicamp, ; Campinas, SP Brazil
                [27 ]GRID grid.412618.8, ISNI 0000 0004 0433 5561, Department of Surgery, , University of Washington, Harborview Medical Center, ; Seattle, WA USA
                [28 ]GRID grid.266100.3, ISNI 0000 0001 2107 4242, UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, ; San Diego, CA USA
                [29 ]GRID grid.411075.6, ISNI 0000 0004 1760 4193, Department of Emergency Surgery, , “A. Gemelli Hospital”, Catholic University of Rome, ; Rome, Italy
                [30 ]Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
                [31 ]GRID grid.7841.a, Department of Surgery, , Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, ; Rome, Italy
                [32 ]GRID grid.8158.4, ISNI 0000 0004 1757 1969, Department of Surgical Sciences and Advanced Technologies “GF Ingrassia”, Cannizzaro Hospital, , University of Catania, ; Catania, Italy
                [33 ]GRID grid.416200.1, Niguarda Hospital Trauma Center, ; Milan, Italy
                [34 ]GRID grid.410686.d, ISNI 0000 0001 1018 9204, Department of Surgery, , Immanuel Kant Baltic Federal University, ; Kaliningrad, Russia
                [35 ]Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
                [36 ]GRID grid.35371.33, ISNI 0000 0001 0726 0380, General Surgery Department, Medical University, , University Hospital St George, ; Plovdiv, Bulgaria
                [37 ]GRID grid.412274.6, ISNI 0000 0004 0428 8304, Department of Surgery, , Tbilisi State Medical University, TSMU, ; Tbilisi, Georgia
                [38 ]GRID grid.260917.b, ISNI 0000 0001 0728 151X, Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, , New York Medical College, ; Valhalla, NY USA
                [39 ]GRID grid.43519.3a, ISNI 0000 0001 2193 6666, Department of Surgery, College of Medicine and Health Sciences, , UAE University, ; Al-Ain, United Arab Emirates
                [40 ]Bronson Trauma Surgery, Kalamazoo, USA
                [41 ]GRID grid.412213.7, ISNI 0000 0001 2289 5077, Hospital de Clinicas, , Universidad Nacional de Asuncion, ; Asuncion, Paraguay
                [42 ]GRID grid.7637.5, ISNI 0000000417571846, Surgical Clinic, Department of Experimental and Clinical Sciences, , University of Brescia, ; Brescia, Italy
                [43 ]GRID grid.411086.a, ISNI 0000 0000 8875 8879, Hospital universitario de Alicante, departamento de Cirugia General, ; Alicante, Spain
                [44 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Department of Surgery, St. Michael Hospital, , University of Toronto, ; Toronto, Canada
                [45 ]GRID grid.414724.0, ISNI 0000 0004 0577 6676, Department of Traumatology, , John Hunter Hospital and University of Newcastle, ; Newcastle, NSW Australia
                [46 ]R. Adams Cowley Trauma Center, Baltimore, MD USA
                [47 ]GRID grid.224260.0, ISNI 0000 0004 0458 8737, Professor Emeritus Virginia Commonwealth University, ; Richmond, VA USA
                [48 ]Harvard Medical School, Massachusetts General Hospital, Boston, USA
                [49 ]GRID grid.5640.7, ISNI 0000 0001 2162 9922, Department of Surgery, , Linkoping University, ; Linkoping, Sweden
                [50 ]GRID grid.413731.3, ISNI 0000 0000 9950 8111, Division of General Surgery, , Rambam Health Care Campus, ; Haifa, Israel
                [51 ]GRID grid.414682.d, ISNI 0000 0004 1758 8744, Department of General Surgery and Trauma, , Bufalini Hospital, ; Cesena, Italy
                Article
                306
                10.1186/s13017-020-00306-3
                7386163
                32295644
                1f6419d6-a58d-475e-bc21-c37484e97ac7
                © The Author(s) 2020

                Open AccessThis 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, visit http://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.

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