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


CONSENSUS STATEMENT

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

Ramon R. Gorter1,2,22 • Hasan H. Eker1 • Marguerite A. W. Gorter-Stam1 •

Gabor S. A. Abis3 • Amish Acharya4 • Marjolein Ankersmit1 • Stavros A. Antoniou5,6 •

Simone Arolfo7 • Benjamin Babic8 • Luigi Boni9 • Marlieke Bruntink2 •

Dieuwertje A. van Dam2 • Barbara Defoort10 • Charlotte L. Deijen1 •

F. Borja DeLacy11 • Peter MNYH Go12 • Annelieke M. K. Harmsen1 •

Rick S. van den Helder
13

• Florin Iordache
14

• Johannes C. F. Ket
15

•

Filip E. Muysoms10 • M. Mahir Ozmen16 • Michail Papoulas17 • Michael Rhodes18 •

Jennifer Straatman1 • Mark Tenhagen2 • Victor Turrado19 • Andras Vereczkei20 •

Ramon Vilallonga
21

• Jort D. Deelder
13

• Jaap Bonjer
1

Received: 4 August 2016 / Accepted: 9 September 2016 / Published online: 22 September 2016

� The Author(s) 2016. This article is published with open access at Springerlink.com

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

Electronic supplementary material The online version of this
article (doi:10.1007/s00464-016-5245-7) contains supplementary
material, which is available to authorized users.

& Ramon R. Gorter
rr.gorter@vumc.nl

1
Department of Surgery, VU University Medical Centre,

Amsterdam, The Netherlands

2
Department of Surgery, Red Cross Hospital, Beverwijk, The

Netherlands

3
Department of Surgery, Spaarne Gasthuis, Haarlem, The

Netherlands

4
Department of Surgery, St Mary’s Hospital, London, UK

5
Department of Surgery, Center for Minimally Invasive

Surgery, Neuwerk Hospital, Mönchengladbach, Germany

6
Department of Surgery, University Hospital of Heraklion,

Heraklion, Greece

7
Department of Surgery, University of Torino, Torino, Italy

8
Department of Surgery, Agaplesion Markus Krankenhaus,

Frankfurt am Main, Germany

9
Department of Surgery, Minimally Invasive Surgery

Research Center, University of Insubria, Varese, Italy

10
Department of Surgery, Maria Middelares Ghent, Ghent,

Belgium

11
Department of Surgery, Hospital Clinic of Barcelona,

Barcelona, Spain

12
Department of Surgery, St. Antonius Hospital, Nieuwegein,

The Netherlands

13
Department of Surgery, Noordwest Clinics Alkmaar,

Alkmaar, The Netherlands

14
Department of Surgery, University of Medicine and

Pharmacy ‘‘Carol Davila’’, Bucharest, Romania

15
Medical Library, Vrije Universiteit, Amsterdam, The

Netherlands

16
Department of Surgery, School of Medicine, Bahcesehir

University, Istanbul, Turkey

17
Department of Surgery, Tel Aviv Sourasky Medical Centre,

Tel Aviv, Israel

18
Department of Surgery, Stepping Hill Hospital, Stockport,

UK

123

Surg Endosc (2016) 30:4668–4690

DOI 10.1007/s00464-016-5245-7

and Other Interventional Techniques 

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web survey and consensus meeting. More than 232 mem-

bers and attendees voted on them. In 41 of 46 statements

and recommendations, more than 70 % agreement was

reached. All 46 statements and recommendations are pre-

sented 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 Appendicitis � Uncomplicated appendicitis �
Complicated appendicitis � Appendectomy � Laparoscopic
appendectomy

Acute appendicitis is a common gastrointestinal disease

affecting 5.7–57/per 100.000 individuals each year with the

highest incidence in children and adolescents [1–6]. The

variation of incidence is due to variations in ethnicity, sex,

age, obesity and season of the year [3, 6–11]. Based upon the

entrenched idea that appendicitis is an irreversible pro-

gressive disease eventually leading to perforation, removal

of the appendix is the gold standard of treatment. The

medical profession has gained much experience in manag-

ing patients with acute appendicitis ever since Fitz’s first

report in 1886 [12]. Large heterogeneity exists, however,

between existing intercontinental, European and national

guidelines regarding diagnosing and managing acute

appendicitis. For instance, in the Netherlands, pre-operative

imaging studies are promoted and considered mandatory in

order to prevent negative appendectomies according to

national guidelines, whereas in guidelines of other countries,

it is not promoted nor considered mandatory [13]. Another

example is the inconsistency regarding the management of

an unexpected ‘‘normal appendix’’ during diagnostic

laparoscopy [13, 14]. This heterogeneity prompted the need

for an European consensus development conference for the

diagnosis and management of acute appendicitis.

The European Association of Endoscopic Surgery

(EAES) initiated a consensus development conference

meeting on the management of acute appendicitis for its

2015 meeting in Bucharest. The aim of this consensus

meeting was to develop practical guidelines based on the

available evidence combined with the expertise of a

selected panel of EAES surgeons. The findings are reported

in this manuscript.

Materials and methods

The coordinating team (HJB, RG, HE and MGS) invited ten

surgeons from nine European countries to serve as experts

in this consensus development conference. An international

research team of 16 young surgical researchers across 11

European countries was formed to evaluate and process the

existing literature on the management of acute appendicitis.

