Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines
急性闌尾炎的診斷和治療：WSES 耶路撒冷指南 2020 年更新

Abstract  抽象

Background and aims  背景和目標

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide.
急性闌尾炎 （AA） 是急性腹痛的最常見原因之一。AA 的診斷仍然具有挑戰性，並且在全球範圍內的不同環境和實踐模式中仍然存在一些關於其管理的爭議。

In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.
2015 年 7 月，世界急診外科學會 （WSES） 在耶路撒冷組織了第一次關於成年患者 AA 診斷和治療的共識會議，旨在制定循證指南。2019 年 6 月在尼傑梅亨舉行了一次更新的共識會議，指南現已更新，以便提供與不同臨床實踐保持一致的循證陳述和建議：使用臨床評分和影像學診斷 AA、手術適應症和時間、使用非手術管理和抗生素、腹腔鏡檢查和手術技術， 術中評分和圍手術期抗生素治療。

Methods  方法

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.
本執行手稿總結了 WSES 關於 AA 診斷和治療的指南。文獻檢索已更新至 2019 年，並根據 GRADE 方法制定了陳述和建議。這些陳述經過投票、最終修改，並最終由共識會議的參與者和合著者委員會批准，每當對陳述或建議存在爭議時，都會使用德爾菲方法進行投票。提供了幾個表格，突出顯示了研究主題和問題、搜索語法以及陳述和 WSES 循證建議。最後，以流程圖的形式為成人和兒童（< 16 歲）患者提供了兩種不同的實用臨床演算法。

Conclusions  結論

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
2020 年 WSES AA 指南旨在就以下每個主題提供最新的循證陳述和建議：（1） 診斷，（2） 無併發症 AA 的非手術治療，（3） 闌尾切除術和院內延遲的時間，（4） 手術治療，（5） AA 的術中分級，（6） 伴有痰或膿腫的穿孔 AA 的管理，以及 （7） 圍手術期抗生素治療。

Background  背景

Acute abdominal pain accounts for 7–10% of all emergency department accesses [1]. Acute appendicitis (AA) is among the most common causes of lower abdominal pain leading patients to attend the emergency department and the most common diagnosis made in young patients admitted to the hospital with an acute abdomen.
急性腹痛佔所有急診科就診的 7-10%[1]。急性闌尾炎 （AA） 是導致患者到急診科就診的下腹痛的最常見原因之一，也是因急腹症入院的年輕患者中最常見的診斷。

The incidence of AA has been declining steadily since the late 1940s. In developed countries, AA occurs at a rate of 5.7–50 patients per 100,000 inhabitants per year, with a peak between the ages of 10 and 30 [2, 3].
自 1940 年代後期以來，AA 的發病率一直在穩步下降。在發達國家，AA 的發生率為每年每 10 萬居民 5.7-50 例，在 10-30 歲之間達到高峰[2,3]。

Geographical differences are reported, with a lifetime risk for AA of 9% in the USA, 8% in Europe, and 2% in Africa [4]. Moreover, there is great variation in the presentation, severity of the disease, radiological workup, and surgical management of patients having AA that is related to country income [5].
據報導，AA 終生風險在美國為 9%，歐洲為 8%，非洲為 2%[4]。此外，AA 患者的表現、疾病嚴重程度、放射學檢查和手術治療與國家收入相關的差異很大[5]。

The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40–57%) and in patients older than 50 years (55–70%) [6].
穿孔率從 16%到 40%不等，年輕年齡組（40-57%）和 50 歲以上患者（55-70%）的穿孔率更高[6]。

Appendiceal perforation is associated with increased morbidity and mortality compared with non-perforating AA. The mortality risk of acute but not gangrenous AA is less than 0.1%, but the risk rises to 0.6% in gangrenous AA. On the other hand, perforated AA carries a higher mortality rate of around 5%. Currently, growing evidence suggests that perforation is not necessarily the inevitable result of appendiceal obstruction, and an increasing amount of evidence now suggests not only that not all patients with AA will progress to perforation, but even that resolution may be a common event [7].
與非穿孔 AA 相比，闌尾穿孔與發病率和死亡率增加有關。急性但非壞疽性 AA 的死亡風險低於 0.1%，但壞疽性 AA 的風險上升至 0.6%。另一方面，穿孔 AA 的死亡率較高，約為 5%。目前，越來越多的證據表明，穿孔不一定是闌尾梗阻的必然結果，越來越多的證據表明，不僅並非所有 AA 患者都會進展為穿孔，而且即使穿孔的消退也可能是一種常見事件[7]。

The clinical diagnosis of AA is often challenging and involves a synthesis of clinical, laboratory, and radiological findings. The diagnostic workup could be improved by using clinical scoring systems that involve physical examination findings and inflammatory markers. Many simple and user-friendly scoring systems have been used as a structured algorithm in order to aid in predicting the risk of AA, but none has been widely accepted [8,9,10]. The role of diagnostic imaging, such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI), is another major controversy [11, 12].
AA 的臨床診斷通常具有挑戰性，需要綜合臨床、實驗室和放射學檢查結果。通過使用涉及體格檢查結果和炎症標誌物的臨床評分系統，可以改進診斷檢查。許多簡單易用的評分系統已被用作結構化演算法，以幫助預測 AA 風險，但尚未被廣泛接受[8,9,10]。 超聲（US）、CT（CT）或磁共振成像（MRI）等診斷成像的作用是另一個主要爭議[11,12]。

Since surgeons started performing appendectomies in the nineteenth century, surgery has been the most widely accepted treatment, with more than 300,000 appendectomies performed annually in the USA [13]. Current evidence shows laparoscopic appendectomy (LA) to be the most effective surgical treatment, being associated with a lower incidence of wound infection and post-intervention morbidity, shorter hospital stay, and better quality of life scores when compared to open appendectomy (OA) [14, 15].
自 19 世紀外科醫生開始進行闌尾切除術以來，手術一直是最廣泛接受的治療方法，美國每年進行超過 30 萬例闌尾切除術[13]。目前的證據表明，腹腔鏡闌尾切除術（LA）是最有效的手術治療方法，與開放式闌尾切除術（open appendectomy， OA）相比，傷口感染發生率和干預后併發症發生率更低，住院時間更短，生活品質評分更好[14,15]。

Despite all the improvements in the diagnostic process, the crucial decision as to whether to operate or not remains challenging. Over the past 20 years, there has been renewed interest in the non-operative management of uncomplicated AA, probably due to a more reliable analysis of postoperative complications and costs of surgical interventions, which are mostly related to the continuously increasing use of minimally invasive techniques [16,17,18].
儘管診斷過程取得了所有改進，但是否進行手術的關鍵決定仍然具有挑戰性。在過去的 20 年裡，人們對無併發症 AA 的非手術治療重新產生了興趣，這可能是由於對術后併發症和手術干預成本的分析更加可靠，這主要與微創技術的使用不斷增加有關[16,17,18]。

The most common postoperative complications, such as wound infection, intra-abdominal abscess, and ileus, vary in frequency between OA (overall complication rate of 11.1%) and LA (8.7%) [19].
最常見的術后併發症，如傷口感染、腹腔內膿腫和腸梗阻，OA（總併發症發生率為 11.1%）和 LA（8.7%）的頻率各不相同[19]。

In August 2013, the Organizational Board of the 2nd World Congress of the World Society of Emergency Surgery (WSES) endorsed its president to organize the first Consensus Conference on AA, in order to develop the WSES Guidelines on this topic. The Consensus Conference on AA was held in Jerusalem, Israel, on July 6, 2015, during the 3rd World Congress of the WSES, following which, the WSES Jerusalem guidelines for diagnosis and treatment of AA were published [20].
2013 年 8 月，世界急診外科學會 （WSES） 第二屆世界大會組織委員會批准其主席組織第一次關於 AA 的共識會議，以制定有關該主題的 WSES 指南。2015 年 7 月 6 日，在第三屆 WSES 世界大會期間，AA 共識會議在以色列耶路撒冷舉行，隨後發佈了 WSES 耶路撒冷 AA 診斷和治療指南[20]。

Over the last 4 years, major issues still open to debate in the management of AA have been reported concerning the timing of appendectomy, the safety of in-hospital delay, and the indications to interval appendectomy following the resolution of AA with antibiotics [21,22,23,24]. Therefore, the board of the WSES decided to convene an update of the 2016 Jerusalem guidelines.
在過去 4 年中，關於闌尾切除術的時機、院內延遲的安全性以及抗生素解決 AA 後間歇闌尾切除術的指征等，AA 治療中仍有待商榷的主要問題[21,22,23,24]。 因此，WSES 董事會決定召集 2016 年耶路撒冷指南的更新。

Materials and methods  材料和方法

These updated consensus guidelines were written under the auspices of the WSES by the acute appendicitis working group.
這些更新的共識指南是由急性闌尾炎工作組在 WSES 的主持下編寫的。

The coordinating researcher (S. Di Saverio) invited six experienced surgeons (G. Augustin, A. Birindelli, B. De Simone, M. Podda, M. Sartelli, and M. Ceresoli) with high-level experience in the management of AA to serve as experts in this 2020 update of the WSES Jerusalem guidelines. The experts reviewed and updated the original list of key questions on the diagnosis and treatment of AA addressed in the previous version of the guidelines. The subject of AA was divided into seven main topics: (1) diagnosis, (2) non-operative management of uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) management of perforated AA with phlegmon or abscess, and (7) antibiotic prophylaxis and postoperative antibiotic treatment.
協調研究員 （S. Di Saverio） 邀請了六位經驗豐富的外科醫生（G. Augustin、A. Birindelli、B. De Simone、M. Podda、M. Sartelli 和 M. Ceresoli）在 AA 管理方面具有高級經驗，擔任 WSES 耶路撒冷指南 2020 年更新的專家。專家們審查並更新了先前版本指南中解決的有關 AA 診斷和治療的原始關鍵問題清單。AA 的主題分為 7 個主要主題：（1）診斷，（2）無併發症 AA 的非手術治療，（3）闌尾切除術的時機和院內延遲，（4）手術治療，（5）AA 的術中分級，（6）穿孔 AA 伴痰或膿腫的處理，以及（7）抗生素預防和術后抗生素治療。

Both adults and pediatric populations were considered and specific statements and recommendations were made for each of two groups. Pediatric patients were defined as including children and adolescents aged between 1 and 16 years old. Infants were excluded from this review.
考慮了成人和兒童人群，併為兩組中的每一組提出了具體的陳述和建議。兒科患者定義為包括 1 至 16 歲的兒童和青少年。本綜述排除了嬰兒。

Based upon the list of topics, research questions (Patients/Population, Intervention/Exposure, Comparison, Outcome (PICO)) were formulated, reviewed, and adopted as guidance to conduct an exploratory literature search (Table 1).
根據主題清單，制定、審查研究問題（患者/人群、干預/暴露、比較、結果 （PICO））作為進行探索性文獻檢索的指導（表 1）。

Table 1 Research topics and key questions
表1 研究課題及關鍵問題

The searches were conducted in cooperation with a medical information specialist from the University of Bologna (A. Gori). A computerized search of different databases (MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials), and new citations were included for the period April 2015 to June 2019. No search restrictions were imposed. Search syntaxes have been reported in (Supplemetary material file 1).
搜索是與博洛尼亞大學 （A. Gori） 的醫學資訊專家合作進行的。納入了 2015 年 4 月至 2019 年 6 月期間不同資料庫（MEDLINE、Scopus、Embase、Web of Science 和 Cochrane 對照試驗中心註冊庫）的計算機化檢索，並納入了新的引文。沒有施加搜索限制。搜索語法已在（補充材料檔 1）中報告。

The search results were selected and categorized to allow comprehensive published abstract of randomized clinical trials, non-randomized studies, consensus conferences, congress reports, guidelines, government publications, systematic reviews, and meta-analyses.
對檢索結果進行選擇和分類，以便對隨機臨床試驗、非隨機研究、共識會議、大會報告、指南、政府出版物、系統評價和薈萃分析進行全面發表的摘要。

In the 2016 Jerusalem guidelines, the Oxford classification was used to grade the evidence level (EL) and the grade of recommendation (GoR) for each statement. In this updated document, quality of evidence and strength of recommendations have been evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.
在 2016 年耶路撒冷指南中，牛津分類用於對每個陳述的證據水準 （EL） 和推薦等級 （GoR） 進行評分。在這份更新的檔中，根據建議分級、評估、制定和評估 （GRADE） 系統評估了證據質量和建議的強度。

The GRADE system is a hierarchical, evidence-based tool, which systematically evaluates the available literature and focuses on the level of evidence based upon the types of studies included. The quality of evidence (QoE) 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. The highest quality of evidence studies (systematic reviews with meta-analysis of randomized controlled trials) was assessed first. If the meta-analysis was of sufficient quality, it was used to answer the research question. If no meta-analysis of sufficient quality was found, randomized controlled trials (RCTs) and non-randomized cohort studies (n-RCS) were evaluated. The strength of the recommendation (SoR) was based on the level of evidence and qualified as weak or strong (Table 2) [25,26,27,28].
GRADE 系統是一種分層的、基於證據的工具，它系統地評估現有文獻，並根據所包含的研究類型關注證據水準。證據品質 （QoE） 可以標記為高、中、低或極低。如果存在顯著偏倚，則可以降級，也可以在多項高品質研究顯示一致結果時升級。首先評估最高質量的證據研究（隨機對照試驗的 meta 分析系統評價）。如果 meta 分析質量足夠高，則用於回答研究問題。如果沒有發現足夠品質的 meta 分析，則評估隨機對照試驗（randomized controlled trials， RCTs）和非隨機佇列研究（non-RCS）。推薦的強度（SoR）基於證據水準，並分為弱或強（表 2）[25,26,27,28]。

Table 2 GRADE Quality of evidence and strength of recommendations
表2 等級證據質量和建議的效力

The first draft of the updated statements and recommendations was commented on by the steering group of the guidelines and the board of governors of the WSES during the 6th WSES congress held in Nijmegen, Holland (26–28 June 2019). Amendments were made based upon the comments, from which a second draft of the consensus document was generated. All finalized statements and recommendations with QoE and SoR were entered into a web survey and distributed to all the authors and the board of governor’s members of the WSES by e-mail. The web survey was open from December 1, 2019, until December 15, 2019. The authors were asked to anonymously vote on each statement and recommendation and indicate if they agreed, (≥ 70% “yes” was categorized as agreement), leading to the final version of the document.
在荷蘭奈梅亨舉行的第六屆 WSES 大會（2019 年 6 月 26 日至 28 日）期間，指南指導小組和 WSES 理事會對更新后的聲明和建議的初稿進行了評論。根據這些意見進行了修正，並據此產生了協商一致檔的第二稿。所有關於 QoE 和 SoR 的最終陳述和建議都已輸入網路調查，並通過電子郵件分發給 WSES 的所有作者和理事會成員。網路調查於 2019 年 12 月 1 日至 2019 年 12 月 15 日開放。作者被要求對每項聲明和建議進行匿名投票，並表明他們是否同意（≥ 70% 的“贊成”被歸類為同意），從而形成了該文件的最終版本。

Results  結果

The literature search yielded 984 articles. The titles, abstracts, and full text were reviewed. In total, 157 articles were selected and reviewed in detail to define 48 statements and 51 recommendations addressing seven topics and 30 research questions. A summary of the updated 2020 guidelines statements and recommendations has been reported in Table 3.
文獻檢索產生了 984 篇文章。對標題、摘要和全文進行了審查。總共選擇並詳細審查了 157 篇文章，以確定 48 個陳述和 51 條建議，涉及 7 個主題和 30 個研究問題。表 3 彙報了更新后的 2020 年指南、聲明和建議的摘要。

Table 3 Summary of the updated 2020 guidelines statements and recommendations
表3 更新后的2020年指南、聲明和建議摘要

Topic 1: Diagnosis  主題 1：診斷

Q.1.1: What is the value of clinical scoring systems in the management of adult patients with suspected appendicitis? Can they be used as basis for a structured management?
Q.1.1：臨床評分系統在疑似闌尾炎成年患者的管理中有什麼價值？它們可以用作結構化管理的基礎嗎？

Risk stratification of patients with suspected AA by clinical scoring systems could guide decision-making to reduce admissions, optimize the utility of diagnostic imaging, and prevent negative surgical explorations. Clinical scores alone seem sufficiently sensitive to identify low-risk patients and decrease the need for imaging and negative surgical explorations (such as diagnostic laparoscopy) in patients with suspected AA.
通過臨床評分系統對疑似 AA 患者進行風險分層可以指導決策以減少入院率、優化診斷成像的效用並防止陰性手術探查。僅臨床評分似乎就足以識別低風險患者，並減少疑似 AA 患者對影像學檢查和陰性手術探查（如診斷性腹腔鏡檢查）的需求。

The RCT by Andersson et al. demonstrated that, in low-risk patients, the use of an AIR (Appendicitis Inflammatory Response) score-based algorithm resulted in less imaging (19.2% vs 34.5%, P < 0.001), fewer admissions (29.5% vs 42.8%, P < 0.001), fewer negative explorations (1.6% vs 3.2%, P = 0.030), and fewer surgical operations for non-perforated AA (6.8% vs 9.7%, P = 0.034). Intermediate-risk patients randomized to the imaging and observation strategies had the same proportion of negative appendectomies (6.4% vs 6.7%, P = 0.884), number of hospital admissions, rates of perforation, and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for AA (53.4% vs 46.3%, P = 0.020) [29].
Andersson 等人的隨機對照試驗表明，在低風險患者中，使用基於 AIR（闌尾炎炎症反應）評分的演算法可減少影像學檢查（19.2% vs 34.5%，P < 0.001），入院次數減少（29.5% vs 42.8%，P < 0.001），陰性探查減少（1.6% vs 3.2%，P = 0.030），非穿孔 AA 的外科手術減少（6.8% vs 9.7%， P = 0.034）。隨機接受影像學檢查和觀察策略的中危患者闌尾切除術陰性比例相同（6.4% vs 6.7%，P = 0.884）、住院次數、穿孔率和住院時間，但常規影像學檢查與 AA 治療患者比例增加相關（53.4% vs 46.3%，P = 0.020）[29]。

Among the many available clinical prediction models for the diagnosis of AA, the AIR score appears to be the best performer and most pragmatic. The review by Kularatna et al. recently summarized the results from validation studies, showing that the overall best performer in terms of sensitivity (92%) and specificity (63%) is the AIR score [30].
在診斷 AA 的眾多可用臨床預測模型中，AIR 評分似乎表現最好且最務實。Kularatna 等人最近總結了驗證研究的結果，表明在敏感性（92%）和特異性（63%）方面，總體表現最好的是 AIR 評分[30]。

Although the Alvarado score is not sufficiently specific in diagnosing AA, a cutoff score of < 5 is sufficiently sensitive to exclude AA (sensitivity of 99%). The Alvarado score could, therefore, be used to reduce emergency department length of stay and radiation exposure in patients with suspected AA. This is confirmed by a large retrospective cohort study that found 100% of males with Alvarado score of 9 or greater, and 100% of females with an Alvarado score of 10 had AA confirmed by surgical pathology. Conversely, 5% or less of female patients with an Alvarado score of 2 or less and 0% of male patients with an Alvarado score of 1 or less were diagnosed with AA at surgery [31].
儘管 Alvarado 評分在診斷 AA 方面不夠特異性，但 < 5 的臨界評分足以排除 AA（敏感性為 99%）。因此，Alvarado 評分可用於減少疑似 AA 患者的急診住院時間和輻射暴露。一項大型回顧性佇列研究證實了這一點，該研究發現 100% 的男性阿爾瓦拉多評分為 9 分或更高，而 100% 的阿爾瓦拉多評分為 10 分的女性經手術病理學證實為 AA。相反，Alvarado 評分為 2 分或以下的女性患者中有 5%或更少，Alvarado 評分為 1 分或以下的男性患者中有 0%在手術時被診斷為 AA[31]。

However, the Alvarado score is not able to differentiate complicated from uncomplicated AA in elderly patients and seems less sensitive in HIV+ patients [32, 33].
然而，Alvarado 評分無法區分老年患者的複雜和無併發症 AA，並且對 HIV+患者似乎不太敏感[32,33]。

The RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) score has shown to achieve better sensitivity and specificity than the Alvarado score in Asian and Middle Eastern population. Malik et al. recently published the first study evaluating the utility of the RIPASA score in predicting AA in a Western population. At a value of 7.5 (a cut of score suggestive of AA in the Eastern population), the RIPASA demonstrated reasonable sensitivity (85.39%), specificity (69.86%), positive predictive value (84.06%), negative predictive value (72.86%), and diagnostic accuracy (80%) in Irish patients with suspected AA and was more accurate than the Alvarado score [34].
RIPASA（Raja Isteri Pengiran Anak Saleha 闌尾炎）評分已被證明在亞洲和中東人群中比 Alvarado 評分具有更好的敏感性和特異性。Malik 等人最近發表了第一項研究，評估 RIPASA 評分在預測西方人群 AA 方面的效用。RIPASA 在愛爾蘭疑似 AA 患者中表現出合理的敏感性（85.39%）、特異度（69.86%）、陽性預測值（84.06%）、陰性預測值（72.86%）和診斷準確性（80%），比 Alvarado 評分更準確[34]。

The Adult Appendicitis Score (AAS) stratifies patients into three groups: high, intermediate, and low risk of AA. The score has been shown to be a reliable tool for stratification of patients into selective imaging, which results in a low negative appendectomy rate. In a prospective study enrolling 829 adults presenting with clinical suspicion of AA, 58% of patients with histologically confirmed AA had score value at least 16 and were classified as high probability group with 93% specificity. Patients with a score below 11 were classified as low probability of AA. Only 4% of patients with AA had a score below 11, and none of them had complicated AA. In contrast, 54% of non-AA patients had a score below 11. The area under ROC curve was significantly larger with the new score 0.882 compared with AUC of Alvarado score 0.790 and AIR score 0.810 [11].
成人闌尾炎評分 （AAS） 將患者分為三組：AA 的高、中和低風險。該評分已被證明是將患者分層到選擇性成像的可靠工具，這導致闌尾切除術陰性率較低。在一項前瞻性研究中，招募了 829 名臨床懷疑 AA 的成年人，58%經組織學證實的 AA 患者的評分值至少為 16，並被歸類為特異性為 93%的高概率組。評分低於 11 分的患者被歸類為 AA 概率低。只有 4%的 AA 患者得分低於 11 分，且均無併發症 AA。相比之下，54% 的非 AA 患者的得分低於 11。ROC 曲線下面積顯著更大，新評分為 0.882，而 Alvarado 評分為 0.790，AIR 評分為 0.810[11]。

