Appendectomy

Appendectomy remains the treatment of choice also for acute appendicitis. Antibiotic therapy is a safe means of primary treatment for patients with uncomplicated acute appendicitis, but it is less effective in the long-term due to significant recurrence rates and probably needs the certainty of a CT proven diagnosis of uncomplicated appendicitis (Recommendation 1A).

Both open and laparoscopic appendectomies are viable approaches to surgical treatment of acute appendicitis (Recommendation 1A). 

Patients with a periappendiceal abscess can be managed with percutaneous image-guided drainage in surgical departments with ready access to diagnostic and interventional radiology. When percutaneous drainage is not available, surgery is suggested (Recommendation 1B).

In patients treated conservatively, interval appendectomy maybe not necessary following initial non-operative treatment of complicated appendicitis. However, interval appendectomies should always be performed for patients with recurrent symptoms (Recommendation 2B).

Routine use of intra-operative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided (Recommendation 2B).

Laparoscopic repair of perforated peptic ulcers can be a safe and effective procedure for experienced surgeons (Recommendation 1A).

Early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies (Recommendation 1A).

Laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis (Recommendation 1A). It is the first choice for patients with acute cholecystitis where adequate resources and skill are available. Some risk factors may predict the risk for conversion to open cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis (Recommendation 1A). 

Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails (Recommendation 1B).

In patients with uncomplicated IAI such as uncomplicated appendicitis and uncomplicated cholecystitis, where the source of infection is treated definitively, post-operative antibiotic therapy is not necessary (Recommendation 1A).

In patients with complicated IAI undergoing an adequate source-control procedure, a short course of antibiotic therapy (3–5 days) is always recommended (Recommendation 1A).

Table 3: Guidelines Statements (Continued)

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 nonoperatively 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