The coordinators generated a list of topics on acute

appendicitis to be addressed (Appendix 1). An exploratory

literature search was conducted in order to identify any

additional topics of interest. All topics were approved by the

experts and subsequently divided into three main parts: pre-

operative care, operative care and after care. Based upon the

topics, research questions were formulated, reviewed and

approved by the panel of experts.

Literature search and processing of the literature

Research questions were used as guidance to conduct lit-

erature searches. The searches were conducted in cooper-

ation with a medical information specialist of the Vrije

Universiteit. Searches were performed in the following

databases: PubMed, Web of science and the Cochrane

library from inception up to 31 December 2014. No limi-

tation was used regarding year of publication. Searches

have been attached in Appendix 2. All papers published in

European languages, and all study types with the exception

of case reports were included in the search.

All articles were screened and reviewed by teams of two

research fellows for eligibility, based on title and abstract.

If eligible for inclusion, full text articles were obtained. If

no full text was available, the article was excluded. In case

of disagreement between the two research fellows, the

coordinator dedicated to the topic acted as referee. Full text

articles were summarized, evaluated and discussed at

research meetings to assess their eligibility for inclusion in

the review process. All included studies were evaluated

according to the GRADE system [15–18]. The GRADE

system systematically evaluates the available literature and

focuses on the level of evidence based upon the types of

studies included. The level of evidence can be marked as

high, moderate, low or very low. This could be either

downgraded in case of significant bias or upgraded when

multiple high-quality studies showed consistent results.

19
Department of Surgery, Hospital de la Santa Creu i Sant Pau,

Barcelona, Spain

20
Department of Surgery, Medical School University of Pécs,

Pecs, Hungary

21
Department of Surgery, University Hospital Vall Hebrón,

Barcelona, Spain

22
Department of Pediatric Surgery, VU University Medical

Centre, P.O. Box 22660, 1100 DD Amsterdam, The

Netherlands

Surg Endosc (2016) 30:4668–4690 4669

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The highest levels of evidence (systematic reviews) were

assessed first. If the systematic review was of sufficient

quality, it was used to answer the research question. If no

systematic review of sufficient quality was found, ran-

domized controlled trials (RCTs) and cohort studies were

evaluated. All selected studies were uploaded to a Men-

deley database that was accessible to all research fellows,

coordinators and experts.

After the literature search, an expert was assigned to

every couple of researchers. This threesome was assigned

research questions from the pre-operative care, operative

care and after care. Hereafter they were responsible for

formulating a statement/conclusion and, if possible, a rec-

ommendation on the assigned research questions. Again,

the quality of the evidence was evaluated according to the

GRADE/SIGN system [15–19]. The strength of the rec-

ommendation was based on the level of evidence and

qualified as weak or strong. This was reflected in terms,

using ‘‘recommend’’ in case of a strong recommendation

and ‘‘suggest’’ in case of a weak recommendation.

A face-to-face consensus meeting among the experts was

held in Amsterdam on the 1 May 2015 to discuss the final

statements and recommendations. The coordinating team all

experts and members of the international research team

attended the meeting. A modified Delphi method was used.

The Delphi method is a structured process, commonly used

to develop healthcare quality indicator and consists of four

key components; iteration, controlled acquisition of feed-

back, aggregation of responses and anonymity. As anon-

ymity was not applicable in our situation, we used the term

modified [20–22]. All statements and recommendations

were shared with proposed levels of evidence with the entire

group. After displaying the statements and recommenda-

tions, the experts casted their votes of agreement or dis-

agreement. Refrain from voting was not allowed. No

discussion was allowed between the experts at this point of

time. In case of 100 % consensus, the statement and rec-

ommendation were accepted without further voting or dis-

cussion. In case of lack of consensus, the research team

responsible for the statement presented the underlying con-

siderations. After discussion between the experts, a second

voting round was conducted. The statement or recommen-

dation was accepted in case of at least 70 % consensus.

Those statements and recommendations with less than 70 %

consensus in the expert meeting were not included in the web

survey or in the 2015 Bucharest meeting.

All finalized recommendations and statements with

levels of evidence were entered into a web survey and

distributed to all EAES members by e-mail. The web

survey was open from 27 May until 3 July 2015. The

recommendations or statements as well as the levels of

evidence were open to several voting options: ‘‘agree’’,

‘‘partly agree’’, ‘‘disagree’’ or ‘‘don’t know’’. The option

‘‘partly agree’’ meant that the voter agreed with the rec-

ommendation, but did not agree with the strength of

recommendation.

All finalized recommendations and statements from the

Amsterdam meeting with levels of evidence were pre-

sented at a plenary session of the 23rd annual meeting of

the EAES on the 5 June 2015 in Bucharest. Live voting was

performed using a digital voting system. Voting options

were the same as the abovementioned.

Both results from the web survey and the Bucharest

meeting are presented in the ‘‘Results’’ section.