In the validation study by Sammalkorpi et al., the AAS score stratified 49% of all AA patients into a high-risk group with the specificity of 93.3%, whereas in the low-risk group the prevalence of AA was 7%. The same study group demonstrated that diagnostic imaging has limited value in patients with a low probability of AA according to the AAS [35].
在 Sammalkorpi 等人的驗證研究中，AAS 評分將 49%的 AA 患者分為高危組，特異性為 93.3%，而在低危組中，AA 的患病率為 7%。同一研究小組證明，根據 AAS，診斷影像學對 AA 概率低的患者價值有限[35]。

Tan et al. recently performed a prospective data collection on 350 consecutive patients with suspected AA for whom the Alvarado score for each patient was scored at admission and correlated with eventual histology and CT findings. The positive likelihood ratio of disease was significantly greater than 1 only in patients with an Alvarado score of 4 and above. An Alvarado score of 7 and above in males and 9 and above in females had a positive likelihood ratio comparable to that of CT scan [36].
Tan 等人最近對 350 名連續疑似 AA 患者進行了前瞻性數據收集，這些患者在入院時對每位患者的 Alvarado 評分進行了評分，並與最終的組織學和 CT 結果相關聯。僅在 Alvarado 評分為 4 及以上的患者中，疾病陽性似然比顯著大於 1。男性的 Alvarado 評分為 7 分及以上，女性為 9 分及以上，其陽性似然比與 CT 掃描相當[36]。

Nearly all clinical signs and symptoms, as isolated parameters, do not significantly discriminate between those pregnant women with and without AA [37,38,39].
幾乎所有臨床體征和癥狀（作為孤立參數）都不能顯著區分 AA 和未合併 AA 的孕婦[37,38,39]。

Of 15 validated risk prediction models taken into consideration in a recently published study enrolling 5345 patients with right iliac fossa pain across 154 UK hospitals, the AAS performed best for women (cutoff score 8 or less, specificity 63.1%, failure rate 3.7%), whereas the AIR score performed best for men (cutoff score 2 or less, specificity 24.7%, failure rate 2.4%) [40].
在最近發表的一項研究中考慮了 15 個經過驗證的風險預測模型，該研究招募了 154 家英國醫院的 5345 名右髂窩疼痛患者，其中 AAS 對女性表現最好（截止評分 8 或更低，特異性 63.1%，失敗率 3.7%），而 AIR 評分對男性表現最好（截止評分 2 或更低，特異性 24.7%， 失敗率 2.4%）[40]。

The Alvarado score can be higher in pregnant women due to the higher WBC values and the frequency of nausea and vomiting, especially during the first trimester, implicating lower accuracy compared to the non-pregnant population. Studies show Alvarado score (cutoff 7 points) sensitivity of 78.9% and specificity of 80.0% in pregnant patients [41, 42]. The RIPASA score has a specificity (cutoff 7.5 points) of 96%, but the score should be validated in larger studies. There are no studies of the Alvarado score discriminating between uncomplicated and complicated AA during pregnancy.
由於白細胞值較高以及噁心和嘔吐的頻率，尤其是在孕早期，孕婦的 Alvarado 評分可能更高，這意味著與非孕婦相比準確性較低。研究表明，妊娠患者的 Alvarado 評分（截止 7 分）敏感性為 78.9%，特異性為 80.0%[41,42]。 RIPASA 評分的特異性（截止值 7.5 分）為 96%，但該評分應在更大規模的研究中得到驗證。沒有關於 Alvarado 評分區分懷孕期間無併發症和複雜 AA 的研究。

The preoperative distinction between uncomplicated and complicated AA is challenging. Recently, prediction models based on temperature, CRP, presence of free fluids on ultrasound, and diameter of the appendix have been shown to be useful for the identification of “high-risk” patients for complicated AA. Atema et al. found that, with the use of scoring systems combining clinical and imaging features, 95% of the patients deemed to have uncomplicated AA were correctly identified [43].
術前區分無併發症和複雜 AA 具有挑戰性。最近，基於溫度、CRP、超聲遊離液體的存在和闌尾直徑的預測模型已被證明可用於識別複雜 AA 的「高危」患者。Atema 等發現，通過使用結合臨床和影像學特徵的評分系統，95% 被認為患有無併發症的 AA 患者被正確識別 [43]。

Statement 1.1 Establishing the diagnosis of acute appendicitis based on clinical presentation and physical examination may be challenging. As the value of individual clinical variables to determine the likelihood of acute appendicitis in a patient is low, a tailored individualized approach is recommended, depending on disease probability, sex, and age of the patient. Recommendation 1.1 We recommend to adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diagnostic pathway in patients with suspected acute appendicitis, depending on age, sex, and clinical signs and symptoms of the patient [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 1.1 根據臨床表現和體格檢查確定急性闌尾炎的診斷可能具有挑戰性。由於個體臨床變數在確定患者急性闌尾炎可能性方面的價值較低，因此建議根據患者的疾病概率、性別和年齡採取量身定製的個體化方法。建議 1.1 我們建議根據患者的年齡、性別和臨床體征和癥狀，對疑似急性闌尾炎患者採用量身定製的個體化診斷方法對風險和疾病概率進行分層，並規劃適當的逐步診斷途徑[QoE：中度;推薦強度：強;1B]。

Statement 1.2 Clinical scores alone, e.g., Alvarado score, AIR score, and the new Adult Appendicitis Score are sufficiently sensitive to exclude acute appendicitis, accurately identifying low-risk patients and decreasing the need for imaging and the negative appendectomy rates in such patients. Recommendation 1.2.1 We recommend the use of clinical scores to exclude acute appendicitis and identify intermediate-risk patients needing of imaging diagnostics [QoE: High; Strength of recommendation: Strong; 1A]. Recommendation 1.2.2 We suggest not making the diagnosis of acute appendicitis in pregnant patients on symptoms and signs only. Laboratory tests and inflammatory serum parameters (e.g., CRP) should always be requested [QoE: Very Low; Strength of recommendation: Weak; 2C].
聲明 1.2 僅臨床評分，例如 Alvarado 評分、AIR 評分和新的成人闌尾炎評分就足以排除急性闌尾炎，準確識別低風險患者並降低此類患者的影像學檢查需求和陰性闌尾切除率。建議 1.2.1 我們建議使用臨床評分來排除急性闌尾炎並識別需要影像學診斷的中危患者[QoE：高;推薦強度：強;1A]. 建議 1.2.2 我們建議不要僅根據癥狀和體徵來診斷妊娠患者的急性闌尾炎。應始終要求進行實驗室檢查和炎症血清參數（例如 CRP）[QoE：非常低;推薦強度：弱;2C]。

Statement 1.3 The Alvarado score is not sufficiently specific in diagnosing acute appendicitis in adults, seems unreliable in differentiating complicated from uncomplicated acute appendicitis in elderly patients, and is less sensitive in patients with HIV. Recommendation 1.3 We suggest against the use of Alvarado score to positively confirm the clinical suspicion of acute appendicitis in adults [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 1.3Alvarado 評分在診斷成人急性闌尾炎方面不夠特異性，在區分老年患者併發性急性闌尾炎和單純性急性闌尾炎方面似乎不可靠，並且對 HIV 感染者敏感性較低。建議 1.3 我們建議不要使用 Alvarado 評分來積極確認成人急性闌尾炎的臨床懷疑[QoE：中度;推薦強度：弱;2B]。

Statement 1.4 The AIR score and the AAS score seem currently to be the best performing clinical prediction scores and have the highest discriminating power in adults with suspected acute appendicitis. The AIR and AAS scores decrease negative appendectomy rates in low-risk groups and reduce the need for imaging studies and hospital admissions in both low- and intermediate-risk groups. Recommendation 1.4 We recommend the use of AIR score and AAS score as clinical predictors of acute appendicitis [QoE: High; Strength of recommendation: Strong; 1A].
聲明 1.4AIR 評分和 AAS 評分目前似乎是表現最好的臨床預測評分，並且在疑似急性闌尾炎的成人中具有最高的鑒別力。AIR 和 AAS 評分降低了低危人群的闌尾切除術陰性率，並減少了低風險和中危人群的影像學檢查和住院需求。建議 1.4 我們建議使用 AIR 評分和 AAS 評分作為急性闌尾炎的臨床預測因數 [QoE：高;推薦強度：強;1A]。

Q.1.2: In pediatric patients with suspected acute appendicitis could the diagnosis be based only on clinical scores?
Q.1.2：對於疑似急性闌尾炎的兒科患者，是否可以僅根據臨床評分進行診斷？

AA is the most common surgical emergency in children, but early diagnosis of AA remains challenging due to atypical clinical features and the difficulty of obtaining a reliable history and physical examination. Several clinical scoring systems have been developed, the two most popular for use in children being the Alvarado score and Samuel’s Pediatric Appendicitis Score (PAS).
AA 是兒童中最常見的外科急症，但由於臨床特徵不典型且難以獲得可靠的病史和體格檢查，AA 的早期診斷仍然具有挑戰性。已經開發了幾種臨床評分系統，其中最流行用於兒童的兩種是 Alvarado 評分和 Samuel 小兒闌尾炎評分 （PAS）。

PAS includes similar clinical findings to the Alvarado score in addition to a sign more relevant in children: right lower quadrant pain with coughing, hopping, or percussion. Several studies comparing the PAS with the Alvarado score have validated its use in pediatric patients. However, in a systematic review by Kulik et al. both scores failed to meet the performance benchmarks of CRP (C-reactive protein). On average, the PAS would over-diagnose AA by 35%, and the Alvarado score would do so by 32% [44].
PAS 包括與 Alvarado 評分相似的臨床表現，此外還有一個與兒童更相關的體征：右下腹疼痛伴咳嗽、跳躍或叩診。幾項將 PAS 與 Alvarado 評分進行比較的研究已經驗證了其在兒科患者中的應用。然而，在 Kulik 等人的系統評價中，這兩個分數都未能達到 CRP（C 反應蛋白）的性能基準。平均而言，PAS 會過度診斷 AA35%，Alvarado 評分會過度診斷 32%[44]。

If we consider patients of preschool age, AA often presents with atypical features, more rapid progression, and higher incidence of complications. This age group is more likely to have lower PAS and Alvarado score than those of school-aged children [45]. This is the reason why Macco et al. retrospectively analyzed data from 747 children (mean age of 11 years) suspected of AA to evaluate the predictive value of the Alvarado score and PAS compared with the AIR score, which includes fewer symptoms than the Alvarado score and PAS, but adds the CRP value and allows for different severity levels of rebound pain, leukocytosis, CRP, and polymorphonucleocytes. The study showed that the AIR had the highest discriminating power and outperformed the other two scores in predicting AA in children [46].
如果考慮學齡前患者，AA 通常表現出非典型特徵、進展更快、併發症發生率更高。該年齡組的 PAS 和 Alvarado 評分可能低於學齡兒童[45]。這就是為什麼 Macco 等人回顧性分析了 747 名疑似 AA 兒童（平均年齡 11 歲）的數據，以評估 Alvarado 評分和 PAS 與 AIR 評分相比的預測價值，AIR 評分包括比 Alvarado 評分和 PAS 更少的癥狀，但添加了 CRP 值並允許不同嚴重程度的反彈痛， 白細胞增多、CRP 和多形核細胞。研究表明，AIR 在預測兒童 AA 方面具有最高的辨別力，優於其他兩個分數[46]。

The use of PAS seems to be useful to rule out or in AA in pediatric female patients. A retrospective observational study demonstrated that at a cutoff of ≥ 8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients, although the specificities did not differ at a cutoff of ≥ 7. At both cutoffs, the positive predictive values were poor in both groups. At a cutoff of ≥ 3, the PAS showed similar sensitivities in both groups [47].
PAS 的使用似乎有助於排除或治療兒科女性患者的 AA。一項回顧性觀察研究表明，在第 8 ≥的臨界值，PAS 對青春期女性的特異性為 89%，對所有其他患者的特異性為 78%，儘管在第 7 ≥的臨界值時特異性沒有差異。在兩個截止值下，兩組的陽性預測值都很差。在≥3 的臨界值下，兩組 PAS 的敏感性相似[47]。

Recently, the new Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte and neutrophil counts, CRP, and calprotectin levels has been shown to accurately predict which children are at low risk of AA and could be safely managed with close observation. A PALabS ≤ 6 has a sensitivity of 99.2%, a negative predictive value of 97.6%, and a negative likelihood ratio of 0.03 [48].
最近，新的小兒闌尾炎實驗室評分 （PALabS） 包括臨床體征、白細胞和中性粒細胞計數、CRP 和鈣衛蛋白水準已被證明可以準確預測哪些兒童患 AA 的風險較低，並且可以通過密切觀察進行安全管理。PALabS ≤ 6 的敏感性為 99.2%，陰性預測值為 97.6%，陰性似然比為 0.03 [48]。

The preoperative clinical scoring system to distinguish perforation risk with pediatric AA proposed by Bonadio et al., based on the duration of symptoms (> 1 day), fever (> 38.0 C), and WBC absolute count (> 13,000/mm³), resulted in a multivariate ROC curve of 89% for perforation (P < 0.001), and the risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present [49].
Bonadio 等人提出的術前臨床評分系統，根據癥狀持續時間（> 1 天）、發熱（> 38.0 C）和白細胞絕對計數（> 13,000/mm³），導致穿孔的多變數 ROC 曲線為 89%（P < 0.001），穿孔風險是累加的，每個額外的預測變數超過其閾值， 從不存在變數的 7%線性增加到 3 個變數都存在時的 85%[49]。

In assessing if the clinical scores can predict disease severity and the occurrence of complications, a retrospective study on the Alvarado score validity in pediatric patients showed that a higher median score was found in patients who suffered postoperative complications. The eight items in the scoring system were analyzed for their sensitivities. Fever, right lower quadrant tenderness, and neutrophilia were found to be the three most sensitive markers in predicting complicated AA (88.6%, 82.3%, and 79.7%). On the other hand, rebound tenderness was found to have the highest positive predictive value (65%) among the eight items to predict complicated AA [50].
在評估臨床評分是否可以預測疾病嚴重程度和併發症發生時，一項關於兒科患者 Alvarado 評分效度的回顧性研究表明，在患有術后併發症的患者中，發現中位評分較高。對評分系統中的 8 個項目進行敏感性分析。發熱、右下腹壓痛和中性粒細胞增多是預測複雜 AA 的 3 個最敏感標誌物（88.6%、82.3%和 79.7%）。另一方面，在預測複雜性 AA 的 8 個專案中，反彈壓痛具有最高的陽性預測值（65%）[50]。

Statement 1.5 In pediatric patients with suspected acute appendicitis, the Alvarado score and Pediatric Appendicitis Score are useful tools in excluding acute appendicitis. Recommendation 1.5 In pediatric patients with suspected acute appendicitis, we suggest against making a diagnosis based on clinical scores alone [QoE: Low; Strength of recommendation: Weak: 2C].
聲明 1.5 對於疑似急性闌尾炎的兒科患者，Alvarado 評分和小兒闌尾炎評分是排除急性闌尾炎的有用工具。建議 1.5 對於疑似急性闌尾炎的兒科患者，我們建議不要僅根據臨床評分[QoE：低;推薦強度：弱：2C]。

Q.1.3: What is the role of serum biomarkers in evaluating adult patients presenting with clinical features evocative of acute appendicitis?
Q.1.3：血清生物標誌物在評估具有急性闌尾炎臨床特徵的成年患者中的作用是什麼？

The diagnostic accuracy of several biomarker panels has been prospectively validated, showing high sensitivity and negative predictive values for AA in large cohorts of patients with right iliac fossa pain, thereby potentially reducing the dependence on CT for the evaluation of possible AA [51].
幾種生物標誌物組的診斷準確性已得到前瞻性驗證，在大型右髂窩疼痛患者佇列中顯示出 AA 的高敏感性和陰性預測值，從而有可能降低對 CT 評估可能 AA 的依賴[51]。

The diagnostic value of baseline and early change of CRP concentrations has been evaluated separately or in combination with the modified Alvarado score in patients with clinically suspected AA in the prospective observational study by Msolli et al. Early change of CRP had a moderate diagnostic value in patients with suspected AA, and even combining CRP values to the modified Alvarado score did not improve diagnostic accuracy [52]. Recently, ischemia-modified albumin (IMA) levels have been used to determine the prediction of severity in AA patients. Kilic et al. found a strong positive correlation between IMA levels and CT findings in distinguishing gangrenous/perforated AA from uncomplicated AA [53]. A combination of clinical parameters, laboratory tests, and US may significantly improve diagnostic sensitivity and specificity and eventually replace the need for CT scan in both adults and children [54].
在 Msolli 等人的前瞻性觀察研究中，已單獨評估或與臨床疑似 AA 患者的基線和早期變化的診斷價值，或與改良的 Alvarado 評分相結合。對於疑似 AA 患者，CRP 的早期改變具有中等診斷價值，即使將 CRP 值與改良的 Alvarado 評分相結合，也無法提高診斷準確性[52]。最近，缺血修飾白蛋白 （IMA） 水準已被用於確定 AA 患者嚴重程度的預測。Kilic 等人發現，IMA 水準與 CT 結果在區分壞疽/穿孔性 AA 和無併發症 AA 方面存在很強的正相關關係[53]。結合臨床參數、實驗室檢查和超聲檢查，可顯著提高診斷敏感性和特異性，並最終取代成人和兒童對 CT 掃描的需求[54]。

Statement 1.6 Biochemical markers represent a promising reliable diagnostic tool for the identification of both negative cases or complicated acute appendicitis in adults. However, further high-quality evidence is needed [QoE: Low; No recommendation].
聲明 1.6 生化標誌物是一種很有前途的可靠診斷工具，用於識別成人陰性病例或複雜急性闌尾炎。然而，需要進一步的高質量證據[QoE：低;無推薦]。

Q.1.4: What is the role of serum biomarkers in evaluating pediatric patients presenting clinical features highly suggestive of acute appendicitis?
Q.1.4：血清生物標誌物在評估高度提示急性闌尾炎的臨床特徵的兒科患者中的作用是什麼？

In pediatric patients, routine diagnostic laboratory workup for suspected AA should include WBC, the differential with the calculation of the absolute neutrophil count (ANC), CRP, and urinalysis.
對於兒科患者，疑似 AA 的常規診斷實驗室檢查應包括 WBC、與中性粒細胞絕對計數 （ANC） 的鑒別結果、CRP 和尿液分析。

Although not widely available, the addition of procalcitonin and calprotectin to the above tests may significantly improve diagnostic discrimination [55].
雖然尚未廣泛使用，但在上述檢查中加入降鈣素原和鈣衛蛋白可能會顯著改善診斷鑒別力[55]。

Biomarkers have also been shown to be useful when used in association with the systematic adoption of scoring systems, as the addition of negative biomarker test results to patients with a moderate risk of AA based on the Pediatric Appendicitis Score (PAS) can safely reclassify many patients to a low-risk group. This may allow surgeons to provide more conservative management in patients with suspected AA and decrease unnecessary resource utilization [56].
生物標誌物在與系統採用評分系統結合使用時也被證明是有用的，因為根據小兒闌尾炎評分 （PAS） 對中度 AA 風險的患者添加陰性生物標誌物測試結果可以安全地將許多患者重新分類為低風險組。這可能使外科醫生能夠對疑似 AA 患者進行更保守的治療，並減少不必要的資源利用[56]。

Zouari et al. highlighted the value of CRP ≥ 10 mg/L as a strong predictor of AA in children < 6 years old [57].
Zouari 等人強調了 CRP≥10mg/L 的價值是 6 歲兒童< AA 的有力預測因數[57]。

Yu et al. reported that PCT had little value in diagnosing AA, with lower diagnostic accuracy than CRP and WBC, but a greater diagnostic value in identifying complicated AA [58]. In a recent meta-analysis, it was confirmed that PCT was more accurate in diagnosing complicated AA, with a pooled sensitivity of 0.89 (95% CI 0.84–0.93), specificity of 0.90 (95% CI 0.86–0.94), and diagnostic odds ratio of 76.73 (95% CI 21.6–272.9) [59].
Yu 等報導，PCT 在診斷 AA 方面價值不大，診斷準確率低於 CRP 和 WBC，但在識別複雜 AA 方面具有更大的診斷價值[58]。最近的一項 meta 分析證實，PCT 在診斷複雜 AA 方面更準確，匯總敏感性為 0.89（95%CI 0.84–0.93），特異度為 0.90（95%CI 0.86–0.94），診斷比值比為 76.73（95%CI 21.6–272.9）[59]。

Zani et al. retrospectively analyzed data from 1197 children admitted for AA and reported that patients with complicated AA had higher CRP and WBC levels than normal patients and those with uncomplicated AA. The authors found a CRP > 40 mg/L in 58% of patients with complicated AA and 37% of patients with uncomplicated AA, and WBC > 15 × 10⁹/L in 58% of patients with complicated AA and 43% of patients with uncomplicated AA [60].
Zani 等回顧性分析了 1197 例因 AA 入院的兒童的數據，報告說，複雜性 AA 患者的 CRP 和 WBC 水準高於正常患者和無併發症 AA 患者。作者發現，58%的複雜性 AA 患者和 37%的無併發症 AA 患者的 CRP 為> 40mg/L，58%的複雜 AA 患者和 43%的無併發症 AA 患者的 WBC > > 為 15×10⁹/L[60]。

One recent study identified a panel of biomarkers, the APPY1 test, consisting of WBC, CRP, and myeloid-related protein 8/14 levels that have the potential to identify, with great accuracy, children and adolescents with abdominal pain who are at low risk for AA. The biomarker panel exhibited a sensitivity of 97.1%, a negative predictive value of 97.4%, and a negative likelihood ratio of 0.08, with a specificity of 37.9% for AA [51].
最近的一項研究確定了一組生物標誌物，即 APPY1 測試，由 WBC、CRP 和髓系相關蛋白 8/14 水平組成，有可能非常準確地識別患有腹痛的兒童和青少年，這些兒童和青少年的風險為 AA。生物標誌物組的敏感性為 97.1%，陰性預測值為 97.4%，陰性似然比為 0.08，對 AA 的特異性為 37.9%[51]。

Benito et al. prospectively evaluated the usefulness of WBC and ANC and other inflammatory markers such as CRP, procalcitonin, calprotectin, and the APPY1 test panel of biomarkers, to identify children with abdominal pain at low risk for AA. The APPY1 test panel showed the highest discriminatory power, with a sensitivity of 97.8, negative predictive value of 95.1, negative likelihood ratio of 0.06, and specificity of 40.6. In the multivariate analysis, only the APPY1 test and ANC > 7500/mL were significant risk factors for AA [55].
前瞻性評估了 WBC 和 ANC 以及其他炎症標誌物（如 CRP、降鈣素原、鈣衛蛋白和 APPY1 生物標誌物測試組）的有用性，以識別 AA 低風險腹痛兒童。APPY1 測試組的鑒別力最高，靈敏度為 97.8，陰性預測值為 95.1，陰性似然比為 0.06，特異度為 40.6。在多因素分析中，只有 APPY1 測試和 ANC > 7500/mL 是 AA 的重要危險因素[55]。

