Table 1

A complete compilation and comparison of the WSES 2016 and the EAES 2016 guidance on the investigation and management of appendicitis

SocietyStatement numberGuidance statementCaptured within the RIFT Study
(1) Diagnostic efficiency of clinical scoring systems
EAESPreop R1The combined variables of clinical assessment and biochemical testing in the Alvarado score should be used to determine the likelihood of appendicitis.Yes
WSES1.1The Alvarado score (with cut-off score<5) is sufficiently sensitive to exclude acute appendicitis.Yes
WSES1.2The Alvarado score is not sufficiently specific in diagnosing acute appendicitis.Yes
WSES1.3An ideal (high sensitivity and specificity), clinically applicable, diagnostic scoring system/clinical rule remains outstanding. This remains an area for future research.Yes
(2) Role of imaging
WSES2.1In patients with suspected appendicitis, a tailored individualised approach is recommended, depending on disease probability, sex and age of the patient.Yes
WSES2.2Imaging should be linked to Risk Stratification such as AIR or Alvarado scoreYes
WSES2.3Low-risk patients being admitted to hospital and not clinically improving or reassessed score could have appendicitis ruled-in or out by abdominal CT.Yes
WSES2.4Intermediate risk classification identifies patients likely to benefit from observation and systematic diagnostic imaging.Yes
WSES2.5High-risk patients (younger than 60 years old) may not require preoperative imaging.Yes
EAESPreop R2We recommend that ultrasound should be performed as a first-level diagnostic imaging although it has lower diagnostic value in case radiological confirmation is desirable.Yes
WSES2.6US standard reporting templates for ultrasound and US three-step sequential positioning may enhance over accuracy.
EAESPreop R3If after ultrasound the diagnosis of appendicitis is not confirmed nor ruled out, we suggest that additional imaging studies (either a CT or MRI) should be performed.Yes
EAESPreop R4In obese patients, a CT or MRI is more accurate than ultrasonography. In case of diagnostic doubt, we recommend a CT or MRI in these specific patients.
EAESPreop R5In pregnant patients, radiation should be avoided. In case of diagnostic doubt, we recommend an MRI in these specific patients.
WSES2.7MRI is recommended in pregnant patients with suspected appendicitis, if this resource is available
EAESPreop R6In children radiation should be avoided. In case of diagnostic doubt, we recommend an MRI in these specific patients.Yes
(3) Non-operative treatment for uncomplicated appendicitis
WSES3.1Antibiotic therapy can be successful in selected patients with uncomplicated appendicitis who wish to avoid surgery and accept the risk up to 38% recurrence.Yes
EAESPreop R7Non-operative treatment (with antibiotics) of uncomplicated appendicitis in adults is not suggested as high-quality evidence of superiority is still lacking.Yes
WSES3.2Current evidence supports initial intravenous antibiotics with subsequent conversion to oral antibiotics.
WSES3.3In patients with normal investigations and symptoms unlikely to be appendicitis but which do not settle: 1) cross-sectional imaging is recommended before surgery; 2) laparoscopy is the surgical approach of choice and 3) there is inadequate evidence to recommend a routine approach at presentYes
(4) Timing of appendectomy and in-hospital delay
WSES4.1Short, in-hospital surgical delay up to 12/24 hours is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate.Yes
WSES4.2Surgery for uncomplicated appendicitis can be planned for next available list minimising delay wherever possible (patient comfort, etc).Yes
EAESOperative R1We recommend that surgery is performed as soon as feasible after diagnosis.Yes
(5) Surgical treatment
WSES5.1.1Laparoscopic 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.Yes
EAESPreop R8Laparoscopic appendectomy is recommended as the procedure of choice in adults with uncomplicated acute appendicitis.Yes
WSES5.1.2Laparoscopy offers clear advantages and should be preferred in obese patients, older patients and patients with comorbidities.Yes
EAESPreop R11Laparoscopic appendectomy is recommended as the procedure of choice in obese patients with acute appendicitis.Yes
EAESPreop R14Laparoscopic appendectomy is recommended as the procedure of choice in patients over 65 years of age.Yes
WSES5.1.3Laparoscopy is feasible and safe in young male patients although no clear advantages can be demonstrated in such patients.Yes
WSES5.1.4Laparoscopy should not be considered as a first choice over open appendectomy in pregnant patients.