Results

The literature search yielded 13,132 articles. The title,

abstract and full text were reviewed. In total, 675 articles

were selected and reviewed in detail to define 75 state-

ments and recommendations, which were subsequently

discussed at the Amsterdam meeting. (Appendix 1) During

this meeting, the following statements and recommenda-

tions were excluded: on incidence and prevalence of

appendicitis (n = 4), on the place of NOTES in acute

appendicitis (n = 1), on the learning curve of appendec-

tomy (n = 1), on day surgery for acute appendicitis

(n = 1) and on the skeletonizing technique of the meso-

appendix (n = 1). Twenty-one statements were combined

leaving a total of 46 statement and recommendations; 8

statements and 14 recommendations for pre-operative care,

1 statement and 15 recommendations for operative care and

2 statements and 6 recommendations for aftercare (Fig. 1).

Of the 675 articles, 100 were excluded due to the fact that

statements and recommendations were excluded or were

combined, rendering 575 articles (Fig. 1; Appendix 3).

Web survey

In total, 317 EAES members responded to the web survey;

90 % were surgeons and 10 % surgical residents.

Bucharest meeting

The 2015 EAES congress in Bucharest was attended by

1166 delegates. During the plenary consensus meeting, 232

delegates voted. Sixty-eight per cent were surgeons, 26 %

surgical residents and 6 % scientists, physician assistants

and others.

4670 Surg Endosc (2016) 30:4668–4690

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Pre-operative care

Establishing the diagnosis of acute appendicitis remains

challenging. The clinical presentation of acute appendicitis

can vary from mild symptoms to signs of generalized

peritonitis and sepsis. Hence, the value of individual clin-

ical variables to determine the likelihood of acute appen-

dicitis in a patient is low [23, 24]. Biochemical testing is

performed routinely in most patients. Its value in con-

firming acute appendicitis is debatable. A recent systematic

review showed that elevated C-reactive protein levels

render the highest diagnostic accuracy followed by

increased numbers of leucocytes with an area under the

curve of 0.75 [95 % CI 0.71–0.78] and 0.72 [95 % CI

0.68–0.76], respectively [24]. The area under the curve

represents the ability of a test to correctly classify patients.

In case the score is between the 0.7 and 0.8, it represents a

fair test. Both clinical and biochemical variables have been

combined into clinical predicting rules (CPR) such as the

Alvarado score and paediatric appendicitis score (PAS)

[25, 26]. This was done to increase the value of the indi-

vidual variables. Ohle et al. [27] demonstrated that the

Alvarado score was good at ‘‘ruling-out’’ appendicitis with

an overall sensitivity and specificity of 96 and 81 %,

respectively. In children, however, it has been shown that

the PAS outperforms the Alvarado score [28]. To increase

the predictive value of these two tests Ebell et al. [29]

identified new cut-off values for the Alvarado score and

PAS, which improved sensitivity and specificity rates.

Based upon the Alvarado score, patients can now be cat-

egorised into low risk (Score \ 4), intermediate (4–8) and
high risk (C9). The use of such CPRs appears useful to

determine the likelihood of acute appendicitis. Distin-

guishing between low, intermediate and high risk provides

guidance whether imaging studies are necessary.

Imaging studies in patients with a clinical suspicion of

acute appendicitis can reduce the negative appendectomy

rate, which has been reported to be as high as 15 %.

Ultrasonography, abdominal computed tomography (CT)

and magnetic resonance imaging (MRI) are most com-

monly used. Ultrasonography is non-invasive, avoids

radiation and is associated with a sensitivity rate between

71 and 94 % and a specificity rate between 81 and 98 %.

The positive likelihood ratio of ultrasonography is high at

values between 6 and 46, while the negative likelihood

ratio is moderate (0.08–0.30) [30–39]. Ultrasonography is

therefore reliable to confirm presence of appendicitis but

unreliable to exclude appendicitis. Furthermore, one should

Fig. 1 Flow diagram of the process prior to the EAES consensus meeting in Bucharest 2015

Surg Endosc (2016) 30:4668–4690 4671

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bear in mind that ultrasonography is highly operator

dependent. Inconclusive ultrasonography findings, mostly

due to failure visualizing the appendix, mandate additional

imaging studies.

Abdominal computed tomography (CT) for suspected

appendicitis has sensitivity and specificity rates between

76–100 % and 83–100 %, respectively, and, therefore, is

superior to ultrasonography. Lower values of sensitivity

and specificity can be explained by the use of enteral

contrast [32, 33, 35–44]. However, the radiation exposure

of abdominal CT is a concern particularly in children and

during pregnancy. The estimated lifetime cancer-related

mortality risk of developing a radiation-induced malig-

nancy is approximately 0.18 % for a 1-year-old child and

0.11 % in a 15-year-old child if an abdominal CT is per-

formed [45, 46]. Computed tomographies employing only a

quarter of the standard radiation dose (low-dose CTs)

provide similar imaging results as standard CTs and are,

hence, an excellent alternative [47]. Regarding the

administration of oral contrast, Andersson et al. [48] con-

cluded in their meta-analysis that a CT scan without oral

contrast was superior to CTs with oral contrast in terms of

sensitivity and specificity. Therefore, low-dose CTs with-

out oral contrast are preferable in patients with suspected

appendicitis [48].