More recently the Appendictis-PEdiatric score (APPE) was developed with the aim of identifying the risk of AA. Patients with an APPE score ≤ 8 were at low risk of AA (sensitivity 94%); those with a score ≥ 15 were at high risk for AA (specificity 93%). Those between 8 and 15 were defined at intermediate-risk [61].
最近開發了 Appendictis-PEdiatric 評分 （APPE），旨在識別 AA 的風險。APPE 評分為 8 分的患者發生 AA 的風險較低≤（敏感性 94%）;得分≥ 15 的人是 AA 的高風險（特異性 93%）。8-15 歲的人群被定義為中等風險[61]。

A number of prospective studies of children were conducted to find urinary biomarkers for AA, such as leucine-rich α-2-glycoprotein (LRG), not to be used alone but combined with PAS and routine blood tests. LRG in conjunction with PAS showed 95% sensitivity, 90% specificity, 91% positive predictive value, and 95% negative predictive value for AA in children [62].
對兒童進行了許多前瞻性研究，以尋找 AA 的尿液生物標誌物，例如富含亮氨酸的 α-2-糖蛋白 （LRG），不能單獨使用，而是與 PAS 和常規血液檢查聯合使用。LRG 聯合 PAS 對兒童 AA 的敏感性為 95%，特異性為 90%，陽性預測值為 91%，陰性預測值為 95%[62]。

Among the new laboratory biomarkers developed, the Appendicitis Urinary Biomarker (AuB—leucine-rich alpha-2-glycoprotein) appears promising as a diagnostic tool for excluding AA in children, without the need for blood sampling (negative predictive value 97.6%) [63].
在開發的新實驗室生物標誌物中，闌尾炎泌尿生物標誌物（AuB-富含亮氨酸的α-2-糖蛋白）似乎有望作為排除兒童 AA 的診斷工具，無需采血（陰性預測值 97.6%）[63]。

Statement 1.7 White blood cell count, the differential with the calculation of the absolute neutrophil count, and the CRP are useful lab tests in predicting acute appendicitis in children; moreover, CRP level on admission ≥ 10 mg/L and leucocytosis ≥ 16,000/mL are strong predictive factors for appendicitis in pediatric patients. Recommendation 1.6.1 In evaluating children with suspected appendicitis, we recommend to request routinely laboratory tests and serum inflammatory biomarkers [QoE: Very Low; Strength of recommendation: Strong: 1D]. Recommendation 1.6.2 In pediatric patients with suspected acute appendicitis, we suggest adopting both biomarker tests and scores in order to predict the severity of the inflammation and the need for imaging investigation [QoE: Very Low; Strength of recommendation: Weak: 2D].
聲明 1.7 白細胞計數、中性粒細胞絕對計數的鑒別值和 CRP 是預測兒童急性闌尾炎的有用實驗室測試;此外，入院時 CRP 水準 ≥ 10 mg/L 和白細胞增多 ≥ 16,000/mL 是兒科患者闌尾炎的有力預測因素。建議 1.6.1 在評估疑似闌尾炎兒童時，我們建議要求常規實驗室檢查和血清炎症生物標誌物 [QoE：極低;推薦強度：強：1D]。建議 1.6.2 對於疑似急性闌尾炎的兒科患者，我們建議同時採用生物標誌物測試和評分，以預測炎症的嚴重程度和影像學檢查的必要性 [QoE：非常低;推薦強度：弱：2D]。

Q.1.5: What is the optimum pathway for imaging in adult patients with suspected acute appendicitis?
Q.1.5：疑似急性闌尾炎成年患者的最佳影像學檢查途徑是什麼？

Estimating pre-image likelihood of AA is important in tailoring the diagnostic workup and using scoring systems to guide imaging can be helpful: low-risk adult patients according to the AIR/Alvarado scores could be discharged with appropriate safety netting, whereas high-risk patients are likely to require surgery rather than diagnostic imaging. Intermediate-risk patients are likely to benefit from systematic diagnostic imaging [64]. A positive US would lead to a discussion of appendectomy and a negative test to either CT or further clinical observation with repeated US. A conditional CT strategy, where CT is performed after the negative US, is preferable, as it reduces the number of CT scans by 50% and will correctly identify as many patients with AA as an immediate CT strategy.
估計 AA 的前圖像可能性對於定製診斷檢查很重要，並且使用評分系統來指導成像可能會有所幫助：根據 AIR/Alvarado 評分的低風險成年患者可以在適當的安全網下出院，而高風險患者可能需要手術而不是診斷成像。中危患者可能受益於系統診斷影像學檢查[64]。陽性超聲將導致討論闌尾切除術和 CT 陰性檢測或重複超聲的進一步臨床觀察。條件 CT 策略（即在超聲陰性後進行 CT）是可取的，因為它可以減少 50% 的 CT 掃描次數，並且可以正確識別與立即 CT 策略一樣多的 AA 患者。

Point-of-care ultrasonography (POCUS) has proven to be a valuable diagnostic tool in diagnosing AA and has a positive impact on clinical decision-making. Overall sensitivity and specificity of US is 76% and 95% and for CT is 99% and 84% respectively [65].
床旁超聲檢查 （POCUS） 已被證明是診斷 AA 的寶貴診斷工具，並對臨床決策產生積極影響。超聲檢查的總體敏感性和特異性分別為 76%和 95%，CT 的總體敏感性和特異性分別為 99%和 84%[65]。

The meta-analysis by Matthew Fields et al. found that the sensitivity and specificity for POCUS in diagnosing AA were 91% and 97%, respectively. The positive and negative predictive values were 91% and 94%, respectively [66]. US reliability for the diagnosis of AA can be improved through standardized results reporting. In the study by Sola et al., following the adoption of a diagnostic algorithm that prioritized US over CT and encompassed standardized templates, the frequency of indeterminate results decreased from 44.3% to 13.1% and positive results increased from 46.4% to 66.1% in patients with AA [67].
Matthew Fields 等人的薈萃分析發現，POCUS 診斷 AA 的敏感性和特異性分別為 91%和 97%。陽性和陰性預測值分別為 91%和 94%[66]。通過標準化結果報告可以提高 AA 診斷的 US 可靠性。在 Sola 等的研究中，在採用超聲優先於 CT 並包含標準化範本的診斷演算法後，AA 患者不確定結果的頻率從 44.3%下降到 13.1%，陽性結果從 46.4%增加到 66.1%[67]。

Recent studies from the Finnish group led by Salminen demonstrated that the diagnostic accuracy of contrast-enhanced low-dose CT is not inferior to standard CT in diagnosing AA or distinguishing between uncomplicated and complicated AA, enabling significant radiation dose reduction. The OPTICAP randomized trial has shown that a low-dose protocol using intravenous contrast media was not inferior to the standard protocol in terms of diagnostic accuracy (79% accurate diagnosis in low-dose and 80% in standard CT by a primary radiologist) and accuracy to categorize AA severity (79% for both protocols). However, the mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44  mSv, respectively) [12]. The radiation dose of appendiceal CT for adolescents and young adults can be reduced to 2 mSv without impairing clinical outcomes and reducing the potential risk of exposure to ionizing radiation simultaneously [68]. The recently published Cochrane systematic review on CT scan for diagnosis of AA in adults identified 64 studies including 71 separate study populations with a total of 10280 participants (4583 with and 5697 without AA). Summary sensitivity of CT scan was 0.95, and summary specificity was 0.94. At the median prevalence of AA (0.43), the probability of having AA following a positive CT result was 0.92, and the probability of having AA following a negative CT result was 0.04. In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96), CT with rectal contrast (0.97), and CT with intravenous and oral contrast enhancement (0.96) than for non-enhanced CT (0.91). Summary sensitivity for low-dose CT (0.94) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95). Summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT [69].
Salminen 領導的芬蘭小組最近的研究表明，對比增強低劑量 CT 在診斷 AA 或區分無併發症和複雜 AA 方面不遜色於標準 CT，從而能夠顯著降低輻射劑量。OPTICAP 隨機試驗表明，使用靜脈造影劑的低劑量方案在診斷準確性（初級放射科醫生在低劑量診斷中準確率為 79%，標準 CT 準確率為 80%）和對 AA 嚴重程度進行分類的準確性（兩種方案均為 79%）方面並不遜色於標準方案。然而，與標準 CT 相比，低劑量 CT 的平均輻射劑量顯著降低（分別為 3.33 和 4.44 mSv）[12]。青少年和年輕成人闌尾 CT 的輻射劑量可降低至 2mSv，同時不影響臨床結局，並降低電離輻射暴露的潛在風險[68]。最近發表的關於 CT 掃描診斷成人 AA 的 Cochrane 系統評價確定了 64 項研究，包括 71 個獨立的研究人群，共有 10280 名受試者（4583 名受試者和 5697 名受試者沒有 AA）。 CT 掃描的總敏感性為 0.95，總特異度為 0.94。在 AA 的中位患病率 （0.43） 下，CT 結果陽性後出現 AA 的概率為 0.92，CT 結果陰性後出現 AA 的概率為 0.04。在基於對比增強的亞組分析中，靜脈造影劑 CT（0.96）、直腸造影劑 CT（0.97）以及靜脈和口服造影劑增強 CT（0.96）的總敏感性高於非增強 CT（0.91）。低劑量 CT 的總敏感性（0.94）與標準劑量或非指定劑量 CT 的總敏感性（0.95）相似。低劑量 CT 與標準劑量或未指定劑量 CT 的總結特異性無差異[69]。

The usefulness of CT for determining perforation in AA is limited [70]. Methods to improve precision in identifying patients with complicated AA should be explored, as these may help improve risk prediction for the failure of treatment with antibiotic therapy and guide patients and providers in shared decision-making for treatment options. In cases with equivocal CT features, repeat US and detection of specific US features (presence of non-compressibility and increased vascular flow of the appendix wall) can be used to discriminate AA from a normal appendix [71].
CT 在確定 AA 穿孔方面的用處有限[70]。應探索提高識別複雜性 AA 患者準確性的方法，因為這些方法可能有助於改善抗生素治療失敗的風險預測，並指導患者和醫務人員共同決策治療方案。對於 CT 特徵不明確的病例，可重複超聲檢查和檢測特定超聲特徵（存在不可壓縮性和闌尾壁血管流量增加）來區分 AA 和正常闌尾[71]。

MRI has at least the same sensitivity and specificity as CT and, although has higher costs and issues around availability in many centers, should be preferred over CT as a first-line imaging study in pregnant women.
MRI 至少具有與 CT 相同的靈敏度和特異性，儘管在許多中心具有更高的成本和可用性問題，但作為孕婦的一線影像學研究，MRI 應優於 CT。

The American College of Radiology Appropriateness Criteria for pregnant women recommend graded compression grayscale US as a preferred initial method in case of suspected AA. These criteria recommend MRI as a second-line imaging method in inconclusive cases, although MRI can be used as a first-line imaging modality if available [72]. Others also recommend MRI after non-visualization or inconclusive US [73]. Despite some excellent US accuracy findings, the main drawback of US is the rate of non-visualization, which goes from 34.1% up to 71% with positive AA on the pathology reports [74, 75]. Low US accuracy for the diagnosis of AA in pregnant patients beyond the 1st trimester of pregnancy is evident and 30% of pregnant women with suspected AA have potentially avoidable surgery. Given the low yield of US, second-line imaging should be considered in those cases with an inconclusive US before surgery. A high rate (8%) of false-negative US results are positive on MRI [73, 76].
美國放射學會孕婦適當性標準建議將分級壓縮灰度超聲作為疑似 AA 的首選初始方法。這些標準推薦 MRI 作為不確定病例的二線影像學檢查方法，但 MRI 可作為一線影像學檢查[72]。其他人也建議在無可見或超聲不確定後進行 MRI[73]。儘管有一些出色的超聲準確性發現，但超聲的主要缺點是非可視化率，從 34.1%上升到 71%，病理報告呈陽性 AA[74,75]。 妊娠早期后孕婦 AA 的診斷準確率較低，30% 的疑似 AA 孕婦接受了可能避免的手術。鑒於超聲的低率，對於術前超聲不確定的病例，應考慮二線影像學檢查。MRI 陽性的超聲假陰性結果率很高（8%）[73,76]。

From 2011, there are three meta-analyses reporting on the use of MRI for AA during pregnancy with the following results: sensitivity 90.5%, 94%, and 91.8%; specificity 98.6%, 97%, and 97.9%; positive predictive value 86.3%; and negative predictive value 99.0% [77, 78]. Unfortunately, non-visualization of the appendix is up to 30–43% in some single-center series [79,80,81,82]. The rate of non-visualization is higher during the 3rd trimester when the largest degree of anatomic distortion occurs due to the gravid uterus [81].
從 2011 年開始，有三項 meta 分析報告了在懷孕期間使用 MRI 治療 AA，結果如下：靈敏度 90.5%、94% 和 91.8%;特異性 98.6%、97%和 97.9%;陽性預測值 86.3%;陰性預測值 99.0%[77,78]。 不幸的是，在一些單中心系列中，闌尾的不可見性高達 30-43%[79,80,81,82]。 妊娠第 3 期的不可見率較高，此時由於妊娠子宮而發生的最大程度的解剖變形[81]。

Although a negative or inconclusive MRI does not exclude AA during pregnancy, many authors suggest MRI as the gold standard in all female patients during their reproductive years, mostly because of its high specificity and sensitivity (100% and 89%, respectively) and the high negative (96–100%) and positive (83.3–100%) predictive values [73, 83, 84].
雖然 MRI 陰性或無定論不能排除妊娠期 AA，但許多作者認為 MRI 是所有女性女性育齡期患者的金標準，主要是因為 MRI 具有較高的特異性和敏感性（分別為 100%和 89%），以及較高的陰性（96-100%）和陽性（83.3-100%）預測值[73,83,84]。

Statement 1.8 Combination of US and clinical (e.g., AIR, AAS scores) parameters forming combined clinico-radiological scores may significantly improve diagnostic sensitivity and specificity and eventually replace the need for a CT scan in adult patients with suspected acute appendicitis. Recommendation 1.7 We recommend the routine use of a combination of clinical parameters and US to improve diagnostic sensitivity and specificity and reduce the need for CT scan in the diagnosis of acute appendicitis. The use of imaging diagnostics is recommended in patients with suspected appendicitis after an initial assessment and risk stratification using clinical scores [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 1.8 結合超聲和臨床（例如 AIR、AAS 評分）參數形成綜合臨床放射學評分，可能會顯著提高診斷敏感性和特異性，並最終取代疑似急性闌尾炎成年患者對 CT 掃描的需求。建議 1.7 我們建議常規結合臨床參數和超聲檢查，以提高診斷敏感性和特異性，並減少急性闌尾炎診斷中對 CT 掃描的需求。對於疑似闌尾炎患者，建議在初步評估和使用臨床評分進行風險分層后使用影像學診斷[QoE：中度;推薦強度：強;1B]。

Statement 1.9 Intermediate-risk classification identifies patients likely to benefit from observation and systematic diagnostic imaging. Recommendation 1.8 We suggest proceeding with timely and systematic diagnostic imaging in patients with intermediate-risk of acute appendicitis [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 1.9 中等風險分類可識別可能從觀察和系統診斷成像中獲益的患者。建議 1.8 我們建議對急性闌尾炎中危患者進行及時和系統的診斷性影像學檢查[QoE：中度;推薦強度：弱;2B]。

Statement 1.10 Patients with strong signs and symptoms and high risk of appendicitis according to AIR score/Alvarado score/AAS and younger than 40 years old may not require cross-sectional pre-operative imaging (i.e., CT scan). Recommendation 1.9 We suggest that cross-sectional imaging (i.e., CT scan) for high-risk patients younger than 40 years old (AIR score 9–12, Alvarado score 9–10, and AAS ≥ 16) may be avoided before diagnostic +/− therapeutic laparoscopy [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 1.10 根據 AIR 評分/Alvarado 評分/AAS 具有強烈體征和癥狀且闌尾炎高風險且年齡小於 40 歲的患者可能不需要橫斷面術前影像學檢查（即 CT 掃描）。建議 1.9 我們建議，對於 40 歲以下的高危患者（AIR 評分 9-12 分，Alvarado 評分 9-10 分，AAS≥16 分），在診斷性+/-治療性腹腔鏡檢查[QoE：中度;推薦強度：弱;2B]。

Comment: This statement and recommendation has raised an intense debate among the panel of experts and consensus was difficult to reach, especially in view of the strong opinions from two parties: one advocating the need of routine imaging with CT scan for all high-risk patients before any surgery and the other advocating the value of the clinical scores and thorough clinical assessment and risk stratification as being enough for proceeding to diagnostic and therapeutic laparoscopy in the subset of patients younger than 40 years old and scoring high in all Alvarado, AIR, and AAS scores.
評論： 這一聲明和建議在專家小組中引起了激烈的爭論，很難達成共識，特別是考慮到兩方的強烈意見：一方主張所有高危患者在任何手術前都需要進行常規 CT 掃描成像，另一方主張臨床評分和徹底的臨床評估和風險分層的價值足以進行診斷和治療性腹腔鏡檢查年齡小於 40 歲且在所有 Alvarado、AIR 和 AAS 評分中得分較高的患者子集。

The results of the first round of the Delphi consensus modified the previous recommendation from 2016 guidelines (see graphs included as Supplementary Material files 2, 3, 4, 5 and 6) as follows: “We suggest appendectomy without pre-operative imaging for high-risk patients younger than 50 years old according to the AIR score”, 8.3% agreement; “We suggest diagnostic +/− therapeutic laparoscopy without pre-operative imaging for high-risk patients younger than 40 years old, AIR score 9–12, Alvarado score 9–10, and AAS ≥ 16”, 70.8% agreement; “Delete recommendation”, 20.8% agreement) were discussed in a further consensus due to the strong opposition by few of the expert panelists who were still not keen to accept the results of the first Delphi and the recommendation despite being already labeled as a weak recommendation (“suggestion” according to GRADE Criteria).
第一輪德爾菲共識的結果修改了 2016 年指南中的先前建議（參見補充材料檔 2、3、4、5 和 6 中包含的圖表），如下：“我們建議根據 AIR 評分對 50 歲以下的高危患者進行闌尾切除術，無需術前成像”，8.3% 的同意率;“我們建議對 40 歲以下的高危患者進行診斷性 +/- 治療性腹腔鏡檢查，無需術前影像學檢查，AIR 評分為 9-12，Alvarado 評分為 9-10，AAS ≥ 16”，70.8% 的同意率;“刪除建議”，20.8% 的同意）在進一步的共識中進行了討論，因為少數專家小組成員強烈反對，他們仍然不熱衷於接受第一個德爾菲的結果和建議，儘管已經被標記為弱建議（根據 GRADE 標準的“建議”）。

A further revision of the statement was proposed and a second round of Delphi was performed before endorsing the final recommendation “We suggest that cross-sectional imaging i.e. CT scan for high-risk patients younger than 40 years old, AIR score 9–12 and Alvarado score 9–10 and AAS ≥ 16 may be avoided before diagnostic +/− therapeutic laparoscopy” which obtained the 68.0% of agreement, whereas the statement “We suggest diagnostic +/− therapeutic laparoscopy without pre-operative imaging for high-risk patients younger than 40 years old and AIR score 9–12; Alvarado score 9–10; AAS ≥ 16” reached 26% and the option “delete the statement and recommendations reached 6%. Some authors also added that cross-sectional imaging, i.e., CT scan for high-risk patients younger than 40 years old may be skipped or imaging may be avoided at all, before diagnostic +/− therapeutic laparoscopy for young male patients. Some also emphasized that the responsible surgeon (not PGY1 trainee) should examine the patient prior to the decision for CT scanning and recommended a highly value-based surgical care. WSES supports this recommendation of a value-based surgical care and these further comments will be the ground for the next future editions of the guidelines, when hopefully further and stronger evidence will be available from the literature about this challenging subgroup of high-risk scoring patients. All the graphs reporting the results of the additional Delphi are reported within the Supplementary Material files 2, 3, 4, 5 and 6.
建議對聲明進行進一步修訂，並在批准最終建議之前進行了第二輪德爾菲測試「我們建議在診斷性 +/- 治療性腹腔鏡檢查之前可以避免對 40 歲以下的高危患者進行橫斷面成像，即 CT 掃描，AIR 評分為 9-12 和 Alvarado 評分為 9-10 和 AAS ≥ 16“，獲得了 68.0% 的同意， 而聲明「我們建議對 40 歲以下且 AIR 評分為 9-12 的高危患者進行診斷性 +/- 治療性腹腔鏡檢查，無需術前成像;阿爾瓦拉多得分 9-10;AAS ≥ 16「達到 26%，」刪除聲明和建議「選項達到 6%。一些作者還補充說，在對年輕男性患者進行診斷性 +/- 治療性腹腔鏡檢查之前，可以跳過橫斷面成像，即對 40 歲以下的高危患者進行 CT 掃描，或者完全避免成像。一些人還強調，負責的外科醫生（不是 PGY1 實習生）應該在決定進行 CT 掃描之前對患者進行檢查，並推薦基於高價值的手術護理。WSES 支援這一基於價值的手術護理的建議，這些進一步的評論將成為該指南未來版本的基礎，屆時希望從文獻中獲得有關這一具有挑戰性的高風險評分患者亞組的進一步和更有力的證據。所有報告額外德爾菲結果的圖表都在補充材料檔 2、3、4、5 和 6 中報告。

Statement 1.11 POCUS (Point-of-care Ultrasound) is a reliable initial investigation with satisfactory sensitivity and specificity in diagnosing acute appendicitis, easing swift decision-making by the emergency physicians or surgeons. POCUS, if performed by an experienced operator, should be considered the most appropriate first-line diagnostic tool in both adults and children. Recommendation 1.10 We recommend POCUS as the most appropriate first-line diagnostic tool in both adults and children, if an imaging investigation is indicated based on clinical assessment [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 1.11POCUS（床旁超聲）是一種可靠的初步檢查，在診斷急性闌尾炎方面具有令人滿意的敏感性和特異性，有助於急診醫生或外科醫生做出快速決策。如果由經驗豐富的作者進行 POCUS，則應被視為成人和兒童最合適的一線診斷工具。建議 1.10 如果根據臨床評估[QoE：中度;推薦強度：強;1B]。