EAESPreop R12Laparoscopic appendectomy is suggested as the procedure of choice in pregnant patients with acute appendicitis. It should even be considered in the third trimester.
WSES5.1.5No major benefits have also been observed in laparoscopic appendectomy in children, but it reduces hospital stay and overall morbidity.Yes
EAESPreop R13Laparoscopic appendectomy is suggested as the procedure of choice in children with acute appendicitis and an indication for appendectomy.Yes
WSES5.1.6In experienced hands, laparoscopy is more beneficial and cost-effective than open surgery for complicated appendicitis.Yes
EAESPreop R9Laparoscopic appendectomy is suggested as the procedure of choice in patients with perforated appendicitis.Yes
EAESAfter care R2We suggest the use of local anaesthetic for subcutaneous and muscular infiltration of incision sites prior to incision.
EAESOperative R6Open: supine, one or both arms out, surgeon at the right side, assistant on the left side. Laparoscopic: supine, right arm out, left arm along the body, surgeon and assistant on the left side.
EAESOperative R7The consensus held a preference for open access to the peritoneal cavity because of rare but serious complications associated with the Verees needle.
EAESOperative R8Based on the literature, no recommendation can be made which trocars should be used and their placement. This should be left at the surgeon’s discretion. Three-port technique should be standard. Single-port approaches can be used by surgeons with sufficient experience.
WSES5.2Peritoneal irrigation does not have any advantages over suction alone in complicated appendicitis.
WSES5.3.1There 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).
WSES5.3.2Monopolar electrocoagulation and bipolar energy are the most cost-effective techniques, even if more experience and technical skills is required to avoid potential complications (eg, bleeding) and thermal injuries.
WSES5.4.1There are no clinical advantages in the use of endostapler over endoloops for stump closure for both adults and children.
EAESOperative R10The use of stapler or suturing is recommended over clips or endoloops when the appendix base is inflamed, necrotic or perforated. The use of alternative measures to secure the appendiceal stump in this case may be insufficient.
EAESAfter care R4To prevent stump appendicitis, it is suggested that the appendiceal stump should be no longer than 0.5 cm. Timely diagnosis allows laparoscopic stump resection. Delayed diagnosis may require extended bowel resection.
WSES5.4.2Endoloops might be preferred for lowering the costs when appropriate skills/learning curve are available.
WSES5.4.3There are no advantages of stump inversion over simple ligation, either in open or laparoscopic surgery.
WSES5.5.1Drains are not recommended in complicated appendicitis in paediatric patients.
EAESOperative R4It is suggested that there is no indication for routine postoperative nasogastric tube placement in children or adults.
EAESOperative R11It is recommended that extraction of the appendix should avoid direct contact of the appendix and the abdominal wall. There are several methods of achieving this and there is no evidence supporting one above the other.
EAESOperative R5It is suggested that there is no indication for routine postoperative catheter placement in children or adults.
WSES5.5.2In 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 intra-abdominal abscess and seem to be associated with delayed hospital discharge.
EAESOperative R12In general, meticulous suction of intraperitoneal fluid or collections is suggested; the philosophy should be: ‘leave no pus behind’. Routine use of drains in appendectomy is not recommended.
WSES5.6Delayed primary skin closure does not seem beneficial for reducing the risk of SSI and increase LOS in open appendectomies with contaminated/dirty wounds.
EAESOperative R13Primary wound closure is recommended for all cases of open appendectomy.