Magnetic resonance imaging (MRI) is used in pregnant

patients and children with inconclusive findings at ultra-

sonography [49]. A recent meta-analysis on MRI in 363

patients with appendicitis, yielded a sensitivity rate of

97 % [95 % CI 92–99 %], a specificity rate of 95 % [95 %

CI 94–99 %], a positive likelihood ratio of 16.3 [95 % CI

9.10–29.10] and a negative likelihood ratio of 0.09 [95 %

CI 0.04–0.20] [50]. These rates are comparable to those of

CT imaging, although these findings should be interpreted

with care as most studies have been performed in a selected

group of patients. MRI is associated with significant costs,

and interpreting the images requires experience. Therefore,

at the present time, use of MRI appears limited to pregnant

women and children.

The algorithm associated with the Alvarado score (rec-

ommendation 4) is shown in Fig. 2.

In obese patients (definition depends on the reference

study), the diagnostic accuracy of ultrasound is diminished

due to an increase of the subcutaneous and intra-abdominal

fat. Anderson et al. [51] demonstrated that the body mass

index (BMI) does not alter the diagnostic accuracy of a CT

scan. CT appears therefore more reliable than ultrasonog-

raphy in obese patients with the exception of children and

pregnancy.

Patients with appendicitis are classified as uncompli-

cated or complicated appendicitis based upon pre-opera-

tive, intra-operative and/or histopathological findings. In

this report, uncomplicated appendicitis has been defined as

an inflamed appendix without signs of gangrene, perfora-

tion, intra-peritoneal purulent fluid, contained phlegmon or

intra-abdominal abscess (IAA). Complicated appendicitis

applies to all patients with either a gangrenous inflamed

appendix with or without perforation, intra-abdominal

abscess, peri-appendicular contained phlegmon or purulent

free fluid. Classification is necessary as treatment strategies

may differ.

Uncomplicated appendicitis

Appendectomy is still considered to be the gold stan-

dard for uncomplicated appendicitis. Two main

approaches to remove an inflamed appendix are avail-

able; the open approach (OA) or the laparoscopic

approach (LA). In 2010, a large Cochrane review on 67

studies showed that LA significantly reduced the rate of

surgical site infection (SSI) (OR 0.43; 95 % CI

0.34–0.54) but significantly increased the risk of an

intra-abdominal abscess (IAA) (OR 1.77; 95 % CI

1.14–2.76) compared to the open approach [52]. It was

stated that LA was associated with fewer superficial

wound infections, less post-operative pain, shorter hos-

pital stay and earlier return to work, but the higher rate

of IAA raised concerns [52]. Ever since, inconsistent

results have been reported regarding the potential higher

incidence of IAA after LA [53–61]. Benefits of LA over

OA reported in meta-analyses are: reduced incidence of

SSI, post-operative and long-term bowel obstruction

with better outcome in terms of shorter hospital stay, its

diagnostic value, less pain, earlier return to work, ear-

lier start of oral intake, improved scar and body satis-

faction and fewer incisional hernias [54, 55, 58, 61–66].

Disadvantages besides the possible higher incidence of

IAA are longer operating time and possibly increased

costs [58, 63].

To reduce the surgical trauma even more, new treatment

strategies have been introduced such as single-incision

laparoscopic surgery (SILS) first reported by Pelosi et al.

[67]. Since then, numerous studies (RCTs and SR) have

been published on the potential advantages and disadvan-

tages of the SILS technique. It can be concluded that SILS

is associated with comparable post-operative morbidity

rates compared to conventional LA [68–70]. The disad-

vantage is the fact that SILS is a more difficult technique as

is reflected by the higher technical failure rate, longer

operating time and conversion rate [71–78]. Main advan-

tages of SILS would be less post-operative pain and better

cosmetic outcomes, although inconsistent results have been

reported [71, 75, 76, 79–81]. At the present time, evidence

is lacking that SILS is superior to conventional LA

[79, 82, 83]. SILS is, however, a safe and feasible

alternative.

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Recently, initial non-operative management of appen-

dicitis has been investigated in the adult population. Five

RCTs reported an effectiveness of 41–85 % at 1-year fol-

low-up [84–88]. Meta-analyses of these studies revealed

that non-operative treatment of acute appendicitis is less

effective but could avoid surgery in 60–85 % of patients

[89–94]. Opponents of this strategy raise concerns such as

recurrent appendicitis, missing an underlying malignancy

and progression of uncomplicated into complicated

appendicitis. Due to the possible avoidance of surgery with

an initial non-operative treatment strategy, morbidity was

diminished [91, 93, 95]. However, both RCTs and meta-

analyses showed significant heterogeneity of methodolog-

ical quality, studies included and definitions of outcome

parameters. Until higher qualitative evidence has been

obtained regarding the potential benefits of initial non-op-

erative management of acute appendicitis and the potential

long-term effects have been investigated appropriately,

appendectomy remains the gold standard in acute uncom-

plicated appendicitis.

Complicated appendicitis

Due to the heterogeneity of the definitions used in the lit-

erature, it is difficult to draw firm conclusions regarding the

treatment of complicated appendicitis. In 2013, Dimitriou

published a retrospective cohort study on 150 patients with

complicated appendicitis (defined as perforated with an

abscess or peritonitis). They showed that LA reduced the

incidence of SSI, number of reoperations and length of

hospital stay as compared to OA with no difference in IAA

rate [96]. A RCT encompassing 81 patients with clinically

and histopathologically confirmed complicated appendici-

tis showed similar outcomes after OA and LA [97]. It

should be noted, however, that the incidence of IAA after

LA for patients with complicated appendicitis was reported

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. ***Ultra-

sound 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

Surg Endosc (2016) 30:4668–4690 4673

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to be higher in some studies. Tuggle and colleagues

reported that LA in patients with complicated appendicitis

was associated with an incidence of IAA of 6.7 versus

3.7 % in patients who underwent an open appendectomy

[98]. The incidence of small bowel obstructions after LA is

lower compared to OA (pooled odds ratio 0.44 [95 % CI

0.26–0.74] with large heterogeneity regarding follow-up

period) [65].