Statement 1.12 When it is indicated, contrast-enhanced low-dose CT scan should be preferred over contrast-enhanced standard-dose CT scan. Diagnostic accuracy of contrast-enhanced low-dose CT is not inferior to standard CT in diagnosing AA or distinguishing between uncomplicated and complicated acute appendicitis and enables significant radiation dose reduction. Recommendation 1.11 We recommend the use of contrast-enhanced low-dose CT scan over contrast-enhanced standard-dose CT scan in patients with suspected acute appendicitis and negative US findings [QoE: High; Strength of recommendation: Strong; 1A].
聲明 1.12 當需要時，應首選對比增強低劑量 CT 掃描，而不是對比增強標準劑量 CT 掃描。對比增強低劑量 CT 在診斷 AA 或區分單純性和複雜性急性闌尾炎方面的診斷準確性不遜色於標準 CT，並能顯著降低輻射劑量。建議 1.11 對於疑似急性闌尾炎且超聲結果為陰性的患者，我們推薦使用對比增強低劑量 CT 掃描，而不是對比增強標準劑量 CT 掃描[QoE：高;推薦強度：強;1A]。

Statement 1.13 In patients with normal investigations and symptoms unlikely to be acute appendicitis but which do not settle, cross-sectional imaging is recommended before surgery. Laparoscopy is recommended to establish/exclude the diagnosis of acute appendicitis and eventually treat the disease. Recommendation 1.12 We recommend cross-sectional imaging before surgery for patients with normal investigations but non-resolving right iliac fossa pain. After negative imaging, initial non-operative treatment is appropriate. However, in patients with progressive or persistent pain, explorative laparoscopy is recommended to establish/exclude the diagnosis of acute appendicitis or alternative diagnoses [QoE: High; Strength of recommendation: Strong; 1A].
聲明 1.13 對於檢查正常且癥狀不太可能是急性闌尾炎但未消退的患者，建議在手術前進行橫斷面影像學檢查。建議進行腹腔鏡檢查以確定/排除急性闌尾炎的診斷並最終治療該疾病。建議 1.12 對於檢查正常但右髂窩疼痛未消退的患者，我們建議在手術前進行橫斷面影像學檢查。陰性成像后，初始非手術治療是合適的。然而，對於進行性或持續性疼痛的患者，建議進行腹腔鏡探查以確定/排除急性闌尾炎的診斷或替代診斷[QoE：高;推薦強度：強;1A]。

Statement 1.14 MRI is sensitive and highly specific for the diagnosis of acute appendicitis during pregnancy. However, a negative or inconclusive MRI does not exclude appendicitis and surgery should be still considered if high clinical suspicion. Recommendation 1.13.1 We suggest graded compression trans-abdominal ultrasound as the preferred initial imaging method for suspected acute appendicitis during pregnancy [QoE: Very Low; Strength of Recommendation: Weak; 2C]. Recommendation 1.13.2 We suggest MRI in pregnant patients with suspected appendicitis, if this resource is available, after inconclusive US [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 1.14MRI 對於妊娠期急性闌尾炎的診斷具有敏感性和高度特異性。然而，陰性或不確定的 MRI 不能排除闌尾炎，如果臨床高度懷疑，仍應考慮手術。建議 1.13.1 我們建議將分級加壓經腹超聲作為妊娠期疑似急性闌尾炎的首選初始影像學檢查方法[QoE：極低;推薦強度：弱;2C]。 建議 1.13.2 我們建議在無定論的超聲檢查后對疑似闌尾炎的孕婦進行 MRI（如果有此資源），[QoE：中度;推薦強度：弱;2B]。

Q.1.6: What is the optimum pathway for imaging in pediatric patients with suspected acute appendicitis?
Q.1.6：疑似急性闌尾炎兒科患者的最佳影像學檢查途徑是什麼？

US is currently the recommended initial imaging study of choice for the diagnosis of AA in pediatric and young adult patients. US has been shown to have high diagnostic accuracy for AA as an initial imaging investigation and to reduce or obviate the need for further imaging without increased complications or unacceptable increases in length of stay [85].
US 是目前診斷兒科和年輕成人患者 AA 的推薦初始影像學研究。超聲檢查對 AA 的初步影像學檢查具有較高的診斷準確性，可減少或消除進一步影像學檢查的需要，而不會增加併發症或住院時間增加，且不會令人接受[85]。

However, the sensitivity and specificity of US for the diagnosis of pediatric AA varies across studies: it is well known that US is operator dependent and may be dependent on patient-specific factors, including BMI [86].
然而，超聲治療診斷小兒 AA 的敏感性和特異性因研究而異：眾所周知，超聲治療依賴於作者，並可能依賴於患者特異性因素，包括 BMI[86]。

A retrospective study assessing the ability of US to identify complicated AA or an appendicolith showed that US has a high specificity and negative predictive value to exclude complicated AA and the presence of an appendicolith in children being considered for non-operative management of uncomplicated AA [87].
一項回顧性研究評估了超聲識別複雜 AA 或闌尾結石的能力，結果顯示，超聲對排除複雜 AA 和兒童中存在闌尾結石具有較高的特異性和陰性預測值，可考慮對無併發症 AA 進行非手術治療[87]。

The study by Bachur et al. found that, among children with suspected AA, the use of US imaging has increased substantially (from 24.0% in 2010 to 35.3% in 2013), whereas the use of CT has decreased (from 21.4% in 2010 to 11.6% in 2013). However, important condition-specific quality measures, including the frequency of appendiceal perforation and readmissions, remained stable, and the proportion of negative appendectomy declined slightly [88].
Bachur 等人的研究發現，在疑似 AA 的兒童中，超聲成像的使用大幅增加（從 2010 年的 24.0% 增加到 2013 年的 35.3%），而 CT 的使用則有所下降（從 2010 年的 21.4% 下降到 2013 年的 11.6%）。然而，重要的特定疾病質量指標，包括闌尾穿孔和再入院的頻率保持穩定，闌尾切除術陰性的比例略有下降[88]。

The use of CT in the pediatric population can be reduced by using appropriate clinical and/or staged algorithm based on US/MRI implementation, with a sensitivity up to 98% and a specificity up to 97% and by applying imaging scoring system, such as the Appy-Score for reporting limited right lower quadrant US exams, that performs well for suspected pediatric AA [89,90,91].
通過使用基於超聲/MRI 實施的適當臨床和/或分期演算法，靈敏度高達 98%，特異性高達 97%，並應用影像學評分系統，例如用於報告有限的右下腹超聲檢查的 Appy-Score，可以減少 CT 在兒科人群中的使用，該系統對疑似兒科 AA 表現良好[89，90,91]。

A systematic literature review was performed to evaluate the effectiveness of abdominal US and abdominal CT in diagnosing AA in adult and pediatric patients. Data reported that for US, the calculated pooled values of sensitivity, specificity, positive predictive value, and negative predictive value were 86%, 94%, 100%, and 92%, respectively. For CT, the calculated pooled values of sensitivity, specificity, positive predictive value, and negative predictive value were 95%, 94%, 95%, and 99%, respectively. These results suggest that US is an effective first-line diagnostic tool for AA and that CT should be performed for patients with inconclusive ultrasonographic finding [92]. Recently, a meta-analysis was carried out to compare the accuracy of US, CT, and MRI for clinically suspected AA in children. The area under the receiver operator characteristics curve of MRI (0.995) was a little higher than that of US (0.987) and CT (0.982) but with no significant difference [93].
進行了系統文獻綜述，以評估腹部超聲和腹部 CT 診斷成人和兒童患者 AA 的有效性。數據顯示，對於 US，計算出的敏感性、特異性、陽性預測值和陰性預測值的匯總值分別為 86%、94%、100% 和 92%。對於 CT，計算出的敏感性、特異性、陽性預測值和陰性預測值的匯總值分別為 95%、94%、95% 和 99%。這些結果表明，超聲檢查是 AA 的有效一線診斷工具，對於超聲檢查結果不確定的患者，應進行 CT[92]。最近，進行了一項薈萃分析，比較了超聲、CT 和 MRI 對兒童臨床疑似 AA 的準確性。MRI 的受試者作者特徵曲線下面積（0.995）略高於 US（0.987）和 CT（0.982），但差異無統計學意義[93]。

Lee et al. compared US and CT in terms of negative appendectomy rate and appendiceal perforation rate in adolescents and adults with suspected appendicitis to evaluate the diagnostic performance as preoperative imaging investigations with a propensity score method. This analysis reported that the use of US instead of CT may increase the negative appendectomy rate but does not significantly affect the rate of perforation [94].
Lee et al. 比較了 US 和 CT 在疑似闌尾炎青少年和成人的闌尾切除陰性率和闌尾穿孔率方面的診斷性能，以評估使用傾向評分方法進行術前影像學檢查的診斷性能。該分析報告稱，使用超聲代替 CT 可能會增加闌尾切除術陰性率，但不會顯著影響穿孔率[94]。

A low dose CT, when indicated, can be an adequate method compared to US and standard dose CT in diagnosing AA in children in terms of sensitivity (95.5% vs 95.0% and 94.5%), specificity (94.9% vs 80.0% and 98.8%), positive-predictive value (96.4% vs 92.7%), and negative-predictive value (93.7% vs 85.7% and 91.3%) [95].
在診斷兒童 AA 方面，低劑量 CT 在敏感性（95.5% vs 95.0%和 94.5%）、特異性（94.9% vs 80.0%和 98.8%）、陽性預測值（96.4% vs 92.7%）和陰性預測值（93.7% vs 85.7%和 91.3%）方面，與超聲 CT 和標準劑量 CT 相比，可能是一種合適的方法[95]。

The diagnostic performance of staged algorithms involving US followed by conditional MRI imaging for the diagnostic workup of pediatric AA has proven to be high (98.2% sensitive and 97.1% specific) [90]. MRI is a feasible alternative to CT for secondary imaging in AA in children, and it can differentiate perforated from non-perforated AA with a high specificity [96].
事實證明，超聲後條件 MRI 成像的分期演算法對兒科 AA 的診斷性檢查具有很高的診斷性能（靈敏度為 98.2%，特異性為 97.1%）[90]。MRI 是兒童 AA 二次成像 CT 的可行替代方法，它可以以高特異性區分穿孔和非穿孔 AA[96]。

MRI plays a role as an imaging investigation to avoid CT radiation dose in children with inconclusive US findings. Moore et al. reported sensitivity of 96.5%, specificity of 96.1%, positive predictive value of 92.0%, and negative predictive value of 98.3% for MRI [97].
MRI 起到影像學檢查的作用，以避免 US 結果不確定的兒童接受 CT 輻射劑量。Moore 等報告 MRI 的敏感性為 96.5%，特異性為 96.1%，陽性預測值為 92.0%，陰性預測值為 98.3%[97]。

In a prospective study conducted by Kinner et al., when the diagnostic accuracy of MRI was compared to CT, sensitivity and specificity were 85.9% and 93.8% for non-enhanced MRI, 93.6% and 94.3% for contrast-enhanced MRI, and 93.6% and 94.3% for CT [98].
在 Kinner 等進行的一項前瞻性研究中，將 MRI 的診斷準確性與 CT 進行比較時，非增強 MRI 的靈敏度和特異性分別為 85.9%和 93.8%，對比增強 MRI 的靈敏度和特異度分別為 93.6%和 94.3%，CT 的靈敏度和特異度分別為 93.6%和 94.3%[98]。

However, the costs and the availability of MRI often prevent its use as the initial imaging investigation in cases of suspected AA.
然而，MRI 的成本和可用性通常阻止其用作疑似 AA 病例的初始影像學檢查。

As second-line imaging modalities after initial US for assessing AA in children and adults, repeated US, CT, and MRI showed comparable and high accuracy in children and adults. These three modalities may be valid as second-line imaging in a clinical imaging pathway for diagnosis of AA. In particular, pooled sensitivities and specificities of second-line US for the diagnosis of AA in children were 91.3% and 95.2%, respectively. Regarding second-line CT, the pooled sensitivities and specificities were 96.2% and 94.6%. Regarding second-line MRI, pooled sensitivities and specificities were 97.4% and 97.1% [99].
作為評估兒童和成人 AA 的初始超聲檢查后的二線成像方式，重複超聲、CT 和 MRI 在兒童和成人中顯示出相當且高精度的。這三種方式可能可作為臨床影像學診斷途徑中的二線影像學檢查，用於診斷 AA。特別是，二線超聲治療兒童 AA 診斷的綜合敏感性和特異性分別為 91.3%和 95.2%。二線 CT 的匯總敏感性和特異性分別為 96.2%和 94.6%。關於二線 MRI，合併敏感性和特異性分別為 97.4%和 97.1%[99]。

Statement 1.15 The use of US in children is accurate and safe in terms of perforation rates, emergency department re-visits, and negative appendectomy rates. CT use may be decreased by using appropriate clinical and/or staged algorithm with US/MRI. MRI has at least the same sensitivity and specificity as CT and, although higher costs, should be preferred over CT as second-line imaging in children. Recommendation 1.14.1 In pediatric patients with suspected appendicitis, we suggest the use of US as first-line imaging. In pediatric patients with inconclusive US, we suggest choosing the second-line imaging technique based on local availability and expertise, as there are currently no strong data to suggest a best diagnostic pathway due to a variety of options and dependence on local resources [QoE: Moderate; Strength of recommendation: Weak: 2B]. Recommendation 1.14.2 Since in pediatric patients with equivocal CT finding the prevalence of true acute appendicitis is not negligible, we suggest against the routine use of CT as first-line imaging in children with right iliac fossa pain [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 1.15 在穿孔率、急診科複診率和闌尾切除術陰性率方面，在兒童中使用 US 是準確和安全的。通過使用適當的臨床和/或分期演算法和 US/MRI，可以減少 CT 的使用。MRI 至少具有與 CT 相同的敏感性和特異性，儘管成本較高，但作為兒童二線成像，MRI 應優於 CT。建議 1.14.1 對於疑似闌尾炎的兒科患者，我們建議使用超聲檢查作為一線影像學檢查。對於超聲不確定的兒科患者，我們建議根據當地的可用性和專業知識選擇二線影像學技術，因為由於多種選擇和對當地資源的依賴，目前沒有強有力的數據表明最佳診斷途徑 [QoE：中度;推薦強度：弱：2B]。建議 1.14.2 由於在患有模棱兩可的 CT 的兒科患者中，發現真正的急性闌尾炎的患病率不可忽略，因此我們建議不要常規使用 CT 作為右髂窩疼痛兒童的一線影像學檢查 [QoE：中度;推薦強度：弱;2B]。

Topic 2: Non-operative management of uncomplicated acute appendicitis
專題2：無併發症急性闌尾炎的非手術治療

Q.2.1: Is non-operative management with or without antibiotics a safe and effective treatment option for adult patients with uncomplicated acute appendicitis?
Q.2.1：對於無併發症的急性闌尾炎成年患者，有或沒有抗生素的非手術治療是否是一種安全有效的治療選擇？

Recent systematic reviews and meta-analyses of RCTs have concluded that the majority of patients with uncomplicated AA can be treated with an antibiotic-first approach [16, 18, 100].
最近對 RCT 的系統評價和 meta 分析得出結論，大多數無併發症的 AA 患者可以通過抗生素優先治療[16,18,100]。

The recent meta-analysis by Harnoss et al. reported a recurrence rate of symptoms within 1 year of 27.4% following antibiotic-first treatment. Taking into consideration any kind of post-interventional complication (including treatment failure), the complication-free treatment success rate of antibiotic therapy was significantly inferior to the rate after surgery (68.4 vs 89.8%). There is also evidence that NOM for uncomplicated AA does not statistically increase the perforation rate in adult patients receiving antibiotic treatment. NOM with antibiotics may fail during the primary hospitalization in about 8% of cases, and an additional 20% of patients might need a second hospitalization for recurrent AA within 1 year from the index admission [16, 17].
Harnoss 等人最近的薈萃分析報告稱，抗生素優先治療后 1 年內癥狀復發率為 27.4%。考慮到任何類型的介入后併發症（包括治療失敗），抗生素治療的無併發症治療成功率顯著低於術后成功率（68.4% vs 89.8%）。還有證據表明，無併發症 AA 的 NOM 不會在統計學上增加接受抗生素治療的成年患者的穿孔率。約 8%的病例在初次住院期間使用抗生素的 NOM 可能失敗，另外 20%的患者可能需要在指數入院后 1 年內因復發性 AA 而需要第二次住院[16,17]。

The success of the non-operative approach requires careful patient selection and exclusion of patients with gangrenous AA, abscesses, and diffuse peritonitis. Hansson et al. in their study on 581 patients with AA published in 2014 found that patients with assumed AA who fulfilled all criteria with CRP < 60 g/L, WBC < 12 × 10⁹/L, and age < 60 years had an 89% of chance of recovery with antibiotics without surgery [101]. In another recent study, patients with a longer duration of symptoms prior to admission (> 24 h) were more likely to have successful NOM. Other independent predictors of NOM success included lower temperature, imaging-confirmed uncomplicated AA with lower modified Alvarado score (< 4), and smaller diameter of the appendix [102].
非手術方法的成功需要仔細選擇患者並排除壞疽性 AA、膿腫和瀰漫性腹膜炎患者。Hansson 等人於 2014 年發表對 581 例 AA 患者進行的研究發現，如果 CRP < 60 g/L、WBC < 12 × 10⁹/L、年齡< 60 歲，且符合所有標準的假定 AA 患者，抗生素康復幾率為 89%，無需手術[101]。在最近的另一項研究中，入院前癥狀持續時間較長（> 24 h）的患者更有可能成功獲得 NOM。NOM 成功的其他獨立預測因素包括較低的溫度、影像學證實的無併發症 AA，改良 Alvarado 評分較低（< 4）和較小的闌尾直徑[102]。

In the APPAC randomized trial appendectomy resulted in an initial success rate of 99.6%. In the antibiotic group, 27.3% of patients underwent appendectomy within 1 year of initial presentation for AA. Of the 256 patients available for follow-up in the antibiotic group, 72.7% did not require surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 82.9% had uncomplicated AA, 10.0% had complicated AA, and 7.1% did not have AA but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment [103].
在 APPAC 隨機試驗中，闌尾切除術的初始成功率為 99.6%。在抗生素組中，27.3% 的患者在 AA 初次就診後 1 年內接受了闌尾切除術。在抗生素組可隨訪的 256 名患者中，72.7% 不需要手術。在隨後接受闌尾切除術的 70 名隨機接受抗生素治療的患者中，82.9% 患有無併發症的 AA，10.0% 患有併發症的 AA，7.1% 沒有 AA 但因疑似復發而接受了闌尾切除術。隨機接受抗生素治療的患者沒有腹腔內膿腫或其他與延遲闌尾切除術相關的主要併發症[103]。

The 5-year follow-up results of the APPAC trial reported that, among patients who were initially treated with antibiotics, the likelihood of late recurrence was 39.1%. Only 2.3% of patients who had surgery for recurrent AA were diagnosed with complicated forms of the disease. The overall complication rate was significantly reduced in the antibiotic group compared to the appendectomy group (6.5% vs 24.4%). This long-term follow-up supports the feasibility of NOM with antibiotics as an alternative to surgery for uncomplicated AA [104]. Furthermore, patients receiving antibiotic therapy incur lower costs than those who had surgery [105].
APPAC 試驗的 5 年隨訪結果顯示，在最初接受抗生素治療的患者中，晚期復發的可能性為 39.1%。在接受復發性 AA 手術的患者中，只有 2.3% 被診斷出患有複雜的疾病。與闌尾切除術組相比，抗生素組的總體併發症發生率顯著降低（6.5% vs 24.4%）。這種長期隨訪支援 NOM 聯合抗生素作為無併發症 AA 手術的替代方法的可行性[104]。此外，接受抗生素治療的患者比接受手術的患者花費更低[105]。

The presence of an appendicolith has been identified as an independent prognostic risk factor for treatment failure in NOM of uncomplicated AA. When presenting together with AA, the presence of appendicoliths is associated with increased perforation risk. The recently published study by Mällinen et al. further corroborates the previous clinical hypothesis showing that the presence of an appendicolith is an independent predictive factor for both perforation and the failure of NOM of uncomplicated AA [106,107,108].
闌尾結石的存在已被確定為無併發症 AA 的 NOM 治療失敗的獨立預後危險因素。當與 AA 一起就診時，闌尾結石的存在與穿孔風險增加有關。Mällinen 等人最近發表的研究進一步證實了先前的臨床假設，即闌尾結石的存在是單純 AA 穿孔和 NOM 失敗的獨立預測因素[106,107,108]。

Case reports show that it may be possible to manage uncomplicated AA non-operatively (definitively or as a bridge therapy) during pregnancy [109, 110]. There is a single study, with 25% of pregnant patients with uncomplicated AA treated conservatively. The failure rate was 15%. Recurrence rate during the same pregnancy was 12% [111]. A small number of published cases had different antibiotic regimens which include different antibiotics or their combinations and different durations of initial intravenous administration with different duration of antibiotic continuation in the form of oral administration (3–7 days in total) [102, 111].
病例報告顯示，妊娠期可能以非手術方式（明確治療或作為橋接療法）治療無併發症的 AA[109,110]。 有一項研究，25% 的無併發症 AA 妊娠患者接受了保守治療。故障率為 15%。同一妊娠期間的復發率為 12%[111]。少數已發表的病例採用不同的抗生素治療方案，包括不同的抗生素或其組合，以及不同的初始靜脈給葯持續時間，以及不同的抗生素口服持續持續時間（總共 3-7 天）[102,111]。

Statement 2.1 The antibiotic-first strategy can be considered safe and effective in selected patients with uncomplicated acute appendicitis. Patients who wish to avoid surgery must be aware of a risk of recurrence of up to 39% after 5 years. Most recent data from meta-analyses of RCTs showed that NOM with antibiotics achieves a significantly lower overall complication rate at 5 years and shorter sick leave compared to surgery. Recommendation 2.1.1 We recommend discussing NOM with antibiotics as a safe alternative to surgery in selected patients with uncomplicated acute appendicitis and absence of appendicolith, advising of the possibility of failure and misdiagnosing complicated appendicitis [QoE: High; Strength of Recommendation: Strong; 1A]. Recommendation 2.1.2 We suggest against treating acute appendicitis non-operatively during pregnancy until further high-level evidence is available [QoE: Very Low; Strength of Recommendation: Weak; 2C].
聲明 2.1 抗生素優先策略對於選定的無併發症急性闌尾炎患者可以被認為是安全有效的。希望避免手術的患者必須意識到 5 年後復發的風險高達 39%。來自隨機對照試驗薈萃分析的最新數據表明，與手術相比，NOM 聯合抗生素在 5 年時的總體併發症發生率顯著降低，病假時間更短。建議 2.1.1 對於無闌尾結石的無併發症急性闌尾炎患者，我們建議討論 NOM 與抗生素作為手術的安全替代方法，並建議失敗的可能性和誤診複雜性闌尾炎[QoE：高;推薦強度：強;1A]. 建議 2.1.2 我們建議在獲得進一步的高水準證據之前，不要在妊娠期進行非手術治療急性闌尾炎 [QoE：極低;推薦強度：弱;2C]。

