Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Ramon R Gorter, Hasan H Eker, Marguerite A W Gorter-Stam, Gabor S A Abis, Amish Acharya, Marjolein Ankersmit, Stavros A Antoniou, Simone Arolfo, Benjamin Babic, Luigi Boni, Marlieke Bruntink, Dieuwertje A van Dam, Barbara Defoort, Charlotte L Deijen, F Borja DeLacy, Peter Mnyh Go, Annelieke M K Harmsen, Rick S van den Helder, Florin Iordache, Johannes C F Ket, Filip E Muysoms, M Mahir Ozmen, Michail Papoulas, Michael Rhodes, Jennifer Straatman, Mark Tenhagen, Victor Turrado, Andras Vereczkei, Ramon Vilallonga, Jort D Deelder, Jaap Bonjer, Ramon R Gorter, Hasan H Eker, Marguerite A W Gorter-Stam, Gabor S A Abis, Amish Acharya, Marjolein Ankersmit, Stavros A Antoniou, Simone Arolfo, Benjamin Babic, Luigi Boni, Marlieke Bruntink, Dieuwertje A van Dam, Barbara Defoort, Charlotte L Deijen, F Borja DeLacy, Peter Mnyh Go, Annelieke M K Harmsen, Rick S van den Helder, Florin Iordache, Johannes C F Ket, Filip E Muysoms, M Mahir Ozmen, Michail Papoulas, Michael Rhodes, Jennifer Straatman, Mark Tenhagen, Victor Turrado, Andras Vereczkei, Ramon Vilallonga, Jort D Deelder, Jaap Bonjer

Abstract

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Keywords: Appendectomy; Appendicitis; Complicated appendicitis; Laparoscopic appendectomy; Uncomplicated appendicitis.

Conflict of interest statement

Compliance with ethical standards Disclosures Dr. Antoniou received personal fees from the EAES (including Journal and Publication Committee) and from the European Hernia Society. Dr. Muysoms received grants personal fees and non-financial support from Medtronic and Johnson & Johnson. He received grants and personal fees from B. Braun and Dynamesh. He received personal fees from BARD davol, Cousin Biotech, WL Gore@ass and Dansac outside the submitted work. Prof. Dr. Bonjer received grants and personal fees from Johnson & Johnson, Applied Medical, Medtronic and Olympus. He received personal fees from Cook. All outside the submitted work. Drs. Defoort, Dr. Go, Prof. Dr. Ozmen, Dr. Rhodes, Drs. Gorter, Dr. Eker, Drs Gorter-Stam, Drs. Abis, Drs. Acharya, Drs. Ankersmit, Drs. Arolfo, Drs. Babic, Prof. Dr. Boni, Drs. Bruntink, Drs. Van Dam, Drs. Deijen, Drs. DeLacy, Drs. Harmsen, Drs. Van den Helder, Dr. Iordache, Drs. Ket, Drs. Papoulas, Drs. Straatman, Drs. Tenhagen, Drs. Turrado, Dr. Vereczkei, Prof. Dr. Vilallonga and Drs. Deelder have no conflict of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Flow diagram of the process prior to the EAES consensus meeting in Bucharest 2015
Fig. 2
Fig. 2
Algorithm. *The cut-off values are based upon the study by Ebell et al. [29]. **One could consider performing additional imaging studies in patients with high probability based upon the Alvarado score in order to reduce the negative appendectomy rate. ***Ultrasound should be performed as a first level diagnostic imaging study, although in specific patient groups (such as the obese) an immediate CT scan might be considered. ****In case of an inconclusive result from the ultrasound, we recommend that additional imaging studies should be performed. Either a CT or MRI is preferred although it is recommended to perform an MRI in children and pregnant patients. It is therefore obligated to rule out pregnancy before a CT scan is obtained in a woman of reproductive age suspected of appendicitis. *****In case all the imaging studies are inconclusive, patients should be observed and reassessed. Diagnostic laparoscopy should be reserved for those patients with a continuous high index of suspicion after reassessment. ******In case of low probability based upon the Alvarado score, other diagnoses should be excluded and the patient can be either discharged with good instruction (with an optional reassessment the next day) or admitted for observation if the clinical condition mandates this. In case appendicitis is excluded, patients should be treated for the set diagnosis according to the local protocols

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Source: PubMed

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