In case of a contained phlegmon or abscess (peri-ap-

pendicular mass), some authors opt for non-operative

treatment while others advocate aggressive operative

treatment. In 2007, Andersson et al. [99] demonstrated that

immediate surgical treatment of patient with an abscess or

phlegmon was associated with higher morbidity compared

to initial non-operative treatment (OR 3.3 95 % CI

1.9–5.6). Similis et al. showed in their meta-analysis of 17

studies regarding this specific patient group that non-op-

erative treatment was associated with fewer complications

(SSI, IAA and bowel obstructions). It must be mentioned

that this meta-analysis was subject to large heterogeneity

[100]. Recent cohort studies draw opposite conclusions

[101, 102]. They opt for a more aggressive surgical

approach at time of presentation in case of an appendicular

mass or appendicular abscess, based upon the idea that

there is a relative high failure rate for non-surgical treat-

ment [101, 102]. In our opinion, with this new evidence, a

new systematic review should be performed. Until then,

initial non-operative treatment of an appendicular mass of

appendicular abscess is the preferred treatment of choice.

Although not covered in this consensus guideline, the value

of interval appendectomy after initial non-operative treat-

ment of an appendicular mass is still subject of debate.

Some opt for an interval appendectomy based upon the

chance of missing an underlying and untreated malignancy

(incidence 6 %) and the chance of developing recurrent

appendicitis (incidence 5–44 %) [101–103]. Both can be

avoided with an interval appendectomy, although data are

lacking on its benefits.

Specific patient groups

Obese patients

Abdominal surgery in obese patients is challenging for

both the anaesthesiologist and surgeon due to higher inci-

dence of respiratory dysfunction, difficult access to the

abdominal cavity, blurred anatomical landmarks and

reduced working space in the abdominal cavity. Clarke

et al. [104] performed a subgroup analysis among 37

patients (14 LA and 23 OA) with a BMI higher than 30 kg/

m
2
and reported similar morbidity after LA and OA [104].

This was confirmed by a meta-analysis, although a reduced

length of hospital stay was noted after LA [105]. More

recently, two recent meta-analyses showed a reduction of

mortality and morbidity rates after LA [106, 107].

Pregnancy

Pregnancy induces anatomical and physiological changes

that challenge the surgeon. The potential effects of carbon

dioxide and increased abdominal pressure during LA on

the foetus remain unclear. Loss of the foetus is most feared.

In 2008, Walsh et al. [108] published a systematic review

of 637 laparoscopic appendectomies in pregnant patients

and noted foetal loss in approximately 6 % of the patients,

with the highest incidence in patients with complicated

appendicitis. Another review confirmed these findings and

reported a nearly twofold increase of foetal loss in the LA

group [109]. Both reviews, however, are mainly dominated

by one study and based on low-grade evidence (retro-

spective studies with small numbers of patients) [108–110].

Recently, a review suggested that based upon the little

available evidence no recommendation can be made

regarding the preferred approach in pregnant patients

[111]. More studies are necessary to ascertain the role of

laparoscopic surgery during pregnancy. Until more evi-

dence comes available, the surgical approach should be at

the surgeon’s discretion. Based upon expert opinion, we

recommend laparoscopy in case of sufficient experience.

Although not supported by the literature, we strongly

advise a multi-disciplinary approach to the pregnant patient

with appendicitis [13, 54, 82, 111, 112].

Children

One meta-analysis included 107,624 children with both

uncomplicated and complicated appendicitis [113].

Laparoscopic appendectomy in children with uncomplicated

appendicitis LA was associated with a significant reduction

of hospital stay with similar morbidity compared to open

surgery. In children with complicated appendicitis, LA was

associated with lower rates of morbidity, SSI, length of

hospital admission and bowel obstruction. However,

laparoscopic surgeries lasted longer and were followed by

more intra-abdominal abscesses [113]. In more recent

prospective cohort studies in children below 5 years of age,

LA was associated with fewer complications [114]. Non-

operative treatment of acute non-complicated appendicitis

appears more promising in children than in adults [115, 116]

Elderly

Elderly patients have higher morbidity, reduced physio-

logical reserves and impaired inflammatory responses,

4674 Surg Endosc (2016) 30:4668–4690

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which increases their peri-operative risks. All studies of

laparoscopic appendectomy in elderly support the use of

laparoscopic surgery [117–121]. One meta-analysis, com-

prising more than 15,000 patients reported that LA reduced

post-operative mortality (0.24; 95 % CI 0.15–0.37), post-

operative complications (0.61; 95 % CI 0.50–0.73) and

length of hospital stay (-0.51; 95 % CI -0.64 to -0.37)

compared to OA (Tables 1, 2, 3, 4) [119].

Timing

Determining the best moment to perform surgery in case

of acute appendicitis is of crucial importance [122, 123].