Q.2.2: Is non-operative management with or without antibiotics a safe and effective treatment option for pediatric patients with uncomplicated acute appendicitis?
Q.2.2：對於無併發症的急性闌尾炎兒科患者，非手術治療聯合或不聯合抗生素是否是安全有效的治療選擇？

Less than 19% of children have a complicated acute appendicitis; hence, the majority of children with uncomplicated AA may be considered for either a non-operative or an operative management [112].
不到 19% 的兒童患有複雜的急性闌尾炎;因此，大多數無併發症 AA 患兒可考慮進行非手術或手術治療[112]。

The antibiotic-first strategy appears effective as an initial treatment in 97% of children with uncomplicated AA (recurrence rate 14%), with NOM also leading to less morbidity, fewer disability days, and lower costs than surgery [113, 114].
抗生素優先策略似乎可作為 97%的無併發症 AA 兒童的初始治療（復發率為 14%）有效，與手術相比，NOM 的發病率更低，殘疾天數更少，費用更低[113,114]。

A systematic review of all evidence available comparing appendectomy to NOM for uncomplicated AA in children included 13 studies, 4 of which were retrospective studies, 4 prospective cohort studies, 4 prospective non-randomized comparative trials, and 1 RCT. The initial success of the NOM groups ranged from 58 to 100%, with 0.1–31.8% recurrence at 1 year [115].
對比較闌尾切除術與 NOM 治療兒童無併發症 AA 的所有現有證據的系統評價包括 13 項研究，其中 4 項是回顧性研究，4 項前瞻性佇列研究，4 項前瞻性非隨機比較試驗和 1 項 RCT。NOM 組的初始成功率為 58%-100%，1 年復發率為 0.1-31.8%[115]。

The meta-analysis by Huang et al. showed that antibiotics as the initial treatment for pediatric patients with uncomplicated AA may be feasible and effective without increasing the risk of complications. However, surgery is preferred for uncomplicated AA with the presence of an appendicolith as the failure rate in such cases is high [116].
Huang 等的 meta 分析表明，抗生素作為無併發症 AA 兒科患者的初始治療可能是可行且有效的，不會增加併發症的風險。然而，對於存在闌尾結石的無併發症 AA，首選手術，因為此類病例的失敗率很高[116]。

The prospective trial by Mahida et al. reported that the failure rate of NOM with antibiotics in children affected by uncomplicated AA with appendicolith was high (60%) at a median follow-up of less than 5 months [117]. The presence of an appendicolith has also been associated with high failure rates in the reports published by Tanaka et al. (failure rate, 47%), Svensson et al. (failure rate, 60%), and Lee et al., concluding that patients with evidence of an appendicolith on imaging had an initial NOM failure rate of more than twice that of patients without an appendicolith [118,119,120].
Mahida 等的前瞻性試驗報導稱，在中位隨訪時間少於 5 個月時，在無併發症 AA 伴闌尾結石的兒童中，NOM 使用抗生素的失敗率很高（60%）[117]。在 Tanaka 等（失敗率，47%）、Svensson 等（失敗率，60%）和 Lee 等發表的報告中，闌尾結石的存在也與高失敗率相關，得出的結論是，影像學檢查有闌尾結石證據的患者的初始 NOM 失敗率是沒有闌尾結石的患者的兩倍多[118，119,120]。

Gorter et al. investigated the risk of complications following NOM and appendectomy for uncomplicated AA in a systematic review. Five studies (RCT and cohort studies) were analyzed, including 147 children (NOM) and 173 children (appendectomy) with 1-year follow-up. The percentage of children experiencing complications ranged from 0 to 13% for NOM versus 0–17% for appendectomy. NOM avoided an appendectomy in 62–81% of children after 1-year follow-up. The authors concluded that NOM can avoid an appendectomy in a large majority of children after 1-year follow-up but evidence was insufficient to suggest NOM in all children with uncomplicated AA [121].
Gorter 等人在一項系統評價中調查了無併發症 AA 的 NOM 和闌尾切除術后併發症的風險。分析了 5 項研究（RCT 和佇列研究），包括 147 名兒童（NOM）和 173 名兒童（闌尾切除術），隨訪 1 年。NOM 的兒童併發症百分比為 0% 至 13%，闌尾切除術為 0-17%。經過 1 年的隨訪，NOM 避免了 62-81% 的兒童進行闌尾切除術。作者得出結論，在隨訪 1 年後，絕大多數兒童的 NOM 可以避免闌尾切除術，但證據不足以提示所有無併發症的 AA 患兒都接受 NOM[121]。

In the meta-analysis by Kessler et al. NOM showed a reduced treatment efficacy (relative risk 0.77, 95% CI 0.71–0.84) and an increased readmission rate (relative risk 6.98, 95% CI 2.07–23.6), with a comparable rate of complications (relative risk 1.07, 95% CI 0.26–4.46). Exclusion of patients with appendicoliths improved treatment efficacy in conservatively treated patients. The authors concluded that NOM was associated with a higher readmission rate [122].
在 Kessler 等人的 meta 分析中，NOM 顯示治療效果降低（相對風險 0.77,95%CI 0.71-0.84）和再入院率增加（相對風險 6.98,95%CI 2.07-23.6），併發症發生率相當（相對風險 1.07,95%CI 0.26-4.46）。排除闌尾結石患者提高了保守治療患者的治療效果。作者得出結論，NOM 與較高的再入院率相關[122]。

Considering these results, NOM can be suggested only for selected pediatric patients presenting with uncomplicated AA.
考慮到這些結果，NOM 只能用於無併發症 AA 的選定兒科患者。

Minneci et al. conducted a prospective patient choice cohort study enrolling 102 patients aged 7 to 17 years and showed that the incidence of complicated AA was 2.7% in the NOM group and 12.3% in the appendectomy group. After 1 year, children managed nonoperatively had fewer disability days and lower appendicitis-related health care costs compared with those who underwent appendectomy [114].
Minneci 等人進行了一項前瞻性患者選擇佇列研究，招募了 102 名年齡在 7 至 17 歲之間的患者，結果顯示，NOM 組複雜性 AA 的發生率為 2.7%，闌尾切除術組為 12.3%。與接受闌尾切除術的患兒相比，1 年後，非手術治療的患兒殘疾天數更少，闌尾炎相關醫療費用也更低[114]。

Statement 2.2 NOM for uncomplicated acute appendicitis in children is feasible, safe, and effective as initial treatment. However, the failure rate increases in the presence of appendicolith, and surgery is recommended in such cases. Recommendation 2.2 We suggest discussing NOM with antibiotics as a safe and effective alternative to surgery in children with uncomplicated acute appendicitis in the absence of an appendicolith, advising of the possibility of failure and misdiagnosing complicated appendicitis [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 2.2NOM 治療兒童無併發症急性闌尾炎作為初始治療是可行、安全且有效的。然而，在存在闌尾結石的情況下，失敗率會增加，在這種情況下建議進行手術。建議 2.2 我們建議討論 NOM 與抗生素作為無闌尾結石的無併發症急性闌尾炎兒童手術的安全有效的替代方法，建議失敗和誤診複雜性闌尾炎的可能性[QoE：中度;推薦強度：弱;2B]。

Q.2.3: What is the best non-operative management of patients with uncomplicated acute appendicitis?
Q.2.3：無併發症急性闌尾炎患者的最佳非手術治療是什麼？

The implementation of treatment and follow-up protocols based on outpatient antibiotic management and new evidence indicating safety and feasibility of same-day laparoscopic appendectomy for uncomplicated AA may result in optimization of the resource used by reducing inpatient admissions and hospital costs for both NOM and surgical treatment in the future. Although the pilot trial by Talan et al. assessed the feasibility of antibiotics-first strategy including outpatient management (intravenous ertapenem greater than or equal to 48 h and oral cefdinir and metronidazole), the majority of RCTs published to date included 48 h minimum of inpatient administration of intravenous antibiotics, followed by oral antibiotics for a total length of 7–10 days [123].
基於門診抗生素管理和新證據的治療和隨訪方案的實施，表明當天腹腔鏡闌尾切除術對無併發症的 AA 的安全性和可行性，可能會通過減少住院人數和住院費用來優化使用的資源未來 NOM 和手術治療。儘管 Talan 等的初步試驗評估了抗生素優先策略的可行性，包括門診治療（靜脈注射厄他培南大於或等於 48 小時，口服頭孢地尼和甲硝唑），但迄今為止發表的大多數 RCT 包括至少住院 48 小時靜脈注射抗生素，然後口服抗生素，總時間為 7-10 日[123]。

The empiric antibiotic regimens for non-critically ill patients with community-acquired intra-abdominal infections as advised by the 2017 WSES guidelines are the following: Amoxicillin/clavulanate 1.2–2.2 g 6-hourly or ceftriazone 2 g 24-hourly + metronidazole 500 mg 6-hourly or cefotaxime 2 g 8-hourly + metronidazole 500 mg 6-hourly.
根據 2017 年 WSES 指南的建議，對於患有社區獲得性腹腔內感染的非危重患者的經驗性抗生素方案如下：阿莫西林/克拉維酸鹽 1.2–2.2 g 6 小時或頭孢三酮 2 g 24 小時 + 甲硝唑 500 mg 6 小時或頭孢噻肟 2 g 8 小時 + 甲硝唑 500 mg 6 小時。

In patients with beta-lactam allergy: Ciprofloxacin 400 mg 8-hourly + metronidazole 500 mg 6-hourly or moxifloxacin 400 24-hourly. In patients at risk for infection with community-acquired ESBL-producing Enterobacteriacea: Ertapenem 1 g 24-hourly or tigecycline 100 mg initial dose, then 50 mg 12-hourly [124].
在 β-內醯胺類過敏患者中：環丙沙星 400 mg，每 8 小時 + 甲硝唑 500 mg，每 6 小時或莫西沙星 400，每 24 小時。對於有感染社區獲得性 ESBL 腸桿菌風險的患者：厄他培南 1g，24 小時一次，或替加環素 100mg，初始劑量，然後 50mg，12 小時一次[124]。

Currently, the APPAC II trial is running, with the aim to assess the safety and feasibility of per-oral antibiotic monotherapy compared with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated AA. Early results of the APPAC II are expected to be published in 2020 [125].
目前，APPAC II 試驗正在進行中，旨在評估與靜脈內抗生素治療相比，口服抗生素單藥治療治療無併發症的 AA 的安全性和可行性。APPAC II 的早期結果預計將於 2020 年發表[125]。

The results of the RCT by Park et al. challenged the need for antibiotic therapy in uncomplicated AA and reported promising results regarding possible spontaneous resolution of uncomplicated AA with supportive care only. Analysis of the primary outcome measure indicated that treatment failure rates in patients presenting with CT-confirmed uncomplicated AA were similar among those receiving supportive care with either a non-antibiotic regimen or a 4-day course of antibiotics, with no difference in the rates of perforated AA between the two groups reported [126]. Whether recovery from uncomplicated AA is the result of antibiotic therapy or natural clinical remission, and so whether antibiotics are superior to simple supportive care remains to be established.
Park 等人的隨機對照試驗結果對無併發症 AA 進行抗生素治療的必要性提出了質疑，並報告了關於僅通過支持治療可能自發消退無併發症 AA 的有希望的結果。主要結局指標分析顯示，CT 證實無併發症 AA 患者的治療失敗率在接受非抗生素方案或 4d 抗生素療程支持治療的患者中相似，兩組之間穿孔 AA 發生率差異無差異[126].從無併發症的 AA 中恢復是抗生素治療的結果還是自然臨床緩解的結果，因此抗生素是否優於簡單的支持治療仍有待確定。

The APPAC III multicenter, double-blind, placebo-controlled, superiority RCT comparing antibiotic therapy with placebo in the treatment of CT scan-confirmed uncomplicated AA is now in its enrollment phase. This new RCT aims to evaluate the role of antibiotics in the resolution of CT-diagnosed uncomplicated AA by comparing antibiotic therapy with placebo to evaluate the role of antibiotic therapy in the resolution of the disease [127].
APPAC III 多中心、雙盲、安慰劑對照、優效性隨機對照試驗，比較抗生素治療與安慰劑治療 CT 掃描證實的無併發症 AA，目前正處於入組階段。這項新的 RCT 旨在通過比較抗生素治療與安慰劑來評估抗生素治療在疾病消退中的作用，以評估抗生素治療在疾病消退中的作用[127]。

If future research demonstrates that antibiotics do not provide any advantage over observation alone in uncomplicated AA, this could have a major impact on reducing the use of antimicrobial agents, especially in this era of increasing antimicrobial resistance worldwide.
如果未來的研究表明，在無併發症的 AA 中，抗生素與單獨觀察相比沒有任何優勢，這可能會對減少抗菌藥物的使用產生重大影響，尤其是在這個全球抗菌素耐藥性不斷增加的時代。

Statement 2.3 Current evidence supports initial intravenous antibiotics with subsequent conversion to oral antibiotics until further evidence from ongoing RCT is available. Recommendation 2.3 In the case of NOM, we recommend initial intravenous antibiotics with a subsequent switch to oral antibiotics based on patient's clinical conditions [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 2.3 目前的證據支援初始靜脈注射抗生素，隨後轉為口服抗生素，直到正在進行的隨機對照試驗獲得進一步證據。建議 2.3 對於 NOM，我們建議初始靜脈注射抗生素，然後根據患者的臨床情況改用口服抗生素 [QoE：中度;推薦強度：強;1B]。

Statement 2.4 Uncomplicated acute appendicitis may safely resolve spontaneously with similar treatment failure rates and shorter length of stay and costs compared with antibiotics. However, there is still limited data for the panel to express in favor of or against the symptomatic treatment without antibiotics [QoE: Moderate; No recommendation].
聲明 2.4 與抗生素相比，無併發症的急性闌尾炎可以安全地自發消退，治療失敗率相似，住院時間和費用更短。然而，該小組支援或反對不使用抗生素的對症治療的數據仍然有限[QoE：中度;無推薦]。

Topic 3: Timing of appendectomy and in-hospital delay
主題 3：闌尾切除術的時機和院內延遲

Q.3.1: Does in-hospital delay increase the rate of complications or perforation for adult patients with uncomplicated acute appendicitis?
Q.3.1：住院延誤是否會增加無併發症急性闌尾炎成年患者的併發症或穿孔發生率？

The theory hypothesizing that perforated AA might be a different disease entity from uncomplicated AA, rather than being the natural evolution of the disease, has some support in the recent meta-analysis by van Dijk et al., demonstrating that delaying appendectomy for up to 24 h after admission does not appear to be a risk factor for complicated AA, postoperative morbidity, or surgical-site infection. Pooled adjusted ORs revealed no significantly higher risk for complicated AA when appendicectomy was delayed for 7–12 or 13–24 h, and meta-analysis of unadjusted data supported these findings by yielding no increased risk for complicated AA or postoperative complications with a delay of 24–48 h [22].
假設穿孔 AA 可能是與無併發症 AA 不同的疾病實體，而不是疾病的自然演變的理論在 van Dijk 等人最近的薈萃分析中得到了一些支援，表明入院後將闌尾切除術推遲長達 24 小時似乎不是複雜 AA 的危險因素， 術後發病率，或手術部位感染。合併調整后的 OR 顯示，當闌尾切除術延遲 7-12 小時或 13-24 小時時，複雜 AA 的風險沒有顯著升高，對未經調整數據的 meta 分析支持了這些發現，因為延遲 24-48 小時后，複雜 AA 或術后併發症的風險沒有增加[22]。

Data from the American College of Surgeons NSQIP demonstrated similar outcomes of appendectomy for AA when the operation was performed on hospital day 1 or 2. Conversely, appendectomies performed on hospital day 3 had significantly worse outcomes, as demonstrated by increased 30-day mortality (0.6%) and all major postoperative complications (8%) in comparison with operations taking place on hospital day 1 (0.1%; 3.4%) or 2 (0.1%; 3.6%). Patients with decreased baseline physical status assessed by the ASA Physical Status class had the worst outcomes (1.5% mortality; 14% major complications) when an operation was delayed to hospital day 3. However, logistic regression revealed higher ASA Physical Status class and open operations as the only predictors of major complications [128].
來自美國外科醫師學會 NSQIP 的數據表明，在住院第 1 天或第 2 天進行手術時，AA 闌尾切除術的結果相似。相反，與住院第 1 天 （0.1%; 3.4%） 或第 2 天 （0.1%; 3.6%） 進行的手術相比，住院第 3 天進行的闌尾切除術的結果明顯更差，30 天死亡率 （0.6%） 和所有主要術后併發症 （8%） 增加。當手術推遲到住院第 3 天時，通過 ASA 身體狀況分級評估的基線身體狀況下降的患者預後最差（死亡率為 1.5%;主要併發症為 14%）。然而，logistic 回歸顯示，ASA 身體狀況等級較高，開放手術是主要併發症的唯一預測因數[128]。

In the study by Elniel et al., a significant increase in the likelihood of perforated AA occurred after 72 h of symptoms, when compared to 60–72 h. The authors argued that it may be reasonable to prioritize patients approaching 72 h of symptoms for operative management [129].
在 Elniel 等人的研究中，與 60-72 小時相比，癥狀出現 72 小時後發生穿孔 AA 的可能性顯著增加。作者認為，優先考慮癥狀接近 72h 的患者進行手術治療可能是合理的[129]。

In a large retrospective series of pregnant women with suspected AA (75.9% with uncomplicated AA, 6.5% with complicated AA, and 17.6% with normal appendix), initial US was diagnostic in 57.9% of patients, whereas 55.8% of patients underwent a delayed repeat study. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US, whereas delaying surgery did not affect maternal or fetal safety. Such algorithm increased the diagnostic yield without increasing the proxies of maternal or fetal morbidity. There was no increased rate of perforated appendices in patients with delayed surgery. Still, the negative appendectomy rate was 17.7% [130].
在一項針對疑似 AA 孕婦的大型回顧性系列研究中（75.9% 為無併發症 AA，6.5% 為 COMPLICATION AA，17.6% 為 AL 正常，17.6% 為闌尾正常），57.9% 的患者診斷為 INITIAL US，而 55.8% 的患者接受了延遲重複研究。在該佇列中，在觀察期間對那些其他方面仍然模棱兩可的患者進行延遲重複超聲檢查提高了超聲檢查的診斷率，而延遲手術不會影響母體或胎兒的安全。這種演算法在不增加母體或胎兒發病率的情況下提高了診斷率。延遲手術患者的闌尾穿孔率沒有增加。儘管如此，闌尾切除術陰性率為 17.7%[130]。

Statement 3.1 Short, in-hospital surgical delay up to 24 h is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate in adults. Surgery for uncomplicated acute appendicitis can be planned for the next available list minimizing delay wherever possible (better patient comfort, etc.). Short, in-hospital delay with observation and repeated trans-abdominal US in pregnant patients with equivocal appendicitis is acceptable and does not seem to increase the risk of maternal and fetal adverse outcomes. Recommendation 3.1 We recommend planning laparoscopic appendectomy for the next available operating list within 24 h in case of uncomplicated acute appendicitis, minimizing the delay wherever possible [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 3.1 在無併發症的急性闌尾炎中，短暫的院內手術延遲長達 24 小時是安全的，並且不會增加成人的併發症和/或穿孔率。無併發症急性闌尾炎的手術可以計劃在下一個可用清單中，盡可能減少延誤（更好的患者舒適度等）。對於患有模棱兩可的闌尾炎的妊娠患者，短期的院內延遲觀察和重複經腹超聲是可以接受的，並且似乎不會增加母體和胎兒不良結局的風險。建議 3.1 如果出現無併發症的急性闌尾炎，我們建議在 24 小時內計劃腹腔鏡闌尾切除術，以進行下一個可用的手術清單，盡可能盡量減少延遲 [QoE：中度;推薦強度：強;1B]。

Statement 3.2 Delaying appendectomy for uncomplicated acute appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical site infection, or morbidity. Conversely, appendectomies performed after 24 h from admission are related to increased risk of adverse outcomes. Recommendation 3.2 We recommend against delaying appendectomy for acute appendicitis needing surgery beyond 24 h from the admission [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 3.2 無併發症急性闌尾炎的闌尾切除術延遲入院后長達 24 小時似乎不是複雜性闌尾炎、術後手術部位感染或併發症的危險因素。相反，入院后 24 小時後進行闌尾切除術與不良結局風險增加有關。建議 3.2 對於需要手術的急性闌尾炎，我們建議不要將闌尾切除術推遲到入院后 24 小時以上 [QoE：中度;推薦強度：強;1B]。

Q.3.2: Does in-hospital delay increase the rate of complications or perforation for pediatric patients with uncomplicated acute appendicitis?
Q.3.2：住院延誤是否會增加無併發症急性闌尾炎兒科患者的併發症或穿孔發生率？

In children appendectomy performed within the first 24 h from presentation is not associated with an increased risk of perforation or adverse outcomes [131]. Similarly, in the multivariate logistic regression analysis by Almstrom et al., increased time to surgery was not associated with increased risk of histopathologic perforation, and there was no association between the timing of surgery and postoperative wound infection, intra-abdominal abscess, reoperation, or readmission [132].
在兒童中，在就診后 24 小時內進行闌尾切除術與穿孔或不良結局風險增加無關[131]。同樣，在 Almstrom 等的多因素 logistic 回歸分析中，手術時間增加與組織病理學穿孔風險增加無關，手術時間與術后傷口感染、腹腔內膿腫、再次手術或再入院之間沒有關聯[132]。

Data from NSQIP-Pediatrics demonstrated that a 16-h delay from emergency department presentation or a 12-h delay from hospital admission to appendectomy was not associated with an increased risk of SSI. Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between emergency department triage and appendectomy (11.5  h vs 9.7  h, P  =  0.36) and similar times from admission to appendectomy (5.5  h vs 4.3  h, P  =  0.36). Independent risk factors for SSI were complicated AA, longer symptom duration, and presence of sepsis/septic shock [133].
NSQIP-Pediatrics 的數據表明，急診科就診延遲 16 小時或入院到闌尾切除術延遲 12 小時與 SSI 風險增加無關。與未發生 SSI 的患者相比，發生 SSI 的患者急診分診與闌尾切除術的時間相似（11.5 h vs 9.7 h，P = 0.36），從入院到闌尾切除術的時間相似（5.5 h vs 4.3 h，P = 0.36）。SSI 的獨立危險因素為複雜性 AA、癥狀持續時間較長、存在膿毒症/膿毒性休克[133]。

