American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction

Abstract

In April 2017, the American Association for the Surgery of Trauma (AAST) asked the AAST Patient Assessment Committee to undertake a gap analysis for published clinical practice guidelines in emergency general surgery (EGS). Committee members performed literature searches to catalogue published guidelines for common EGS diseases and also to identify gaps in the literature where guidelines could be created. For five of the most common EGS conditions, acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction, we found multiple well-referenced guidelines published by leading professional organizations. We have summarized guideline recommendations for each of these disease states stratified by the AAST EGS anatomic severity score based on these published consensus guidelines. These summaries could be used to help inform evidence-based clinical decision-making, but are intended to be flexible and updatable in real time as further research emerges. Comprehensive guidelines were available for all of the diseases queried and identified gaps most commonly represented areas lacking a solid evidence base. These are therefore areas where further research is needed.

Acute appendicitis management guidelines summary

Multiple societies have published guidelines for the diagnosis and management of appendicitis. Notably, a consensus statement was published in Surgical Endoscopy in 2015, and a summary from the World Society of Emergency Surgery was published in the World Journal of Emergency Surgery in 2016. Several other comprehensive guidelines covering imaging recommendations, antimicrobial prophylaxis and duration, laparoscopic versus open surgical approach, and optimal management of perforated appendicitis have been published. This review summarizes and references evidence-based guidelines for appendicitis by stage, as a reference guide for surgeons practicing emergency general surgery.

American Association for the Surgery of Trauma grade	Description	Management	References
I	Acutely inflamed appendix, intact	Laparoscopic appendectomy Non-operative therapy with antibiotics may be a reasonable alternative No postoperative antibiotics are indicated in surgically managed appendicitis	1 2 3 4 6 7 3 2
II	Gangrenous appendix, intact	Laparoscopic appendectomy	1 2 3 4 6 7
III	Perforated appendix with local contamination	Laparoscopic appendectomy	1 2 3 4 6 7
IV	Perforated appendix with periappendiceal phlegmon or abscess	Laparoscopic appendectomy Non-operative therapy with antibiotics may be chosen in select patients	1 2 3 4 6 7 3
V	Perforated appendix with generalized peritonitis	Laparoscopic appendectomy when feasible	1 2 3 4 6 7

Key points

Laparoscopic appendectomy is considered the gold standard for acute appendicitis and should be the procedure of choice, except when laparoscopy is contraindicated or not feasible. Studies have demonstrated the laparoscopic approach is equivalent to, or better than, the open technique in most circumstances. Conversion to open may be necessary in technically difficult cases, however. Laparoscopic appendectomy is safe in the obese, elderly patients, pediatric patients and pregnant patient populations, including in the third trimester.^{1, 2, 3, 4, 6, 7}

Non-operative therapy is a reasonable approach in uncomplicated acute appendicitis. Patients should be educated that the possibility of recurrence exists. Non-operative therapy may also be considered in some cases of acute appendicitis with phlegmon or abscess.³ In most other situations, appendectomy is the standard of care.

CT imaging is more reliable that ultrasound for the diagnosis of acute appendicitis. The use of intravenous contrast may improve the sensitivity of this test and is generally recommended when CT imaging is performed. Exceptions to CT may be pursued in pregnant women and children to minimize exposure to radiation. Ultrasound is preferred for diagnosis in pregnant patients and children. If ultrasound is equivocal, MRI would be the next diagnostic test of choice.^{2, 3, 5, 8}

Preoperative antibiotics should be administered as soon as the diagnosis of acute appendicitis is made. There is no indication for postoperative antibiotics in uncomplicated appendicitis.² There are also no data supporting improvement in clinical outcomes with any given scoring system for acute appendicitis.³

Technical maneuvers, such as peritoneal irrigation, variations in appendiceal stump closure or methods of mesenteric vascular control have demonstrated no difference in outcomes.³