Acute appendicitis has been considered to be an irre-

versible progressive disease although recent studies have

questioned this dogma [84, 89, 124]. Nowadays, the idea

is endorsed that two types of appendicitis exist: uncom-

plicated (non-perforating) and complicated (perforating)

appendicitis. The aetiology and pathogenesis of acute

appendicitis remain largely unknown. Predicting a mild

or fulminant course of appendicitis is not possible.

Delaying an appendectomy increases the risk of perfo-

rated appendicitis, which is associated with higher inci-

dence of short and long-term morbidity [125–127].

Hence, it is recommended to perform appendectomy as

soon as possible. Although it should be noted that some

studies have revealed that the clinical outcome was not

affected by time to surgery (when surgery was performed

within 12 h after presentation at the emergency depart-

ment) [128, 129].

Antibiotic prophylaxis

Antibiotic prophylaxis has been proven effective in pre-

vention of superficial surgical site infections and intra-ab-

dominal abscesses in patients with appendicitis [130–132].

Prophylaxis should be commenced at the time of estab-

lishing the diagnosis of acute appendicitis. The choice of

antibiotics is dependent on the local microbiome and drug

resistance pattern and is not influenced by age.

Technique

Open access to the abdominal cavity as well as closed

access using the Veress needle are accepted techniques to

perform laparoscopy [133–135]. The debate on the pre-

ferred technique continues. However, in children, the

majority of surgeons employs open establishment of a

pneumoperitoneum.

The placement of the camera port and the work ports

depend on the anatomy of the patient and preference of the

operating surgeon. Primary principle of trocar placement in

laparoscopy is that a triangular working space should be

pursued.

Intra-operative procedure

Increased employment of pre-operative radiologic testing

(e.g. ultrasound, CT or MRI) in cases of suspected appen-

dicitis has significantly reduced the incidence of a normal

appearing appendix encountered during surgery [136].

Macroscopic distinction between a normal appendix and

appendicitis during surgery can be difficult [137, 138]. The

‘‘gold standard’’ for defining appendicitis is histopathology.

In some studies, histopathological assessment revealed

abnormal findings in up to 26 % of macroscopically normal

appearing appendices [139, 140]. Therefore, it is recom-

mended to perform an appendectomy in case of a normal

appearing appendix during surgery for suspected

appendicitis.

Several studies have investigated the safety of different

methods of securing the appendicular stump [82, 141–143].

None of the different closure methods has a clear advan-

tage in case of a healthy appendix base. Stapler devices

provide the most standardized and patent closure of the

appendix base. Suturing of the appendix base provides

sufficient closure as well, but is technically more

demanding than other techniques [142]. In case of perfo-

ration of the appendicular base, clips or endoloops do not

provide secure closure and staple devices or laparoscopic

suturing is required [82].

Reduction of bacterial load by meticulous suction of intra-

peritoneal fluids is advised [144–146]. The right paracolic

and pelvic area should be inspected to leave no fluid col-

lections behind. Irrigation of the intra-peritoneal space in

case of perforated appendicitis seems to be contra-produc-

tive leading to a higher number of abscesses [144, 145]. It is

believed that irrigation of the intra-peritoneal space leads to

spreading of bacteria. Routine use of drains does not reduce

the incidence of abscesses [145, 147]. Necessity of a drain for

special indications is left to the discretion of the surgeon.

Intra-operative unexpected findings

When an appendicular mass is encountered during surgery,

one should restrain from continuing the operation. Con-

tinuation of the operation can necessitate bowel resec-

tion. Antibiotic treatment of phlegmon and drainage of any

abscess should be performed [99, 148, 149].

Surg Endosc (2016) 30:4668–4690 4675

123



The extent of surgical resection in case of suspected

malignancy depends on the location and size of the

appendicular mass [150–154]. Routine inclusion of

the meso-appendix with the appendectomy is advised.

Definitive histological findings determine whether an

additional resection after total appendectomy is

Table 2 Pre-operative care:
statements web survey

LOE level of evidence

X means present, Box means not present

Table 1 Pre-operative care:
statements EAES meeting 2015

LOE level of evidence

X means present, Box means not present

4676 Surg Endosc (2016) 30:4668–4690

123



Table 3 Pre-operative care:
recommendations EAES

meeting 2015

LOE level of evidence, SOR strength of recommendation

X means present, Box means not present

Surg Endosc (2016) 30:4668–4690 4677

123



indicated. In cases of small neuroendocrine tumours

(NET) or low-grade appendicular mucinous neoplasms

(LAMN), a total meso-appendicular resection can be

sufficient. In cases of a NET [ 1 cm, LAMN grade 3–4

or an adenocarcinoma of the appendix, a formal right

hemicolectomy is indicated to provide an oncologically

sufficient resection. It is advised to perform a total meso-

appendicular resection at the primary operation and an

Table 4 Pre-operative care:
recommendations web survey

LOE level of evidence, SOR strength of recommendation

X means present, Box means not present

4678 Surg Endosc (2016) 30:4668–4690

123



additional hemicolectomy at a later stage when indicated

(Tables 5, 6, 7, 8) [150–154].

