Review

. 2020 Apr 15;15(1):27.

doi: 10.1186/s13017-020-00306-3.

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

Salomone Di Saverio^{1

2}, Mauro Podda³, Belinda De Simone⁴, Marco Ceresoli⁵, Goran Augustin⁶, Alice Gori⁷, Marja Boermeester⁸, Massimo Sartelli⁹, Federico Coccolini¹⁰, Antonio Tarasconi⁴, Nicola De' Angelis¹¹, Dieter G Weber¹², Matti Tolonen¹³, Arianna Birindelli¹⁴, Walter Biffl¹⁵, Ernest E Moore¹⁶, Michael Kelly¹⁷, Kjetil Soreide¹⁸, Jeffry Kashuk¹⁹, Richard Ten Broek²⁰, Carlos Augusto Gomes²¹, Michael Sugrue²², Richard Justin Davies²³, Dimitrios Damaskos²⁴, Ari Leppäniemi¹³, Andrew Kirkpatrick²⁵, Andrew B Peitzman²⁶, Gustavo P Fraga²⁷, Ronald V Maier²⁸, Raul Coimbra²⁹, Massimo Chiarugi¹⁰, Gabriele Sganga³⁰, Adolfo Pisanu³, Gian Luigi De' Angelis³¹, Edward Tan²⁰, Harry Van Goor²⁰, Francesco Pata³², Isidoro Di Carlo³³, Osvaldo Chiara³⁴, Andrey Litvin³⁵, Fabio C Campanile³⁶, Boris Sakakushev³⁷, Gia Tomadze³⁸, Zaza Demetrashvili³⁸, Rifat Latifi³⁹, Fakri Abu-Zidan⁴⁰, Oreste Romeo⁴¹, Helmut Segovia-Lohse⁴², Gianluca Baiocchi⁴³, David Costa⁴⁴, Sandro Rizoli⁴⁵, Zsolt J Balogh⁴⁶, Cino Bendinelli⁴⁶, Thomas Scalea⁴⁷, Rao Ivatury⁴⁸, George Velmahos⁴⁹, Roland Andersson⁵⁰, Yoram Kluger⁵¹, Luca Ansaloni⁵², Fausto Catena⁴

Affiliations

¹ Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. salo75@inwind.it.
² Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy. salo75@inwind.it.
³ Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy.
⁴ Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy.
⁵ Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy.
⁶ Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia.
⁷ Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy.
⁸ Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands.
⁹ Macerata Hospital, Macerata, Italy.
¹⁰ General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
¹¹ Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France.
¹² Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia.
¹³ 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 Queen's Medical Center, University of Hawaii, Honolulu, HI, USA.
¹⁶ Denver Health System - Denver Health Medical Center, Denver, USA.
¹⁷ Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia.
¹⁸ Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
¹⁹ Department of Surgery, University of Jerusalem, Jerusalem, Israel.
²⁰ 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 Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
²⁴ Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
²⁵ General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada.
²⁶ Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA.
²⁷ Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil.
²⁸ Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA.
²⁹ UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA.
³⁰ Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy.
³¹ Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy.
³² Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy.
³³ Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy.
³⁴ Niguarda Hospital Trauma Center, Milan, Italy.
³⁵ Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia.
³⁶ Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy.
³⁷ General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria.
³⁸ Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia.
³⁹ Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA.
⁴⁰ Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
⁴¹ Bronson Trauma Surgery, Kalamazoo, USA.
⁴² Hospital de Clinicas, Universidad Nacional de Asuncion, Asuncion, Paraguay.
⁴³ Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy.
⁴⁴ Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain.
⁴⁵ Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada.
⁴⁶ Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
⁴⁷ R. Adams Cowley Trauma Center, Baltimore, MD, USA.
⁴⁸ Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.
⁴⁹ Harvard Medical School, Massachusetts General Hospital, Boston, USA.
⁵⁰ Department of Surgery, Linkoping University, Linkoping, Sweden.
⁵¹ Division of General Surgery, Rambam Health Care Campus, Haifa, Israel.
⁵² Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy.

PMID: 32295644
PMCID: PMC7386163
DOI: 10.1186/s13017-020-00306-3

Review

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

Salomone Di Saverio et al. World J Emerg Surg. 2020.

. 2020 Apr 15;15(1):27.

doi: 10.1186/s13017-020-00306-3.

Authors

Affiliations

¹ Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. salo75@inwind.it.
² Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy. salo75@inwind.it.
³ Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy.
⁴ Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy.
⁵ Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy.
⁶ Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia.
⁷ Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy.
⁸ Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands.
⁹ Macerata Hospital, Macerata, Italy.
¹⁰ General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
¹¹ Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France.
¹² Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia.
¹³ 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 Queen's Medical Center, University of Hawaii, Honolulu, HI, USA.
¹⁶ Denver Health System - Denver Health Medical Center, Denver, USA.
¹⁷ Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia.
¹⁸ Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
¹⁹ Department of Surgery, University of Jerusalem, Jerusalem, Israel.
²⁰ 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 Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
²⁴ Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
²⁵ General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada.
²⁶ Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA.
²⁷ Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil.
²⁸ Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA.
²⁹ UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA.
³⁰ Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy.
³¹ Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy.
³² Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy.
³³ Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy.
³⁴ Niguarda Hospital Trauma Center, Milan, Italy.
³⁵ Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia.
³⁶ Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy.
³⁷ General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria.
³⁸ Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia.
³⁹ Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA.
⁴⁰ Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
⁴¹ Bronson Trauma Surgery, Kalamazoo, USA.
⁴² Hospital de Clinicas, Universidad Nacional de Asuncion, Asuncion, Paraguay.
⁴³ Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy.
⁴⁴ Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain.
⁴⁵ Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada.
⁴⁶ Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
⁴⁷ R. Adams Cowley Trauma Center, Baltimore, MD, USA.
⁴⁸ Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.
⁴⁹ Harvard Medical School, Massachusetts General Hospital, Boston, USA.
⁵⁰ Department of Surgery, Linkoping University, Linkoping, Sweden.
⁵¹ Division of General Surgery, Rambam Health Care Campus, Haifa, Israel.
⁵² Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy.

PMID: 32295644
PMCID: PMC7386163
DOI: 10.1186/s13017-020-00306-3

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.

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

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

**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

See this image and copyright information in PMC

References

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

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

Authors

Affiliations

Abstract

Conflict of interest statement

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