Gurien et al. retrospectively analyzed data from 484 children who underwent appendectomy at 6, 8, and 12 h from admission for AA and reported a mean elapsed time from admission to theatre of 394 min. SSIs, appendiceal perforations, and small bowel obstructions were similar between early and delayed groups, and no statistically significant differences were found for SSIs in the non-perforated delayed versus immediate groups. Time from admission to theatre did not predict perforation, whereas WBC count at the time of admission was a significant predictor of perforation (OR 1.08; P < 0.001) [134].
回顧性分析了 484 名在入院 6、8 和 12 小時接受闌尾切除術的兒童的數據，報告了從入院到手術室的平均經過時間為 394 分鐘。早期組和延遲組之間的 SSI、闌尾穿孔和小腸梗阻相似，未發現非穿孔延遲組與即刻組的 SSI 差異有統計學意義。從入院到手術室的時間不能預測穿孔，而入院時的白細胞計數是穿孔的重要預測因數（OR 1.08;P < 0.001）[134]。

Recently, the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee developed recommendations regarding time to appendectomy for AA in children by a systematic review of the published articles between January 1, 1970, and November 3, 2016. The committee stated that appendectomy performed within the first 24 h from presentation is not associated with an increased risk of perforation or adverse outcomes [135].
最近，美國小兒外科協會結果和循證實踐委員會通過對 1970 年 1 月 1 日至 2016 年 11 月 3 日期間發表的文章進行系統回顧，制定了有關兒童 AA 闌尾切除術時間的建議。該委員會指出，在就診后 24 小時內進行闌尾切除術與穿孔或不良結局風險增加無關[135]。

Regarding complicated AA, some authors support initial antibiotics with delayed operation whereas others support immediate operation. Regarding complicated appendicitis, some authors support initial antibiotics with delayed operation whereas others support immediate operation. A population-level study with a 1-year follow-up period found that children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data support that early appendectomy is the best management in complicated AA [136].
關於複雜的 AA，一些作者支援延遲手術的初始抗生素，而另一些作者則支援立即手術。關於複雜性闌尾炎，一些作者支援延遲手術的初始抗生素，而另一些作者則支援立即手術。一項為期 1 年的人群研究發現，接受晚期闌尾切除術的兒童比接受早期闌尾切除術的兒童更容易出現併發症。這些數據支援早期闌尾切除術是複雜 AA 的最佳治療方法[136]。

Statement 3.3 Appendectomy performed within the first 24 h from presentation in the case of uncomplicated appendicitis is not associated with an increased risk of perforation or adverse outcomes. Early appendectomy is the best management in complicated appendicitis. Recommendation 3.3 We suggest against delaying appendectomy for pediatric patients with uncomplicated acute appendicitis needing surgery beyond 24 h from the admission. Early appendectomy within 8 h should be performed in case of complicated appendicitis [QoE: Low; Strength of Recommendation: Weak; 2C].
聲明 3.3 在無併發症闌尾炎的情況下，在就診后的前 24 小時內進行闌尾切除術與穿孔或不良後果的風險增加無關。早期闌尾切除術是複雜性闌尾炎的最佳治療方法。建議 3.3 對於需要手術的無併發症急性闌尾炎兒科患者，我們建議不要在入院后 24 小時後推遲闌尾切除術。如果出現複雜的闌尾炎，應在 8 小時內進行早期闌尾切除術 [QoE：低;推薦強度：弱;2C]。

Topic 4: Surgical treatment
主題 4：手術治療

Q.4.1: Does laparoscopic appendectomy confer superior outcomes compared with open appendectomy for adult patients with acute appendicitis?
Q.4.1：對於成年急性闌尾炎患者，腹腔鏡闌尾切除術是否比開放式闌尾切除術具有更好的預後？

Several systematic reviews of RCTs comparing laparoscopic appendectomy (LA) versus open appendectomy (OA) have reported that the laparoscopic approach for AA is often associated with longer operative times and higher operative costs, but it leads to less postoperative pain, shorter length of stay, and earlier return to work and physical activity [137]. LA lowers overall hospital and social costs [138], improves cosmesis, and significantly decreases postoperative complications, in particular SSI.
幾項比較腹腔鏡闌尾切除術（laparoscopic appendectomy， LA）與開放式闌尾切除術（open appendectomy， OA）的隨機對照試驗的系統評價報告稱，腹腔鏡治療 AA 的手術時間通常較長，手術費用較高，但術后疼痛較小，住院時間較短，並能更早恢復工作和體力活動[137]。LA 可降低總體住院費用和社會費用[138]，改善美容效果，並顯著減少術后併發症，尤其是 SSI。

The 2018 updated Cochrane review on LA versus OA showed that, except for a higher rate of IAA (intra-abdominal abscess) after LA in adults, laparoscopic demonstrates advantages over OA in pain intensity on day one, SSI, length of hospital stay, and time until return to normal activity [139].
2018 年更新的關於 LA 與 OA 的 Cochrane 綜述顯示，除了成人 LA 后 IAA（腹腔內膿腫）發生率較高外，腹腔鏡在第 1 天疼痛強度、SSI、住院時間和恢復正常活動的時間方面均優於 OA[139]。

In the meta-review by Jaschinski et al. including nine systematic reviews and meta-analyses (all moderate to high quality), the pooled duration of surgery was 7.6 to 18.3 min shorter with OA. Pain scores on the first postoperative day were lower after LA in two out of three reviews. The risk of IAA was higher for LA in half of six meta-analyses, whereas the occurrence of SSI pooled by all reviews was lower after LA. LA shortened hospital stay from 0.16 to 1.13 days in seven out of eight meta-analyses [14].
在 Jaschinski 等人的 meta 綜述中，包括 9 項系統評價和 meta 分析（均為中等至高品質），OA 的合併手術持續時間縮短了 7.6 至 18.3 分鐘。在三項評價中，有兩項在 LA 後術后第一天的疼痛評分較低。在六項 meta 分析中，有一半的 LA 發生 IAA 的風險較高，而所有綜述匯總的 SSI 發生率在 LA 后較低。在 8 項 meta 分析中，LA 將住院時間從 0.16 日縮短至 1.13 日，有 8 項 meta 分析[14]。

The evidence regarding treatment effectiveness of LA versus OA in terms of postoperative IAA, however, changed over the last decade. The cumulative meta-analysis by Ukai et al. demonstrated that, of the 51 trials addressing IAA, trials published up to and including 2001 showed statistical significance in favor of OA. The effect size in favor of OA began to disappear after 2001, leading to an insignificant result with an overall cumulative OR of 1.32 (95% CI 0.84–2.10) when LA was compared with OA [140].
然而，在過去十年中，關於 LA 與 OA 在術後 IAA 方面的治療效果的證據發生了變化。Ukai 等人的累積 meta 分析表明，在涉及 IAA 的 51 項試驗中，截至 2001 年（含 2001 年）發表的試驗顯示出有利於 OA 的統計學意義。2001 年後，有利於 OA 的效應量開始消失，導致結果不顯著，當 LA 與 OA 進行比較時，總累積 OR 為 1.32（95%CI 0.84–2.10）[140]。

LA appears to have significant benefits with improved morbidity compared to OA in complicated AA as well, as demonstrated in the meta-analysis by Athanasiou et al. In the pooled analysis, LA had significantly less SSI, with reduced time to oral intake, and length of hospitalization. There was no significant difference in IAA rates. Operative time was longer during LA but did not reach statistical significance in the RCT subgroup analysis [141].
正如 Athanasiou 等人的薈萃分析所證明的那樣，與 OA 相比，LA 似乎在改善複雜 AA 的發病率方面具有顯著益處。在匯總分析中，LA 的 SSI 顯著減少，口服攝入時間縮短，住院時間縮短。IAA 率沒有顯著差異。LA 期間的手術時間較長，但在 RCT 亞組分析中未達到統計學意義[141]。

Statement 4.1 Laparoscopic appendectomy offers significant advantages over open appendectomy in terms of less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, overall costs, and better quality of life scores. Recommendation 4.1 We recommend laparoscopic appendectomy as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available [QoE: High; Strength of recommendation: Strong; 1A].
聲明 4.1 腹腔鏡闌尾切除術在疼痛更小、手術部位感染發生率更低、住院時間縮短、更早重返工作崗位、總體成本和更好的生活品質評分方面比開放式闌尾切除術具有顯著優勢。建議 4.1 對於無併發症和複雜的急性闌尾炎，我們推薦腹腔鏡闌尾切除術作為比開放式闌尾切除術的首選方法，因為在腹腔鏡設備和專業知識的情況下，有腹腔鏡設備和專業知識[QoE：高;推薦強度：強;1A]。

Q.4.2: Does laparoscopic appendectomy confer superior outcomes compared with open appendectomy for pediatric patients with acute appendicitis?
Q.4.2：腹腔鏡闌尾切除術是否比開放式闌尾切除術對急性闌尾炎兒科患者預後更好？

The laparoscopic approach to AA seems to be safe and effective in children.
腹腔鏡 AA 方法似乎對兒童安全有效。

Zhang et al. conducted a meta-analysis of nine studies to compare the influence of different surgical procedures on perforated AA in the pediatric population and found that LA was associated with lower incidence of SSI and bowel obstruction, but the rate of IAA was higher than in OA [142].
Zhang 等人對 9 項研究進行了 meta 分析，比較了不同外科手術對兒科人群穿孔 AA 的影響，發現 LA 與較低的 SSI 和腸梗阻發生率相關，但 IAA 的發生率高於 OA[142]。

Yu et al. conducted a meta-analysis of two RCTs and 14 retrospective cohort studies, showing that LA for complicated AA reduces the rate of SSIs (OR 0.28; 95% CI 0.25–0.31) without increasing the rate of postoperative IAA (OR 0.79; 95% CI 0.45–1.34). The results showed that the operating time in the LA group was longer than that of the OA groups (WMD 13.78, 95% CI 8.99–18.57), whereas the length of hospital stay in the LA groups was significantly shorter (WMD − 2.47, 95% CI − 3.75 to − 1.19), and the time to oral intake was shorter in the LA group than in the OA group (WMD − 0.88, 95% CI − 1.20 to − 0.55) [15].
Yu 等人對兩項隨機對照試驗和 14 項回顧性佇列研究進行了 meta 分析，結果顯示，複雜 AA 的 LA 可降低 SSI 的發生率（OR 0.28;95%CI 0.25–0.31），而不會增加術后 IAA 的發生率（OR 0.79;95%CI 0.45–1.34）。結果顯示，LA 組的手術時間長於 OA 組（WMD 13.78,95% CI 8.99–18.57），而 LA 組的住院時間明顯短（WMD − 2.47,95% CI − 3.75 至 − 1.19），LA 組的口服攝入時間短於 OA 組（WMD − 0.88， 95% CI − 1.20 至 − 0.55） [15]。

Statement 4.2 Laparoscopic appendectomy is associated with lower postoperative pain, lower incidence of SSI, and higher quality of life in children. Recommendation 4.2 We recommend laparoscopic appendectomy should be preferred over open appendectomy in children where laparoscopic equipment and expertise are available [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 4.2 腹腔鏡闌尾切除術與兒童術后疼痛降低、SSI 發生率降低和生活品質提高有關。建議 4.2 我們建議在有腹腔鏡設備和專業知識的兒童中，腹腔鏡闌尾切除術應優於開放式闌尾切除術 [QoE：中度;推薦強度：強;1B]。

Q.4.3: Does laparoscopic single-incision surgery confer any advantage over the three-trocar technique in performing laparoscopic appendectomy for adult patients with acute appendicitis?
Q.4.3：腹腔鏡單切口手術在對成年急性闌尾炎患者進行腹腔鏡闌尾切除術方面是否比三套管針技術具有任何優勢？

Recent studies provide level 1a evidence that single-incision laparoscopic appendectomy (SILA) is as feasible, effective, and safe as the conventional three-port LA. High-level meta-analyses conducted in adults, although demonstrating no significant difference in the safety of SILA versus that of three-port LA, have not supported the application of SILA because of its significantly longer operative times and the higher doses of analgesia required compared with those for three-port LA [143]. A total of 8 RCTs published between 2012 and 2014 with a total of 995 patients were included in the meta-analysis by Aly et al. No significant differences between SILA and conventional three-port laparoscopic appendectomy (CLA) was found in terms of complication rates, postoperative ileus, length of hospital stay, return to work, or postoperative pain. CLA was significantly superior to SILA with reduced operating time (mean difference 5.81 [2.01, 9.62], P = 0.003) and conversion rates (OR 4.14 [1.93, 8.91], P = 0.0003). Conversely, SILA surgery had better wound cosmesis (mean difference 0.55 [0.33, 0.77], P = 0.00001) [144].
最近的研究提供了 1a 級證據，表明單切口腹腔鏡闌尾切除術 （SILA） 與傳統的三埠 LA 一樣可行、有效和安全。在成人中進行的高水準 meta 分析顯示，與三孔 LA 相比，SILA 的安全性沒有顯著差異，但與三孔 LA 相比，SILA 的手術時間明顯更長，鎮痛劑量更高，因此不支援 SILA 的應用[143]。Aly 等人的薈萃分析納入了 2012 年至 2014 年間發表的 8 項隨機對照試驗，共 995 名患者。SILA 與常規三孔腹腔鏡闌尾切除術 （CLA） 在併發症發生率、術后腸梗阻、住院時間、重返工作崗位或術后疼痛方面無顯著差異。CLA 顯著優於 SILA，手術時間縮短（平均差 5.81[2.01,9.62]，P=0.003）和轉化率（OR4.14[1.93,8.91]，P=0.0003）。相反，SILA 手術的傷口美容效果更好（平均差 0.55[0.33,0.77]，P = 0.00001）[144]。

Statement 4.3 Single-incision laparoscopic appendectomy is basically feasible, safe, and as effective as conventional three-port laparoscopic appendectomy, operative times are longer, requires higher doses of analgesia, and is associated with a higher incidence of wound infection. Recommendation 4.3 We recommend conventional three-port laparoscopic appendectomy over single-incision laparoscopic appendectomy, as the conventional laparoscopic approach is associated with shorter operative times, less postoperative pain, and lower incidence of wound infection [QoE: High; Strength of recommendation: Strong; 1A].
聲明 4.3 單切口腹腔鏡闌尾切除術基本可行、安全，與常規三孔腹腔鏡闌尾切除術一樣有效，手術時間較長，需要更高劑量的鎮痛，並且與傷口感染發生率較高相關。建議 4.3 我們推薦常規三孔腹腔鏡闌尾切除術而不是單切口腹腔鏡闌尾切除術，因為傳統的腹腔鏡方法具有更短的手術時間、更少的術后疼痛和更低的傷口感染發生率 [QoE：高;推薦強度：強;1A]。

Q.4.4: Does laparoscopic single-incision surgery confer any advantage over the three-trocar technique in performing laparoscopic appendectomy for pediatric patients with acute appendicitis?
Q.4.4：腹腔鏡單切口手術在對兒科急性闌尾炎患者進行腹腔鏡闌尾切除術方面是否比三套管針技術具有任何優勢？

In children, two recent RCTs showed that SILA is feasible with an acceptable margin of safety, although it does not produce any significant difference in terms of analgesic use and length of hospital stay [145], and it is associated with longer operative times and more severe surgical trauma compared with the three-port technique, as measured by CRP and IL-6 levels [146]. In the large meta-analysis by Zhang et al., no significant differences were observed between SILA and CLA with respect to the incidence of total postoperative complications, IAA, ileus, wound hematoma, length of hospital stay, or the frequency of use of additional analgesics. However, SILA was associated with a higher incidence of SSI compared with three-port LA and required a longer operative time [147].
在兒童中，最近的 2 項 RCT 顯示，SILA 是可行的，安全邊際可接受，儘管它在鎮痛藥的使用和住院時間方面沒有任何顯著差異[145]，並且與 CRP 和 IL-6 水平測量的三孔技術相比，SILA 與更長的手術時間和更嚴重的手術創傷相關[146].在 Zhang 等人的大型薈萃分析中，SILA 和 CLA 在術后總併發症發生率、IAA、腸梗阻、傷口血腫、住院時間或使用額外鎮痛藥的頻率方面沒有觀察到顯著差異。然而，與三埠 LA 相比，SILA 與 SSI 的發生率更高，並且需要更長的手術時間[147]。

Karam et al. conducted a retrospective study with the aim to compare surgical outcomes of children with AA treated with the transumbilical laparoscopically assisted appendectomy (TULAA) versus the CLA and showed that TULAA had a shorter operative time (median, 40 vs 67 min; P < 0.001), a shorter length of stay (median, 20 vs 23 h; P < 0.001), and lower costs (median $6266 vs $8927; P < 0.001), even if SSI rate was slightly higher in the TULAA group (6% vs 4%; P = 0.19) [148].
Karam 等人進行了一項回顧性研究，旨在比較接受經臍腹腔鏡輔助闌尾切除術 （TULAA） 與 CLA 治療的 AA 兒童的手術結果，結果表明 TULAA 的手術時間較短（中位數，40 分鐘 vs 67 分鐘;P < 0.001），住院時間較短（中位，20 vs 23 小時;P < 0.001）和更低的成本（中位數 6266 美元對 8927 美元;P < 0.001），即使 TULAA 組的 SSI 率略高（6% vs 4%;P = 0.19） [148]。

Sekioka et al. reported that mean operative time was significantly shorter in TULAA than in CLA for both uncomplicated and complicated AA. In addition, complication rates in complicated AA were significantly lower in TULAA than in CLA. Moreover, the postoperative hospital stay was significantly shorter in TULAA than in CLA [149].
Sekioka 等人報告說，對於無併發症和複雜 AA，TULAA 的平均手術時間明顯短於 CLA。此外，TULAA 中複雜 AA 的併發症發生率顯著低於 CLA。此外，TULAA 的術后住院時間明顯短於 CLA[149]。

Statement 4.4 In children with acute appendicitis, the single incision/transumbilical extracorporeal laparoscopic-assisted technique is as safe as the laparoscopic three-port technique. Recommendation 4.4 In pediatric patients with acute appendicitis and favorable anatomy, we suggest performing single-incision/transumbilical extracorporeal laparoscopic assisted appendectomy or traditional three-port laparoscopic appendectomy based on local skills and expertise [QoE: Low; Strength of recommendation: Weak; 2C].
聲明 4.4 在患有急性闌尾炎的兒童中，單切口/經臍體外腹腔鏡輔助技術與腹腔鏡三孔技術一樣安全。建議 4.4 對於急性闌尾炎且解剖結構良好的兒科患者，我們建議根據當地技能和專長進行單切口/經臍體外腹腔鏡輔助闌尾切除術或傳統三孔腹腔鏡闌尾切除術 [QoE：低;推薦強度：弱;2C]。

Q.4.5: Is outpatient laparoscopic appendectomy safe and feasible for patients with uncomplicated acute appendicitis?
Q.4.5：對於無併發症的急性闌尾炎患者，門診腹腔鏡闌尾切除術是否安全可行？

In the USA, outpatient LA protocols are currently applied at multiple institutions with the aim to reduce the length of stay and decrease overall health care costs for AA. Results from these experiences demonstrate that outpatient LA can be performed with a high rate of success, low morbidity, and low readmission rate in the case of non-perforated AA [150]. In the study by Frazee et al., 484 patients with uncomplicated AA were managed as outpatients. Only seven patients (1.2%) were readmitted after outpatient management for transient fever, nausea/vomiting, migraine headache, urinary tract infection, partial small bowel obstruction, and deep venous thrombosis. There were no mortalities or reoperations. Including the readmissions, overall success with outpatient management was 85% [151]. The recent RCT by Trejo-Avila et al. stated that ERAS implementation for appendectomy is associated with a significantly shorter LOS, allowing for the ambulatory management of patients with uncomplicated AA. The authors concluded that ambulatory LA is safe and feasible with similar rates of morbidity and readmissions compared with conventional care [152].
在美國，目前多家機構採用門診 LA 方案，旨在縮短住院時間並降低 AA 的總體醫療保健成本。這些經驗表明，在非穿孔 AA 的情況下，門診 LA 的成功率高，併發症發生率低，再入院率低[150]。在 Frazee 等人的研究中，484 名無併發症的 AA 患者作為門診患者接受治療。僅 7 例患者（1.2%）因短暫發熱、噁心/嘔吐、偏頭痛、尿路感染、部分小腸梗阻和深靜脈血栓形成在門診治療后再次入院。沒有死亡或再次手術。包括再入院在內，門診治療的總體成功率為 85%[151]。Trejo-Avila 等人最近的隨機對照試驗指出，闌尾切除術的 ERAS 實施與顯著縮短的 LOS 相關，從而允許對無併發症的 AA 患者進行門診管理。作者得出結論，門診 LA 是安全可行的，與傳統治療相比，其併發症發生率和再入院率相似[152]。

Statement 4.5 Outpatient laparoscopic appendectomy for uncomplicated acute appendicitis is feasible and safe without any difference in morbidity and readmission rates. It is associated with potential benefits of earlier recovery after surgery and lower hospital and social costs. Recommendation 4.5 We suggest the adoption of outpatient laparoscopic appendectomy for uncomplicated appendicitis, provided that an ambulatory pathway with well-defined ERAS protocols and patient information/consent are locally established [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 4.5 門診腹腔鏡闌尾切除術治療無併發症的急性闌尾炎是可行且安全的，發病率和再入院率沒有任何差異。它與手術后早期恢復以及降低住院和社會成本的潛在好處有關。建議 4.5 對於無併發症的闌尾炎，我們建議採用門診腹腔鏡闌尾切除術，前提是當地建立了具有明確定義的 ERAS 方案和患者資訊/同意的門診途徑 [QoE：中度;推薦強度：弱;2B]。

Q.4.6: Is laparoscopic appendectomy indicated over open appendectomy in specific patient groups?
Q.4.6：在特定患者群體中，腹腔鏡闌尾切除術是否適用於開放式闌尾切除術？

LA is a safe and effective method to treat AA in specific settings such as the elderly and the obese. LA can be recommended for patients with complicated AA even with higher risk categories. In the retrospective cohort study by Werkgartner et al. investigating the benefits of LA in patients with high peri- and postoperative risk factors (ASA 3 and 4), LA was associated with slightly longer operative times and shorter hospital stay. Overall complications, graded according to the Clavien-Dindo classification, were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA [153]. For high-risk patients, LA has proven to be safe and feasible and was also associated with decreased rates of mortality, postoperative morbidity, and shorter hospitalization.
LA 是一種安全有效的方法，可以在老年人和肥胖者等特定環境中治療 AA。LA 可以推薦用於複雜 AA 患者，即使是高風險類別的患者。在 Werkgartner 等人的回顧性佇列研究中，調查了 LA 對圍手術期和術后危險因素（ASA 3 和 4）高患者的益處，LA 與手術時間稍長和住院時間較短相關。根據 Clavien-Dindo 分類，LA 術后患者的總體併發症發生率略高，而 OA 術后患者的嚴重併發症發生率更高[153]。對於高危患者，LA 已被證明是安全可行的，並且還與降低死亡率、術後發病率和縮短住院時間有關。

