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Table 3: Guidelines Statements

From: WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

  LE GoR Statement
1) Diagnostic efficiency of clinical scoring systems    
1.1 1 A The Alvarado score (with cutoff score < 5) is sufficiently sensitive to exclude acute appendicitis.
1.2 1 A The Alvarado score is not sufficiently specific in diagnosing acute appendicitis.
1.3 1 B An ideal (high sensitivity and specificity), clinically applicable, diagnostic scoring system/clinical rule remains outstanding. This remains an area for future research
2) Role of imaging    
2.1 2 B In patients with suspected appendicitis a tailored individualised approach is recommended, depending on disease probability, sex and age of the patient
2.2 2 B Imaging should be linked to Risk Stratification such as AIR or Alvarado score
2.3 2 B Low risk patients being admitted to hospital and not clinically improving or reassessed score could have appendicitis ruled-in or out by abdominal CT
2.4 2 B Intermediaterisk classification identifies patients likely to benefit from observation and systematic diagnostic imaging.
2.5 2 B Highrisk patients (younger than 60 yearsold) may not require preoperative imaging.
2.6 3 B US Standard reporting templates for ultrasound and US three step sequential positioning may enhance over accuracy .
2.7 2 B MRI is recommended in pregnant patients with suspected appendicitis, if this resource is available
3) Nonoperative treatment for uncomplicated appendicitis    
3.1 1 A Antibiotic therapy can be successful in selected patients with uncomplicated appendicitis who wish to avoid surgery and accept the risk up to 38 % recurrence.
3.2 2 B Current evidence supports initial intravenous antibiotics with subsequent conversion to oral antibiotics.
3.3 2 B In patients with normal investigations and symptoms unlikely to be appendicitis but which do not settle:
• Cross-sectional imaging is recommended before surgery
• Laparoscopy is the surgical approach of choice
• There is inadequate evidence to recommend a routine approach at present
4) Timing of appendectomy and in-hospital delay    
4.1 2 B Short, in-hospital surgical delay up to 12/24 h is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate.
4.2 2 B Surgery for uncomplicated appendicitis can be planned for next available list minimizing delay wherever possible (patient comfort etc.).
5) Surgical treatment    
5.1.1 1 A Laparoscopic appendectomy should represent the first choice where laparoscopic equipment and skills are available, since it offers clear advantages in terms of less pain, lower incidence of SSI, decreased LOS, earlier return to work and overall costs.
5.1.2 2 B Laparoscopy offers clear advantages and should be preferred in obese patients, older patients and patients with comorbidities
5.1.3 2 B Laparoscopy is feasible and safe in young male patients although no clear advantages can be demonstrated in such patients.
5.1.4 1 B Laparoscopy should not be considered as a first choice over open appendectomy in pregnant patients
5.1.5 1 A No major benefits have also been observed in laparoscopic appendectomy in children, but it reduces hospital stay and overall morbidity
5.1.6 3 B In experienced hands, laparoscopy is more beneficial and cost-effective than open surgery for complicated appendicitis
5.2 2 B Peritoneal irrigation does not have any advantages over suction alone in complicated appendicitis
5.3.1 3 B There are no clinical differences in outcomes, LOS and complications rates between the different techniques described for mesentery dissection (monopolar electrocoagulation, bipolar energy, metal clips, endoloops, Ligasure, Harmonic Scalpel etc.).
5.3.2 3 B Monopolar electrocoagulation and bipolar energy are the most cost-effective techniques, even if more experience and technical skills is required to avoid potential complications (e.g. bleeding) and thermal injuries.
5.4.1 1 A There are no clinical advantages in the use of endostapler over endoloops for stump closure for both adults and children
5.4.2 3 B Endoloops might be preferred for lowering the costs when appropriate skills/learning curve are available
5.4.3 2 B There are no advantages of stump inversion over simple ligation, either in open or laparoscopic surgery
5.5.1 3 B Drains are not recommended in complicated appendicitis in paediatric patients
5.5.2 1 A In adult patients, drain after appendectomy for perforated appendicitis and abscess/peritonitis should be used with judicious caution, given the absence of good evidence from the literature. Drains did not prove any efficacy in preventing intraabdominal abscess and seem to be associated with delayed hospital discharge.
5.6 1 A Delayed primary skin closure does not seem beneficial for reducing the risk of SSI and increase LOS in open appendectomies with contaminated/dirty wounds
6) Scoring systems for intraoperative grading of appendicitis and their clinical usefulness    
6.1 2 B The incidence of unexpected findings in appendectomy specimens is low but the intraoperative diagnosis alone is insufficient for identifying unexpected disease. From the current available evidence, routine histopathology is necessary
6.2 4 C There is a lack of validated system for histological classification of acute appendicitis and controversies exist on this topic.
6.3 2 B Surgeon’s macroscopic judgement of early grades of acute appendicitis is inaccurate
6.4 4 C If the appendix looks “normal” during surgery and no other disease is found in symptomatic patient, we recommend removal in any case.
6.5 2 B We recommend adoption of a grading system for acute appendicitis based on clinical, imaging and operative findings, which can allow identification of homogeneous groups of patients, determining optimal grade disease management and comparing therapeutic modalities
7) Nonsurgical treatment for complicated appendicitis :abscess or phlegmone    
7.1 2 B Percutaneous drainage of a periappendiceal abscess, if accessible, is an appropriate treatment in addition to antibiotics for complicated appendicitis.
7.2 1 A Nonoperative management is a reasonable first line treatment for appendicitis with phlegmon or abscess
7.3 2 B Operative management of acute appendicitis with phlegmon or abscess is a safe alternative to nonoperative management in experienced hands
7.4 1 A Interval appendectomy is not routinely recommended both in adults and children.
7.5 2 B Interval appendectomy is recommended for those patients with recurrent symptoms.
7.6 3 C Colonic screening should be performed in those patients with appendicitis treated non-operatively if >40y/o
8) Preoperative and Postoperative Antibiotics    
8.1 1 A In patients with acute appendicitis preoperative broad-spectrum antibiotics are always recommended
8.2 2 B For patients with uncomplicated appendicitis, postoperative antibiotics are not recommended
8.3 2 B In patients with complicated acute appendicitis, postoperative, broad-spectrum antibiotics are always recommended
8.4 2 B Although discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria such as fever and leucocytosis, a period of 3–5 days for adult patients is generally recommended