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SAGES guideline for the diagnosis and treatment of appendicitis

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Abstract

Background

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

Methods

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

Results

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

Conclusions

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

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Abbreviations

CT:

Computed tomography scan

EtD:

Evidence to decision

GRADE:

The Grading of Recommendations Assessment, Development, and Evaluation

h:

Hours

IBD:

Inflammatory bowel disease

ICTRP:

International Clinical Trials Platform

ICU:

Intensive care

IR:

Interventional radiology

KQ:

Key question

LOS:

Length of stay

OR:

Operating room

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-analyses

QOL:

Quality of life

RIGHT:

Essential Reporting Items for Practice Guidelines in Healthcare

SAGES:

The Society of American Gastrointestinal and Endoscopic Surgeons

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Acknowledgements

We would like to thank Sarah Colón, the SAGES senior program coordinator, Holly Burt, the SAGES librarian, and the SAGES guideline committee members for their help with the creation of this guideline.

Funding

SERF.

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Authors and Affiliations

  1. Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA

    Sunjay S. Kumar & Ryan Lamm

  2. Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA

    Amelia T. Collings

  3. Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA

    Ivy N. Haskins

  4. Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Stefan Scholz

  5. Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA

    Pramod Nepal

  6. Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA

    Arianne T. Train

  7. Department of General Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Dimitrios I. Athanasiadis

  8. School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK

    Philip H. Pucher

  9. Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

    Joel F. Bradley III

  10. Department of Surgery, Queen’s University, Kingston, ON, Canada

    Nader M. Hanna

  11. Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA

    Francisco Quinteros

  12. Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA

    Nisha Narula

  13. University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA

    Bethany J. Slater

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  1. Sunjay S. Kumar
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Corresponding author

Correspondence to Bethany J. Slater.

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Disclaimer

Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. This guideline is intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. This guideline is applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question. Some studies or treatment options may not be available in certain regions, and as such individual decision-making must be used. This guideline is developed under the auspices of SAGES, the guidelines committee, and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available.

Disclosures

Dr. Haskins declared royalties from UpToDate, Inc which is not directly related to this work. Dr. Quinteros declared personal payments from Medtronic, THD America, and Applied Medical. Dr. Slater declared work as a consultant for Hologic and Cook Medical. Drs. Kumar, Collings, Lamm, Scholz, Nepal, Train, Athanasiadis, Pucher, Bradley III, Hanna, and Narula have no conflicts of interest or financial ties to disclose.

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Kumar, S.S., Collings, A.T., Lamm, R. et al. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc (2024). https://doi.org/10.1007/s00464-024-10813-y

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  • DOI: https://doi.org/10.1007/s00464-024-10813-y

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