In the recent meta-analysis by Wang et al., 12 studies with 126,237 elderly patients in the LA group and 213,201 patients in the OA group were analyzed. Postoperative mortality, as well as postoperative complications and SSI were reduced following LA. IAA rate was similar between LA and OA. Duration of surgery was longer following LA, and the length of hospital stay was shorter following LA [154].
在 Wang 等人最近的薈萃分析中，分析了 12 項研究，涉及 126,237 名 LA 組老年患者和 213,201 名 OA 組患者。LA 後術后死亡率、術后併發症和 SSI 均有所降低。LA 和 OA 之間的 IAA 率相似。LA 術后手術時間較長，LA 術后住院時間較短[154]。

Results from the American College of Surgeons NSQIP (pediatric database) demonstrated that obesity was not found to be an independent risk factor for postoperative complications following LA. Although operative time was increased in obese children, obesity did not increase the likelihood of 30-day postoperative complications [155].
美國外科醫師學會 NSQIP（兒科資料庫）的結果表明，未發現肥胖是 LA 術后併發症的獨立危險因素。儘管肥胖兒童的手術時間增加，但肥胖並未增加術后 30d 併發症的可能性[155]。

LA also appears to be a safer alternative approach to OA in obese adult patients. In the systematic review by Dasari et al. including seven retrospective cohort studies and one randomized controlled trial, LA in obese patients was associated with reduced mortality (RR 0.19), reduced overall morbidity (RR 0.49), reduced superficial SSI (RR 0.27), and shorter operating times and postoperative length of hospital stay, compared to OA [156].
LA 似乎也是肥胖成年患者 OA 的更安全的替代方法。Dasari 等的系統評價包括 7 項回顧性佇列研究和 1 項隨機對照試驗，與 OA 相比，肥胖患者的 LA 與死亡率降低（RR 0.19）、總體發病率降低（RR 0.49）、淺表 SSI 降低（RR 0.27）以及手術時間縮短和術后住院時間相關[156]。

Despite concerns about the safety of LA during pregnancy being highlighted over the last 10 years due to a possible increase in fetal loss rate, more recent large systematic reviews and meta-analyses of comparative studies concluded that it is not reasonable to state that LA in pregnant women might be associated with a greater risk of fetal loss. Twenty-two comparative cohort studies were included in the pooled analysis by Lee et al., which involved 4694 women of whom 905 underwent LA and 3789 underwent OA. Fetal loss was significantly higher among those who underwent LA compared with those who underwent OA, with a pooled OR of 1.72. However, the sensitivity analysis showed that the effect size was influenced by one of the studies because its removal resulted in there being no significant difference between LA and OA with respect to the risk of fetal loss (OR 1.16). A significant difference was not evident between LA and OA with respect to preterm delivery (OR 0.76), and patients who underwent LA had shorter hospital stays and a lower SSI risk compared with those who underwent OA [157].
儘管由於胎兒丟失率可能增加，過去 10 年來人們對妊娠期 LA 安全性的擔憂得到了強調，但最近的大型系統評價和比較研究的薈萃分析得出的結論是，說孕婦的 LA 可能與更大的胎兒流產風險有關是不合理的。Lee 等人的匯總分析納入了 22 項比較佇列研究，涉及 4694 名女性，其中 905 名接受了 LA，3789 名接受了 OA。與接受 OA 的患者相比，接受 LA 的胎兒丟失率顯著更高，合併 OR 為 1.72。然而，敏感性分析表明，效應大小受到其中一項研究的影響，因為它的去除導致 LA 和 OA 在胎兒丟失風險方面沒有顯著差異 （OR 1.16）。LA 和 OA 在早產方面差異不明顯（OR 0.76），與 OA 患者相比，LA 患者的住院時間更短，SSI 風險更低[157]。

Statement 4.6 Laparoscopic appendectomy seems to show relevant advantages compared to open appendectomy in obese adult patients, older patients, and patients with comorbidities. Laparoscopic appendectomy is associated with reduced mortality, reduced overall morbidity, reduced superficial wound infections, and shorter operating times and postoperative length of hospital stay in such patients. Recommendation 4.6 We suggest laparoscopic appendectomy in obese patients, older patients, and patients with high peri- and postoperative risk factors [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 4.6 與開放式闌尾切除術相比，腹腔鏡闌尾切除術在肥胖成年患者、老年患者和合併症患者中似乎顯示出相關優勢。腹腔鏡闌尾切除術與降低死亡率、降低總體發病率、減少淺表傷口感染以及縮短手術時間和術后住院時間有關。建議 4.6 我們建議對肥胖患者、老年患者以及圍手術期和術后危險因素較高的患者進行腹腔鏡闌尾切除術 [QoE：中度;推薦強度：弱;2B]。

Statement 4.7 Laparoscopic appendectomy during pregnancy is safe in terms of risk of fetal loss and preterm delivery and it is preferable to open surgery as associated to shorter length of hospital stay and lower incidence of surgical site infection. Recommendation 4.7 We suggest laparoscopic appendectomy should be preferred to open appendectomy in pregnant patients when surgery is indicated. Laparoscopy is technically safe and feasible during pregnancy where expertise of laparoscopy is available [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 4.7 就胎兒流產和早產的風險而言，懷孕期間腹腔鏡闌尾切除術是安全的，並且最好進行開放手術，因為住院時間更短，手術部位感染的發生率更低。建議 4.7 我們建議在需要手術的妊娠患者中，應首選腹腔鏡闌尾切除術，而不是開放式闌尾切除術。腹腔鏡檢查在懷孕期間在技術上是安全可行的，因為有腹腔鏡檢查的專業知識 [QoE：中度;推薦強度：弱;2B]。

Q.4.7: Does aspiration alone confer clinical advantages over lavage and aspiration for patients with complicated acute appendicitis?
Q.4.7：對於複雜性急性闌尾炎患者，單獨抽吸是否比灌洗和抽吸具有臨床優勢？

The best available evidence suggests that peritoneal irrigation with normal saline during LA does not provide additional benefits compared with suction alone in terms of IAA, SSI, and length of stay, but it may prolong the operative time.
現有的最佳證據表明，在 IAA、SSI 和住院時間方面，與單獨抽吸相比，LA 期間用生理鹽水進行腹膜沖洗不會提供額外的益處，但它可能會延長手術時間。

The recent meta-analysis by Siotos et al., including more than 2500 patients from five studies, has shown that the use of irrigation, despite adding 7 min to the duration of the operation, overall did not demonstrate a significant decrease in IAA. Both for the adult and pediatric subpopulations, the use of irrigation was associated with a non-significant lower odd of IAA [158].
Siotos 等人最近的薈萃分析包括來自五項研究的 2500 多名患者，表明儘管使用沖洗使手術持續時間增加了 7 分鐘，但總體上並未顯示 IAA 顯著下降。對於成人和兒童亞群，使用沖洗與 IAA 的低幾率無顯著相關[158]。

In the same way, the large meta-analysis by Hajibandeh et al. (three RCTs and two retrospective observational studies included) demonstrated that there was no difference between peritoneal irrigation and suction alone in terms of IAA rate, SSI, and length of stay. These results remained consistent when RCTs, adult patients, and pediatric patients were analyzed separately [159]. However, the quality of the best available evidence on this point is moderate; therefore, high-quality, adequately powered randomized studies are required to provide a more robust basis for definite conclusions.
同樣，Hajibandeh 等人的大型 meta 分析（包括三項隨機對照試驗和兩項回顧性觀察性研究）表明，腹膜沖洗和單獨抽吸在 IAA 率、SSI 和住院時間方面沒有差異。當分別分析 RCT、成人患者和兒童患者時，這些結果保持一致[159]。然而，關於這一點的最佳可用證據的品質是中等的;因此，需要高品質、功效充足的隨機研究，為明確的結論提供更可靠的基礎。

Statement 4.8 Peritoneal irrigation does not have any advantage over suction alone in complicated appendicitis in both adults and children. The performance of irrigation during laparoscopic appendectomy does not seem to prevent the development of IAA and wound infections in neither adults nor pediatric patients. Recommendation 4.8 We recommend performing suction alone in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 4.8 腹膜沖洗在成人和兒童的複雜性闌尾炎中都比單獨抽吸沒有任何優勢。腹腔鏡闌尾切除術期間的沖洗效果似乎並不能阻止成人和兒童患者發生 IAA 和傷口感染。建議 4.8 對於腹腔鏡闌尾切除術的腹腔內積聚物的複雜性闌尾炎患者，我們建議單獨進行抽吸術[QoE：中度;推薦強度：強;1B]。

Q.4.8: Does the type of mesoappendix dissection technique (endoclip, endoloop, electrocoagulation, Harmonic Scalpel, or LigaSure) produce different clinical outcomes for patients with acute appendicitis undergoing appendectomy?
Q.4.8：闌尾系膜夾層技術（內夾、內環、電凝、諧波手術刀或 LigaSure）的類型是否會對接受闌尾切除術的急性闌尾炎患者產生不同的臨床結果？

Simplified and cost-effective techniques for LA have been described. They use either two endoloops, securing the blood supply, or a small number of endoclips.
已經描述了簡化且具有成本效益的 LA 技術。他們使用兩個內環來確保血液供應，或者使用少量內夾。

In the case of an inflamed and edematous mesoappendix, it has been suggested that the use of LigaSure^TM, especially in the presence of gangrenous tissue, may be advantageous [160, 161]. Despite the potential advantages, LigaSure ^TM represents a high-cost option and it may be logical using endoclips if the mesoappendix is not edematous. Diamantis et al. compared LigaSure^TM and Harmonic Scalpel with monopolar electrocoagulation and bipolar coagulation: the first two caused more minimal thermal injury of the surrounding tissue than other techniques [162]. Recently, significantly higher thermal damage was found on the mesoappendix and appendiceal base in patients treated with LigaSure ^TM than in patients for whom Harmonic Scalpel was used during LA [163].
對於闌尾中膜發炎和水腫，有人認為使用 LigaSure^TM 可能是有益的，尤其是在存在壞疽組織的情況下[160,161]。 儘管有潛在的優勢，但 LigaSure ^TM 是一種高成本的選擇，如果闌尾系膜沒有水腫，使用內夾可能是合乎邏輯的。Diamantis 等將 LigaSure^TM 和 Harmonic Scalpel 與單極電凝和雙極凝血進行了比較：前兩種技術對周圍組織的熱損傷比其他技術更小[162]。最近，在接受 LigaSure ^TM 治療的患者中，闌尾中膜和闌尾基部的熱損傷明顯高於在 LA 期間使用諧波手術刀的患者[163]。

Monopolar electrocoagulation, being safe, quick, and related to very low rates of complications and conversion to OA, can be considered the most cost-effective method for mesoappendix dissection in LA [164]. A recent retrospective cohort study by Wright et al. has proposed that the use of a single stapler line for transection of the mesoappendix and appendix as a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes [165].
單極電凝安全、快速，併發症發生率和轉化為 OA 的發生率極低，可被認為是 LA 闌尾系膜清掃術最具成本效益的方法[164]。Wright 等人最近的一項回顧性佇列研究提出，使用單根吻合器線橫切闌尾系膜和闌尾是一種安全有效的技術，可以縮短手術時間，並取得良好的手術效果[165]。

Statement 4.9 There are no clinical differences in outcomes, length of hospital stay, and complication rates between the different techniques described for mesentery dissection (monopolar electrocoagulation, bipolar energy, metal clips, endoloops, LigaSure, Harmonic Scalpel, etc.). Recommendation 4.9 We suggest the use of monopolar electrocoagulation and bipolar energy as they are the most cost-effective techniques, whereas other energy devices can be used depending on the intra-operative judgment of the surgeon and resources available [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 4.9 描述的腸系膜剝離的不同技術（單極電凝、雙極能量、金屬夾、內環、LigaSure、諧波手術刀等）在結果、住院時間和併發症發生率方面沒有臨床差異。建議 4.9 我們建議使用單極電凝和雙極能量，因為它們是最具成本效益的技術，而可以使用其他能量設備，具體取決於外科醫生的術中判斷和可用資源 [QoE：中等;推薦強度：弱;2B]。

Q.4.9: Does the type of stump closure technique (stapler or endoloop, ligation or invagination of the stump) produce different clinical outcomes for patients with acute appendicitis undergoing appendectomy?
Q.4.9：殘端閉合技術的類型（吻合器或內環、結紮或殘端內陷）是否會對接受闌尾切除術的急性闌尾炎患者產生不同的臨床結果？

The stump closure may vary widely in practice and the associated costs can be significant. While earlier studies initially reported advantages with routine use of endostaplers in terms of complication and operative times, more recent studies have repeatedly demonstrated no differences in intra- or postoperative complications between either endostapler or endoloops stump closure [166].
樹樁閉合在實踐中可能差異很大，相關成本可能很高。雖然早期研究最初報導了常規使用內吻合器在併發症和手術時間方面的優勢，但最近的研究一再證明，內吻合器或內環殘端閉合術在術中或術后併發症方面沒有差異[166]。

Recent evidence shows that the use of Hem-O-Lok (HOL) clips is safe and reduced the costs of the procedure in comparison to the use of endoloops. In the study by Al-Termini et al., HOL clip use was associated with lower overall complications rate compared with endoloops. The minimum endoloop cost per single appendectomy was $273.13, while HOL clip cost was $32.14 [167].
最近的證據表明，與使用內環相比，使用 Hem-O-Lok （HOL） 夾子是安全的，並且降低了手術成本。在 Al-Termini 等人的研究中，與內環相比，使用 HOL 夾與較低的總體併發症發生率相關。每次闌尾切除術的最低內環費用為 273.13 美元，而 HOL 夾子費用為 32.14 美元[167]。

The multicenter prospective observational study by Van Rossem et al. has demonstrated that the infectious complication rate is not influenced by the type of appendicular stump closure when comparing endoloops or an endostapler. Median operating time was not different between endoloop and endostapler use (42.0 vs 44.0 min) and no significant effect of stump closure type was observed for any infectious complication or IAA. In multivariable analysis, complicated AA was identified as the only independent risk factor for IAA [168].
Van Rossem 等人的多中心前瞻性觀察研究表明，在比較內環或內吻合器時，感染併發症發生率不受闌尾殘端閉合類型的影響。內環和內膜釘劑使用之間的中位手術時間沒有差異（42.0 與 44.0 分鐘），並且沒有觀察到殘端閉合類型對任何感染併發症或 IAA 的顯著影響。在多變數分析中，複雜性 AA 被確定為 IAA 的唯一獨立危險因素[168]。

In the same way, the large systematic review and meta-analysis by Ceresoli et al. showed that in complicated AA, the stump closure technique did not affect outcomes. A total of 5934 patients from 14 studies were included in the analysis. Overall, endostapler use was associated with a similar IAA rate but a lower incidence of SSI, whereas the length of stay and readmission and reoperation rates were similar [169].
同樣，Ceresoli 等人的大型系統評價和薈萃分析表明，在複雜的 AA 中，樹樁閉合技術不會影響結果。來自 14 項研究的 5934 名患者被納入分析。總體而言，使用內吻合器與 IAA 發生率相似，但 SSI 發生率較低，而住院時間、再入院率和再手術率相似[169]。

The most recent Cochrane review comparing mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated AA included eight RCTs encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. No differences in total complications, intra-operative complications, or postoperative complications between ligature and all types of mechanical devices were found. However, the analyses of secondary outcomes revealed that the use of mechanical devices saved approximately 9 min of the total operating time when compared with the use of a ligature, even though this result did not translate into a clinically or statistically significant reduction in inpatient hospital stay [170].
最近的 Cochrane 綜述比較了機械闌尾殘端閉合（吻合器、夾子或電熱裝置）與結紮（內環、Roeder 環或體內結技術）治療無併發症的 AA，包括 8 項隨機對照試驗，涉及 850 名受試者。五項研究比較了鈦夾與結紮，兩項研究比較了內窺鏡吻合器裝置與結紮，一項研究比較了內窺鏡吻合器裝置、鈦夾和結紮。未發現結紮與所有類型機械裝置之間總併發症、術中併發症或術后併發症的差異。然而，次要結局分析顯示，與使用結紮線相比，使用機械裝置可節省約 9min 的總手術時間，儘管這一結果並未轉化為住院住院時間的臨床或統計學顯著縮短[170]。

Recently, 43 randomized controlled trials enrolling over 5,000 patients were analyzed in the network meta-analysis by Antoniou et al. The authors concluded that the use of suture ligation of the appendix in LA seems to be superior to other methods for the composite parameters of organ/space and superficial operative site infection [171].
最近，Antoniou 等人在網路薈萃分析中分析了 43 項隨機對照試驗，招募了 5,000 多名患者。作者得出結論，在 LA 中，在器官/間隙和淺表手術部位感染的複合參數方面，使用縫合結紮闌尾似乎優於其他方法[171]。

Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in LA for AA. In the recent meta-analysis by Knight et al. including over 700 patients, polymeric clips were found to be the cheapest method (€20.47 average per patient) and had the lowest rate of complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of in-patient stay were similar between groups [172].
目前的證據表明，聚合物夾是 AA LA 樹樁閉合的一種有效且具有成本效益的方法。在 Knight 等人最近的薈萃分析中，包括 700 多名患者，發現聚合物夾是最便宜的方法（每位患者平均 20.47 歐元），與其他常用的閉合方法相比，併發症發生率最低 （2.7%）。同時，各組的手術時間和住院時間相似[172]。

Many studies compared the simple ligation and the stump inversion and no significant difference was found. Eleven RCTs (2634 patients) were included in the systematic review and meta-analysis by Qian et al. Postoperative pyrexia and infections were similar between simple ligation and stump inversion groups, respectively, but the former group had a shorter operative time, less incidence of postoperative ileus, and quicker postoperative recovery. The clinical results revealed that simple ligation was significantly superior to stump inversion [173].
許多研究比較了簡單結紮和殘端倒置，沒有發現顯著差異。Qian 等人的系統評價和 meta 分析納入了 11 項 RCT（2634 名患者）。單純結紮組和殘端倒置組術后發熱和感染情況相近，但前一組手術時間較短，術后腸梗阻發生率較低，術后恢復較快。臨床結果顯示，簡單結扎明顯優於殘端倒置[173]。

Statement 4.10 There are no clinical advantages in the use of endostaplers over endoloops for stump closure for both adults and children in either simple or complicated appendicitis, except for a lower incidence of wound infection when using endostaplers in children with uncomplicated appendicitis. Polymeric clips may be the cheapest and easiest method (with shorter operative times) for stump closure in uncomplicated appendicitis. Recommendation 4.10 We recommend the use of endoloops/suture ligation or polymeric clips for stump closure for both adults and children in either uncomplicated or complicated appendicitis, whereas endostaplers may be used when dealing with complicated cases depending on the intra-operative judgment of the surgeon and resources available [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 4.10 對於單純性或複雜性闌尾炎的成人和兒童，使用內塞口封口器比內環沒有臨床優勢，除了在患有無併發症的闌尾炎兒童中使用內塞口封口器時傷口感染的發生率較低。聚合物夾可能是單純性闌尾炎殘端閉合最便宜、最簡單的方法（手術時間更短）。建議 4.10 對於無併發症或複雜性闌尾炎的成人和兒童，我們建議使用內環/縫合結紮或聚合物夾來閉合殘端，而在處理複雜病例時，可以使用內吻合器，具體取決於外科醫生的術中判斷和可用資源 [QoE：中度;推薦強度：強;1B]。

Statement 4.11 Simple ligation should be preferred to stump inversion, either in open or laparoscopic surgery, as the major morbidity and infectious complications are similar. Simple ligation is associated with shorter operative times, less postoperative ileus and quicker recovery. Recommendation 4.11 We recommend simple ligation over stump inversion either in open and laparoscopic appendectomy [QoE: High; Strength of recommendation: Strong; 1A].
聲明 4.11 無論是在開放手術還是腹腔鏡手術中，單純結紮術都應優於殘端內翻術，因為主要發病率和感染併發症相似。簡單結紮與更短的手術時間、更少的術后腸梗阻和更快的恢復有關。建議 4.11 我們建議在開放式闌尾切除術和腹腔鏡闌尾切除術中進行簡單結紮而不是殘端內翻術 [QoE：高;推薦強度：強;1A]。

Q.4.10: Is the use of abdominal drains recommended after appendectomy for complicated acute appendicitis in adult patients?
Q.4.10：對於成年患者複雜的急性闌尾炎，是否建議在闌尾切除術后使用腹部引流管？

The updated 2019 Cochrane review on the issue included six RCTs (521 participants), comparing abdominal drainage and no drainage in patients undergoing emergency OA for complicated AA. The authors found that there was insufficient evidence to determine the effects of abdominal drainage and no drainage on intra-peritoneal abscess or for SSI at 14 days. The increased risk of a 30-day overall complication rate in the drainage group was rated as very low-quality evidence, as well as the evidence that drainage increases hospital stay by 2.17 days compared to the no drainage group. Thus, there is no evidence for any clinical improvement by using abdominal drainage in patients undergoing OA for complicated AA [174].
關於該問題的更新的 2019 年 Cochrane 綜述包括六項隨機對照試驗（521 名受試者），比較了因複雜 AA 而接受緊急 OA 的患者的腹部引流和不引流。作者發現，沒有足夠的證據來確定腹部引流和不引流對腹膜內膿腫或 14 天時 SSI 的影響。引流組 30 天總體併發症發生率增加的風險被評為極低質量證據，以及與不引流組相比引流使住院時間增加 2.17 天的證據。因此，沒有證據表明，對於接受 OA 治療併發併發症 AA 的患者，使用腹部引流術可改善臨床[174]。

Low-quality studies have reported that routine drainage has not proven its utility and seems to cause more complications, higher length of hospital stay, and transit recovery time [175]. In the large retrospective cohort study by Schlottmann et al. the placement of intra-abdominal drains in complicated AA did not present benefits in terms of reduced IAA and even lengthened hospital stay [176].
低品質研究報告稱，常規引流尚未證明其效用，似乎會導致更多併發症、更長的住院時間和轉運恢復時間[175]。在 Schlottmann 等的大型回顧性佇列研究中，在複雜 AA 中放置腹腔內引流管在降低 IAA 甚至延長住院時間方面沒有帶來益處[176]。