Post-operative antibiotics

The incidence of SSI after appendectomy has been

reported to range from 0 to 11 % [155–164]. The severity

of appendicitis strongly influences the risk of developing

post-operative complications resulting in a substantially

higher complication rate (up to 2–4 times) in patients with

complicated appendicitis. In this specific group, post-

operative administration of antibiotics significantly redu-

ces the rate of SSI. In addition, to reduce bacteraemia

and sepsis, these patients are uniformly treated with a

course of post-operative antibiotics [155–158, 163]. In

uncomplicated appendicitis, there is no evidence sup-

porting routine administration of post-operative antibi-

otics. Therefore, only one pre-operative dose is advised

[155–158].

Advice on type of antibiotics depends on local

microbiome and resistance patterns and therefore should

be left up to the discretion of the surgeon [159, 160].

Available evidence on duration of treatment is limited

and mainly focused on children. However, there is no

firm evidence on the duration (3, 5, 7, 10 days) and

route of administration (usually intravenous administra-

tion for 48 h, then oral administration) [156, 157, 159,

161, 162].

Post-operative complications

The incidence of post-operative complications ranges from

3.0 to 28.7 % [164–174]. Complications include small

bowel obstruction (0–1.9 %.), SSI (1.2–12.0 %), IAA

(1.6–8 %), stump leakage and stump appendicitis

[164–174]. Literature suggests a higher rate of complica-

tions in complicated appendicitis [166, 167, 171, 175].

Literature on stump leakage and stump appendicitis is

limited, and no exact incidences have been reported

in the literature, although it is assumed that it is more

Table 5 Operative care:
statements EAES meeting 2015

LOE level of evidence

X means present, Box means not present

Table 6 Operative care:
statements web survey

LOE level of evidence

X means present, Box means not present

Surg Endosc (2016) 30:4668–4690 4679

123



common in patients with complicated appendicitis and

after OA [176]. A recommendation to avoid stump

leakage or stump appendicitis is to resect the appendix

as a whole [176]. Therefore, the stump should be no

longer than 0.5 cm and caecal taenia should be followed

onto the appendix at removal to ensure complete

resection. Stump appendicitis is significantly more

associated with perforation, as diagnosis is delayed by

misled attention. This is caused by the assumption that

the appendix as a whole is resected. Prevention is cru-

cial. In case of timely diagnosis, stump resection with

laparoscopic or open approach is feasible. In case of

perforation, extended bowel resection is usually required

[176].

In the initial management of IAA after appendectomy

conservative measures (i.e. non-operative with antibiotics)

are effective in most patients. However, in case of lack of

improvement or deterioration, a more invasive strategy

Table 7 Operative care: recommendations EAES meeting 2015

LOE level of evidence, SOR strength of recommendation

X means present, Box means not present

4680 Surg Endosc (2016) 30:4668–4690

123



should be applied (percutaneous drainage or surgical (la-

paroscopic) drainage) [177–179].

Post-operative care

The use of prophylactic anti-emetics diminishes the incidence

of post-operative nausea and vomiting. Increasing the diet is

best determined by the patient’s ability to tolerate oral intake.

There is no evidence that a liberal diet causes complications in

the post-operative period [164, 180].

Post-operative pain management should follow local

protocol for pain management after abdominal surgery.

Post-operative analgesia with PCA provides effective and

safe pain relief in children and adults and is less time

costly [181]. Recently positive results have been pub-

lished regarding the pre-emptive incision site infiltration

with a local anaesthetic. Studies demonstrated that this

decreases the total opioid consumption and lowers pain

Table 8 Operative care:
recommendations web survey

LOE level of evidence, SOR strength of recommendation

X means present, Box means not present

Surg Endosc (2016) 30:4668–4690 4681

123



score experienced by patients in the first 24 h after sur-

gery [182–184].

Pathology

Carcinoid is the most commonly found neoplasm in

appendectomy specimens at an incidence between 0.13 and

2.4 % [185–190]. Other unexpected findings can be

encountered in 1.4–2.4 % of patients, including: divertic-

ulitis (1.2 %), tuberculosis appendix 0.08 %, endometriosis

(3.6 %), adenocarcinoma (\1 %) and mucinous cystade-
noma (0.2–0.6 %) [191–194].

Treatment of unexpected findings ranges from no further

surgical treatment, to right hemi colectomy and even

hyperthermic intra-peritoneal chemotherapy (HIPEC) in

some cases [195–197]. Even though the incidence of

unexpected findings seems low, the actual number of

patients is significant and correct diagnosis is crucial for

adequate treatment (Tables 9, 10, 11, 12) [198–202].

Discussion

This EAES consensus development conference regarding

the diagnosis and management of acute appendicitis

resulted in 46 statements and recommendations based upon

the available evidence. Results from this meeting led to this

paper, which can be used as a guideline for surgeons

treating patients with appendicitis. Local guidelines,

national guidelines and guidelines from scientific commu-

nities regarding appendicitis were available but showed

great heterogeneity [13, 14, 203]. With this consensus

meeting, we managed to gather experts from different

European nations to compare and debate management of

patients with acute appendicitis. This led to a consensus

meeting in which 41 of the 46 statements and the majority

of the members of the EAES supported recommendations.

The transfer of knowledge between the member countries,

the opportunity to discuss views and above all, the creation

of a widely supported paper appears valuable.