EAESOperative S1Various reasons exist to convert laparoscopic appendicectomy. However, no recommendation about when to convert can be given. It should be stated that conversion to open surgery is not regarded as a complication.Yes
EAESAfter care R3There is no reason to restrict the postoperative diet after an uncomplicated appendectomy.
(6) Scoring systems for intraoperative grading of appendicitis and their clinical usefulness
WSES6.1The 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.Yes
EAESAfter care R1It is recommended to send all appendices to the pathology department routinely and the operated will review the results.Yes
EAESOperative R15It is suggested that definitive treatment of a suspected malignancy will depend on final histological and staging information after initial treatment of the operative findings and may require further surgery or adjunct treatment.
WSES6.2There is a lack of validated system for histological classification of acute appendicitis and controversies exist on this topic.
WSES6.3Surgeon’s macroscopic judgement of early grades of acute appendicitis is inaccurate.Yes
WSES6.4If the appendix looks ‘normal’ during surgery and no other disease is found in symptomatic patient, we recommend removal in any case.Yes
EAESOperative R9It is suggested to remove the ‘normal’ appearing appendix when operating for suspected appendicitis when no other pathology is identified.Yes
WSES6.5We 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) Non-surgical treatment for complicated appendicitis: abscess or phlegmon
WSES7.1Percutaneous drainage of a periappendiceal abscess, if accessible, is an appropriate treatment in addition to antibiotics for complicated appendicitis.Yes
WSES7.2Non-operative management is a reasonable first-line treatment for appendicitis with phlegmon or abscess.Yes
EAESAfter care R5Initial treatment of intra-abdominal abscess is conservative with antibiotics. In some patients, this may need to be combined with radiological or surgical drainage.Yes
EAESPreop R10Non-operative treatment is suggested as the procedure of choice for patients with an appendiceal mass in the absence of diffuse peritonitis. Data are lacking on the benefits of interval appendectomy.Yes
WSES7.3Operative management of acute appendicitis with phlegmon or abscess is a safe alternative to non-operative management in experienced hands.Yes
EAESOperative R14It is recommended to treat an inflammatory mass conservatively. We recommend that when encountered during laparoscopy, refrain from appendectomy. During follow-up: additional imaging is advised. Data are lacking on the benefits of interval appendectomy.
WSES7.4Interval appendectomy is not routinely recommended both in adults and children.Yes
WSES7.5Interval appendectomy is recommended for those patients with recurrent symptoms.Yes
WSES7.6Colonic screening should be performed in those patients with appendicitis treated non-operatively if >40 years old.
(8) Preoperative and postoperative antibiotics
WSES8.1In patients with acute appendicitis, preoperative broad-spectrum antibiotics are always recommended.
EAESOperative R2Prophylactic antibiotics are recommended in appendectomy in adults.
EAESOperative R3Prophylactic antibiotics are recommended in appendectomy in children.
WSES8.2For patients with uncomplicated appendicitis, postoperative antibiotics are not recommended.
EAESAfter care S1Evidence for duration of administration of postoperative antibiotics is lacking.
EAESAfter care S2There is no evidence of routine use of postoperative antibiotics in uncomplicated appendicitis.
EAESAfter care R6In complicated appendicitis, postoperative antibiotics are recommended.
WSES8.3In patients with complicated acute appendicitis, postoperative, broad-spectrum antibiotics are always recommended.
WSES8.4Although 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.
  • Those statements captured within the RIFT study’s data collection have been highlighted. The EAES guidance is split into statements (S) and recommendations (R) under three sections; preoperative care, operative managements and after care. The WSES guidance is numbered and listed under the sections described in the table.

  • EAES, European Association of Endoscopic Surgery’s guidance; LOS, length of stay; Preop, preoperative; RIFT, Right Iliac Fossa Pain Treatment; SSI, surgical site infections; WSES, World Society of Emergency Surgery.