Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines
Authors: Di Saverio Salomone , Podda Mauro , De Simone Belinda , Ceresoli Marco , Augustin Goran , Gori Alice , Boermeester Marja , Sartelli Massimo , Coccolini Federico , Tarasconi Antonio , de’ Angelis Nicola , Weber Dieter G. , Tolonen Matti , Birindelli Arianna , Biffl Walter , Moore Ernest E. , Kelly Michael , Soreide Kjetil , Kashuk Jeffry , Ten Broek Richard , Gomes Carlos Augusto , Sugrue Michael , Davies Richard Justin , Damaskos Dimitrios , Leppäniemi Ari , Kirkpatrick Andrew , Peitzman Andrew B. , Fraga Gustavo P. , Maier Ronald V. , Coimbra Raul , Chiarugi Massimo , Sganga Gabriele , Pisanu Adolfo , de’ Angelis Gian Luigi , Tan Edward , Van Goor Harry , Pata Francesco , Di Carlo Isidoro , Chiara Osvaldo , Litvin Andrey , Campanile Fabio C. , Sakakushev Boris , Tomadze Gia , Demetrashvili Zaza , Latifi Rifat , Abu-Zidan Fakri , Romeo Oreste , Segovia-Lohse Helmut , Baiocchi Gianluca , Costa David , Rizoli Sandro , Balogh Zsolt J. , Bendinelli Cino , Scalea Thomas , Ivatury Rao , Velmahos George , Andersson Roland , Kluger Yoram , Ansaloni Luca , Catena Fausto 
Published: April 2020

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.