Our list of topics was created by the coordinating team

and expert panel and was thought to cover the most

important topics in the field of acute appendicitis. Despite

local differences, the general idea within the consensus

group on the management of patients with acute appen-

dicitis was comparable. In some cases, differences of

treatment strategies between members of the expert panel

were due to available surgical supplies and finances. This is

reflected for instance on the statements and recommenda-

tions regarding SILS and MRI. However, we want to

emphasize that in defining statements we refrained from

stating specific procedures. We rather stated the general

principles to follow. In this way, the results from this

Table 9 After care: statements
EAES meeting 2015

LOE level of evidence

X means present, Box means not present

Table 10 After care:
statements web survey

LOE level of evidence

X means present, Box means not present

4682 Surg Endosc (2016) 30:4668–4690

123



consensus guideline can also be applied in areas with

limited resources.

The methodology of a consensus guideline is always

subject to discussion. In the literature, there are several

ways to conduct consensus conferences [20, 204–206].

However, not one was suited for our situation. It was

therefore decided to modify the Delphi method, as

described in the method section, in order to systematically

evaluate each statement and recommendation [20–22]. We

decided to finalize only those statements and recommen-

dation with 70 % or more consensus, which is the arbitrary

cut-off value we selected. The results of both the web-

based survey and the live voting at the EAES conference in

Bucharest are presented independently rather than com-

bined to rule out any bias. As expected, small differences

were noted between the several voting rounds. Although

supported by the experts, some statements and recom-

mendations were not supported by the scientific commu-

nity in both the web survey as in the Bucharest meeting.

The topics that were not supported were on accuracy of

MRI compared to CT, the application of SILS, extensive

work-up in the elderly and treatment strategy for immune

compromised patients and the open access to the peritoneal

cavity. Explanations for these discrepancies might be

related to local habits, experience and financial situation.

Of more interest are the discrepancies noted between the

outcome in the web survey and during the Bucharest

meeting. Discrepancies were noted on the topic of MRI

application in children, the preferred approach in pregnant

patients and the use of local anaesthetics prior to incision.

This can again be explained by the fact that local habits,

experience, composition of the voting public and financial

situation might influence the outcome. The question was

raised if the web survey alone would be sufficient to reach

a consensus for future meetings. Limiting a consensus

meeting to only the web survey would limit the time as

well as the costs involved. Moreover, a higher percentage

of surgeons participated in the web survey. In our opinion,

however, the integration of an actual face-to-face meeting

in the consensus methodology raises more awareness,

provides an opportunity to discuss views and encourages

the transfer of knowledge eventually leading to the creation

of a widely supported paper.

The literature review was ended in December 2014. No

studies after that were integrated for the consensus meeting

as this was decided in our methodology. Therefore, new

studies might have been conducted on some topics. Future

research should be focused on the laparoscopic appendec-

tomy in pregnant patients, elucidating the value of MRI in

specific patient groups, evaluating the outcomes of initial

non-operative treatment for both uncomplicated and com-

plicated appendicitis, specific patient groups and the need

for interval appendectomy. We therefore propose that these

statements are updated on a regular basis.

Table 11 After care:
recommendations EAES

meeting

LOE level of evidence, SOR strength of recommendation

X means present, Box means not present

Surg Endosc (2016) 30:4668–4690 4683

123



Although some limitations can be identified in our

methodology, we have integrated a new systematic method

for a consensus meeting. In our opinion, this is the way

forward and we need to efflorescence this method.

Reproducibility, involving members of the scientific com-

munity and applicability are key components of a con-

sensus meeting. We believe that only after evaluation of

the general opinion within the EAES such guidelines

should be put into order.

In conclusion, the consensus meeting of the EAES

resulted in several statements and recommendations

regarding the diagnosis and management of appendicitis

based upon available evidence and expert opinion and was

supported by the European surgical community. It provides

guidance to surgeons and surgical residents facing patients

with acute appendicitis.

Funding This project was supported by a grant from the EAES.

Compliance with ethical standards

Disclosures Dr. Antoniou received personal fees from the EAES
(including Journal and Publication Committee) and from the Euro-

pean 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. Ver-

eczkei, Prof. Dr. Vilallonga and Drs. Deelder have no conflict of

interest or financial ties to disclose.

Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creative

commons.org/licenses/by/4.0/), which permits unrestricted use, distri-

bution, and reproduction in any medium, provided you give appropriate

credit to the original author(s) and the source, provide a link to the

Creative Commons license, and indicate if changes were made.

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http://dx.doi.org/10.1186/1824-7288-36-68
http://dx.doi.org/10.1186/1750-1172-9-71
http://dx.doi.org/10.1186/1477-7819-7-51
http://dx.doi.org/10.1186/1477-7819-7-51

	Diagnosis and management of acute appendicitis. EAES consensus development conference 2015
	Abstract
	Materials and methods
	Literature search and processing of the literature

	Results
	Web survey
	Bucharest meeting

	Pre-operative care
	Uncomplicated appendicitis
	Complicated appendicitis
	Specific patient groups
	Obese patients
	Pregnancy
	Children
	Elderly


	Timing
	Antibiotic prophylaxis
	Technique
	Intra-operative procedure
	Intra-operative unexpected findings
	Post-operative antibiotics
	Post-operative complications
	Post-operative care
	Pathology
	Discussion
	Funding
	References