Statement 4.12 In adult patients, the use of drains after appendectomy for perforated appendicitis and abscess/peritonitis should be discouraged. Drains are of no benefit in preventing intra-abdominal abscess and lead to longer length of hospitalization, and there is also low-quality evidence of increased 30-day morbidity and mortality rates in patients in the drain group. Recommendation 4.12 We recommend against the use of drains following appendectomy for complicated appendicitis in adult patients [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 4.12 對於成年患者，應不鼓勵闌尾切除術后使用引流管治療闌尾穿孔炎和膿腫/腹膜炎。引流管對預防腹腔內膿腫沒有益處，並導致住院時間延長，而且還有低質量證據表明引流組患者的 30 天發病率和死亡率增加。建議 4.12 對於成人患者的複雜性闌尾炎，我們建議不要在闌尾切除術后使用引流管[QoE：中度;推薦強度：強;1B]。

Q.4.11: Is the use of abdominal drains recommended after appendectomy for complicated acute appendicitis in pediatric patients?
Q.4.11：對於兒科患者複雜的急性闌尾炎，是否建議在闌尾切除術后使用腹部引流管？

The prophylactic use of abdominal drainage after LA for perforated AA in children does not prevent postoperative complications and may be associated with negative outcomes.
LA 術后預防性使用腹腔引流治療兒童穿孔 AA 並不能預防術后併發症，並可能與不良結局相關。

Aneiros Castro et al. retrospectively analyzed 192 pediatric patients (mean age of 7.77 ± 3.4 years) undergoing early LA for perforated AA and reported that there were no statistically significant differences between the drain and no drain groups in the rate of IAA, SSI, and bowel obstruction. However, drains were statistically associated with an increased requirement for antibiotic and analgesic medication, fasting time, operative time, and length of hospital stay [177].
Aneiros Castro 等人回顧性分析了 192 例早期 LA 治療穿孔 AA 的兒科患者（平均年齡 7.77 歲±3.4 歲），報告引流組和無引流組在 IAA、SSI 和腸梗阻發生率方面無統計學意義差異。然而，引流與抗生素和鎮痛藥物需求增加、禁食時間、手術時間和住院時間增加有統計學意義[177]。

Statement 4.13 The prophylactic use of abdominal drainage after laparoscopic appendectomy for perforated appendicitis in children does not prevent postoperative complications and may be associated with negative outcomes. Recommendation 4.13 We suggest against the prophylactic use of abdominal drainage after laparoscopic appendectomy for complicated appendicitis in children [QoE: Low; Strength of recommendation: Weak; 2C].
聲明 4.13 腹腔鏡闌尾切除術治療兒童穿孔闌尾炎后預防性使用腹部引流並不能預防術后併發症，並且可能與不良結局有關。建議 4.13 我們建議不要在腹腔鏡闌尾切除術后預防性使用腹部引流治療兒童複雜性闌尾炎 [QoE：低;推薦強度：弱;2C]。

Q.4.12: What are the best methods to reduce the risk of SSI in open appendectomies with contaminated/dirty wounds?
Q.4.12：降低傷口受污染/骯髒的開放性闌尾切除術中 SSI 風險的最佳方法是什麼？

Wound edge protectors significantly reduce the rate of SSI in open abdominal surgery. The systematic review and meta-analysis by Mihaljevic et al. (16 randomized controlled trials including 3695 patients investigating wound edge protectors published between 1972 and 2014) showed that wound edge protectors significantly reduced the rate of SSI (RR 0.65). A similar effect size was found in the subgroup of patients undergoing colorectal surgery (RR 0.65). Of the two common types of wound protectors, double-ring devices were found to exhibit a greater protective effect (RR 0.29) than single-ring devices (RR 0.71) [178].
傷口邊緣保護器可顯著降低開腹手術中 SSI 的發生率。Mihaljevic 等人的系統評價和薈萃分析（1972 年至 2014 年間發表的 16 項隨機對照試驗，包括 3695 名研究傷口邊緣保護劑的患者）表明，傷口邊緣保護劑可顯著降低 SSI 發生率（RR 0.65）。在接受結直腸手術的患者亞組中發現了類似的效應大小 （RR 0.65）。在兩種常見的傷口保護器中，雙環裝置比單環裝置（RR 0.71）表現出更大的保護作用（RR 0.29）[178]。

The use of ring retractors showed some evidence of SSI reduction (RR 0.44) in the meta-analysis by Ahmed et al., which included four RCTs with 939 patients. On subgroup analysis, ring retractor was more effective in more severe degrees of appendiceal inflammation (contaminated group) [179].
在 Ahmed 等人的薈萃分析中，使用環牽開器顯示出一些 SSI 減少的證據 （RR 0.44），其中包括四項隨機對照試驗，涉及 939 名患者。亞組分析顯示，環牽開器在更嚴重程度的闌尾炎症（污染組）中更有效[179]。

A recent RCT comparing primary and delayed primary wound closure in complicated AA showed that the superficial SSI rate was lower in patients who underwent primary wound closure than delayed primary wound closure (7.3% vs 10%), although the risk difference of − 2.7% was not statistically significant. Postoperative pain, length of stay, recovery times, and quality of life were nonsignificantly different with corresponding risk differences of 0.3, − 0.1, − 0.2, and 0.02, respectively. However, costs for primary wound closure were lower than delayed primary wound closure [180].
最近一項比較複雜 AA 中原發性傷口閉合和延遲原發性傷口閉合的隨機對照試驗表明，接受原發性傷口閉合的患者淺表 SSI 率低於延遲原發性傷口閉合的患者（7.3% vs 10%），儘管 -2.7% 的風險差異沒有統計學意義。術后疼痛、住院時間、恢復時間和生活質量差異不顯著，相應的風險差異分別為 0.3、− 0.1、− 0.2 和 0.02。然而，原發性創面閉合的費用低於延遲原發性創面閉合[180]。

In the RCT by Andrade et al. comparing skin closure with a unique absorbable intradermal stitch and traditional closure technique (non-absorbable separated stitches), OA skin closure with the former has shown to be safe, with a reduced seroma and abscess incidence and an equivalent dehiscence and superficial SSI incidence. Furthermore, the relative risk of complications with traditional skin closure was 2.91 higher, compared to this new technique [181].
在 Andrade 等人的隨機對照試驗中，將皮膚閉合與獨特的可吸收皮內縫合和傳統閉合技術（不可吸收的分離縫合）進行比較，前者將 OA 皮膚閉合證明是安全的，血清腫和膿腫的發生率降低，裂開和淺表 SSI 發生率相當。此外，與這種新技術相比，傳統皮膚閉合併發症的相對風險高出 2.91[181]。

Statement 4.14 The use of wound ring protectors shows some evidence of surgical site infection reduction in open appendectomy, especially in case of complicated appendicitis with contaminated/dirty wounds. Recommendation 4.14 We recommend wound ring protectors in open appendectomy to decrease the risk of SSI [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 4.14 使用傷口環保護器顯示出開放性闌尾切除術中手術部位感染減少的一些證據，特別是在傷口受污染/骯髒的複雜闌尾炎的情況下。建議 4.14 我們建議在開放性闌尾切除術中使用傷口環保護器，以降低 SSI 的風險 [QoE：中度;推薦強度：強;1B]。

Statement 4.15 Delayed primary skin closure increases the length of hospital stay and overall costs in open appendectomies with contaminated/dirty wounds and does not reduce the risk of SSI. Subcuticular suture seems preferable in open appendectomy for acute appendicitis as it is associated with a lower risk of complications (surgical site infection/abscess and seroma) and lower costs. Recommendation 4.15 We recommend primary skin closure with a unique absorbable intradermal suture for open appendectomy wounds [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 4.15 延遲原發性皮膚閉合會增加傷口受污染/骯髒的開放性闌尾切除術的住院時間和總體費用，並且不會降低 SSI 的風險。皮下縫合似乎更適合急性闌尾炎的開放性闌尾切除術，因為它具有較低的併發症（手術部位感染/膿腫和血清腫）的風險和較低的成本。建議 4.15 對於開放性闌尾切除術傷口，我們建議使用獨特的可吸收皮內縫合線進行初次皮膚閉合 [QoE：中度;推薦強度：弱;2B]。

Topic 5: Intra-operative grading of acute appendicitis
主題 5：急性闌尾炎的術中分級

Q.5.1: What is the value of scoring systems for intra-operative grading of acute appendicitis?
Q.5.1：評分系統對急性闌尾炎術中分級的價值是什麼？

There is considerable variability in the intra-operative classification of AA. In the multicenter cohort study by Strong et al. involving 3,138 patients, the overall disagreement between the surgeon and the pathologist was reported in 12.5% of cases (moderate reliability, k 0.571). Twenty-seven percent of appendices assessed as normal by the surgeon revealed inflammation at histopathological assessment, while 9.6% of macroscopically appearing inflamed AA revealed to be normal [182].
AA 的術中分類存在相當大的差異。在 Strong 等人涉及 3,138 名患者的多中心佇列研究中，12.5% 的病例報告了外科醫生和病理學家之間的總體分歧（中等可靠性，k 0.571）。經外科醫生評估為正常的闌尾中，有 27%的在組織病理學評估中顯示炎症，而肉眼可見的發炎 AA 中有 9.6%顯示為正常[182]。

In 2018, a survey among Dutch surgeons demonstrated that a clear standard of care is missing both in patient selection and in determining the length of antibiotic treatment following appendectomy. However, the authors assessed the inter-observer variability in the classification of AA during laparoscopy and demonstrated that agreement was minimal for both the classification of AA (κ score 0.398) and the decision to prescribe postoperative antibiotic treatment (κ score 0.378) [183].
2018 年，一項針對荷蘭外科醫生的調查表明，在患者選擇和確定闌尾切除術后抗生素治療的持續時間方面都缺乏明確的護理標準。然而，作者評估了腹腔鏡檢查中 AA 分類的觀察者間差異，並證明 AA 分類（κ 評分 0.398）和術后抗生素治療的決定（κ 評分 0.378）的一致性微乎其微[183]。

The definition of complicated AA varies among studies. Apart from the common component of perforation, it may or may not also include non-perforated gangrenous AA, the presence of a fecalith and/or AA in the presence of pus, or purulent peritonitis, or abscess.
複雜性 AA 的定義因研究而異。除了穿孔的常見成分外，它可能還包括也可能不包括非穿孔壞疽性 AA、存在膿液的情況下存在糞便和/或 AA，或化膿性腹膜炎或膿腫。

Although most surgeons agree that AA with perforation, intra-abdominal abscess, or purulent peritonitis can be defined as complicated AA, for which postoperative antibiotic therapy is indicated, there is still a considerable variation in the indications for prolonged antibiotic therapy after appendectomy, and the antibiotic regimen that should be used [184].
儘管大多數外科醫生認為 AA 伴穿孔、腹腔內膿腫或化膿性腹膜炎可定義為複雜性 AA，術后需要抗生素治療，但闌尾切除術后長期抗生素治療的指征和應使用的抗生素方案仍存在相當大的差異[184]。

As the intra-operative classification of AA dictates the patient’s postoperative management, such variation in practice may influence clinical outcomes, and standardization may impact the appropriate use of antibiotics worldwide given the issue of rising antimicrobial resistance.
由於 AA 的術中分類決定了患者的術後管理，因此這種實踐差異可能會影響臨床結果，並且鑒於抗菌素耐藥性上升的問題，標準化可能會影響全球範圍內抗生素的適當使用。

In order to evaluate the appendix during diagnostic laparoscopy, in 2013, Hamminga et al. proposed the LAPP (Laparoscopic APPendicitis) score (six criteria), with a single-center prospective pilot study (134 patients), reporting high positive and negative predictive values (99% and 100%, respectively) [185]. In 2015, Gomes et al. proposed a grading system for AA that incorporates clinical presentation, imaging, and laparoscopic findings. The system, encompassing four grades (0 = normal looking appendix, 1 = inflamed appendix, 2 = necrosis, 3 = inflammatory tumor, 4 = diffuse peritonitis) provides a standardized classification to allow more uniform patient stratification for AA research and to aid in determining optimal management according to the grade of the disease [186].
為了評估診斷性腹腔鏡檢查中的闌尾，2013 年，Hamminga 等提出了 LAPP（腹腔鏡 APPendicitis）評分（6 項標準），並進行了一項單中心前瞻性試驗研究（134 例患者），報告了較高的陽性和陰性預測值（分別為 99%和 100%）[185]。2015 年，Gomes 等人提出了一種 AA 分級系統，該系統結合了臨床表現、影像學和腹腔鏡檢查結果。該系統包括 4 個等級（0 = 闌尾正常，1 = 闌尾發炎，2 = 壞死，3 = 炎性腫瘤，4 = 瀰漫性腹膜炎），提供標準化分類，以便對 AA 研究進行更統一的患者分層，並有助於根據疾病分級確定最佳治療 [186]。

In 2018, the WSES grading system was validated in a prospective multicenter observational study, performed in 116 worldwide surgical departments from 44 countries over a 6-month period, which showed that 3.8% of patients had grade 0, while 50.4% had grade 1, 16.8% grade 2a, 3.4% grade 2b, 8.8% grade 3a, 4.8% grade 3b, 1.9% grade 3c, and 10.0% grade 4. About half of the patients were grade 1 (inflamed appendix), and this is probably the most common situation for an emergency surgeon [186, 187].
2018 年，WSES 分級系統在一項前瞻性多中心觀察性研究中得到了驗證，該研究在 44 個國家的 116 個外科科室進行了為期 6 個月的調查，結果顯示 3.8% 的患者為 0 級，而 50.4% 的患者為 1 級，16.8% 為 2a 級，3.4% 為 2b 級，8.8% 為 3a 級，4.8% 為 3b 級，1.9% 為 3c 級， 和 10.0% 的 4 級。大約一半的患者是 1 級（闌尾發炎），這可能是急診外科醫生最常見的情況[186,187]。

In 2014, the AAST also proposed a system for grading the severity of emergency general surgery diseases based on several criteria encompassing clinical, imaging, endoscopic, operative, and pathologic findings, for eight commonly encountered gastrointestinal conditions, including AA, ranging from grade I (mild) to grade V (severe) [188]. In 2017, Hernandez et al. validated this system in a large cohort of patients with AA, showing that increased AAST grade was associated with open procedures, complications, and length of stay. AAST grade in emergency for AA determined by preoperative imaging strongly correlated with operative findings [189]. In 2018, the same researchers assessed whether the AAST grading system corresponded with AA outcomes in a US pediatric population. Results showed that increased AAST grade was associated with increased Clavien-Dindo severity of complications and length of hospital stay [190].
2014 年，AAST 還提出了一套系統，根據臨床、影像學、內窺鏡、手術和病理表現等多項標準對普通外科急診疾病的嚴重程度進行分級，適用於包括 AA 在內的 8 種常見胃腸道疾病，範圍從 I 級（輕度）到 V 級（重度）[188]。2017 年，Hernandez 等人在一大群 AA 患者中驗證了該系統，表明 AAST 等級的增加與開放手術、併發症和住院時間有關。術前影像學檢查確定的 AA 急診 AAST 分級與手術表現密切相關[189]。2018 年，同一位研究人員評估了 AAST 分級系統是否與美國兒科人群的 AA 結果相對應。結果顯示，AAST 分級升高與 Clavien-Dindo 併發症嚴重程度和住院時間增加有關[190]。

Moreover, increasing anatomic severity, as defined by AAST grade, has shown to be associated with increasing costs. Length of stay exhibited the strongest association with costs, followed by AAST grade, Clavien-Dindo Index, age-adjusted Charlson score, and surgical wound classification [191]. In 2019, a study by Mällinen et al. corroborated the known clinical association of an appendicolith to complicated AA. The study’s purpose was to assess differences between uncomplicated CT confirmed AA and AA presenting with appendicolith with two prospective patient cohorts. Using multivariable logistic regression models adjusted for age, gender, and symptom duration, statistically significant differences were detected in the depth of inflammation ≤ 2.8 mm (adjusted OR 2.18 (95% CI 1.29–3.71, P = 0.004), micro-abscesses (adjusted OR 2.16 (95% CI 1.22–3.83, P = 0.008), the number of eosinophils and neutrophils ≥ 150/mm² (adjusted OR 0.97 (95% CI 0.95–0.99, P = 0.013), and adjusted OR 3.04 (95% CI 1.82–5.09, P < 0.001, respectively) between the two groups of patients [108].
此外，根據 AAST 等級的定義，解剖嚴重程度的增加已被證明與成本的增加有關。住院時間與費用的相關性最強，其次是 AAST 分級、Clavien-Dindo 指數、年齡調整 Charlson 評分和手術傷口分類[191]。2019 年，Mällinen 等人的一項研究證實了闌尾結石與複雜 AA 的已知臨床關聯。該研究的目的是評估兩個前瞻性患者佇列的無併發症 CT 確認 AA 和伴有闌尾結石的 AA 之間的差異。使用根據年齡、性別和癥狀持續時間調整的多變數 logistic 回歸模型，在炎症深度≤2.8 mm（調整后的 OR 2.18（95%CI 1.29–3.71，P = 0.004）、微膿腫（調整后的 OR 2.8 mm（調整后的 OR 2.18（95%CI 1.29–3.71，P = 0.004）、微膿腫（調整后的 OR 2.8 mm（調整后的 OR 2.8 mm（調整后的 OR 2.18（調整后的 OR 2.18（95%CI 1.29–3.71，P = 0.004）、微膿腫（調整后的 OR 2.8 mm（調整后的 OR 2.18（95%CI 1.29–3.71，P = 0.00 16（95%CI 1.22–3.83，P = 0.008）、嗜酸性粒細胞和中性粒細胞數量≥150/^mm2（調整后的 OR 0.97（95%CI 0.95–0.99， P = 0.013），調整后的 OR 為 3.04（分別為 95%CI 1.82–5.09，P < 0.001）[108]。

The Sunshine Appendicitis Grading System score (SAGS) can be used to simply and accurately classify the severity of AA, to independently predict the risk of intra-abdominal collection and guide postoperative antibiotic therapy [192].
陽光闌尾炎分級系統評分（sunshine appendicitis grading system， SAGS）可用於簡單準確地對 AA 的嚴重程度進行分類，獨立預測腹腔內收集的風險，指導術后抗生素治療[192]。

Based on the results of a large retrospective cohort study, Farach et al. concluded that in children operative findings are more predictive of clinical course than histopathologic results. The authors found there was poor agreement between intra-operative findings and histopathologic findings, and, although 70% of patients with intra-operative findings of uncomplicated AA were labeled as complex pathology, 86% followed a fast track protocol (same-day discharge) with a low complication rate (1.7%) [193].
根據一項大型回顧性佇列研究的結果，Farach 等人得出結論，在兒童中，手術結果比組織病理學結果更能預測臨床病程。作者發現，術中表現與組織病理學表現之間的一致性較差，儘管 70%的術中發現無併發症 AA 的患者被標記為複雜病理，但 86%的患者遵循快速通道方案（當日出院），併發症發生率較低（1.7%）[193]。

Statement 5.1 The incidence of unexpected findings in appendectomy specimens is low. The intra-operative diagnosis alone is insufficient for identifying unexpected disease. From the currently available evidence, routine histopathology is necessary. Recommendation 5.1 We recommend routine histopathology after appendectomy [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 5.1 闌尾切除術標本中意外發現的發生率很低。僅靠術中診斷不足以識別意外疾病。根據目前可用的證據，常規組織病理學是必要的。建議 5.1 我們建議闌尾切除術后常規組織病理學檢查[QoE：中度;推薦強度：強;1B]。

Statement 5.2 Operative findings and intra-operative grading seem to correlate better than histopathology with morbidity, overall outcomes and costs, both in adults and children. Intra-operative grading systems can help the identification of homogeneous groups of patients, determining optimal postoperative management according to the grade of the disease and ultimately improve utilization of resources. Recommendation 5.2 We suggest the routine adoption of an intra-operative grading system for acute appendicitis (e.g., WSES 2015 grading score or AAST EGS grading score) based on clinical, imaging and operative findings [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 5.2 手術結果和術中分級似乎比組織病理學更能與成人和兒童的發病率、總體結果和費用相關。術中分級系統可以幫助識別同質性患者群體，根據疾病分級確定最佳術后管理，最終提高資源利用率。建議 5.2 我們建議根據臨床、影像學和手術結果常規採用急性闌尾炎術中分級系統（例如，WSES 2015 分級評分或 AAST EGS 分級評分）[QoE：中度;推薦強度：弱;2B]。

Q.5.2: Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found?
Q.5.2：當未發現其他解釋性病理時，是否應該在腹腔鏡檢查中切除急性右髂窩疼痛的肉眼正常闌尾？

Laparoscopic management of normal appendix still represents a dilemma for the surgeon, as no high-level evidence-based recommendations are available to date.
正常闌尾的腹腔鏡治療仍然是外科醫生的兩難境地，因為迄今為止還沒有高水準的循證建議。

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2010 guidelines stated that, if no other pathology is identified, the decision to remove the appendix should be considered, but based on the individual clinical scenario [194]. In the same way, the European Association of Endoscopic Surgery (EAES) 2016 guidelines recommended performing an appendectomy in the case of a normal appearing appendix during surgery for suspected AA [195].
美國胃腸和內鏡外科醫生協會（American Gastrointestinal and Endoscopic Surgeons， SAGES）2010 年指南指出，如果未發現其他病變，應考慮切除闌尾，但應根據個體臨床情況而定[194]。同樣，歐洲內鏡外科協會（European Association of Endoscopic Surgery， EAES）2016 年指南建議，在疑似 AA 手術中，如果闌尾正常，應進行闌尾切除術[195]。

Intra-operative macroscopic distinction between a normal appendix and AA during surgery can be challenging. Several studies have shown a 19% to 40% rate of pathologically abnormal appendix in the setting of no visual abnormalities [182, 196]. Therefore, the risk of leaving a potentially abnormal appendix must be weighed against the risk of appendectomy in each individual scenario. Cases of postoperative symptoms requiring reoperation for appendectomy have been described in patients whose normal appendix was left in place at the time of the original procedure. The risks of leaving in situ an apparently normal appendix are related to later AA, subclinical or endo-appendicitis with persisting symptoms, and missed appendiceal malignancy.
術中巨集觀區分正常闌尾和手術期間的 AA 可能具有挑戰性。多項研究表明，在無視力異常的情況下，闌尾病理異常的發生率為 19%-40%[182,196]。 因此，在每種情況下，必須權衡留下潛在異常闌尾的風險與闌尾切除術的風險。在原始手術時正常闌尾留在原位的患者中，已經描述了需要再次手術進行闌尾切除術的術后癥狀病例。將看似正常的闌尾留在原位的風險與後來的 AA、癥狀持續存在的亞臨床或內闌尾炎以及漏診闌尾惡性腫瘤有關。

According to the retrospective study by Grimes et al., including 203 appendectomies performed with normal histology, fecaliths may be the cause of right iliac fossa pain in the absence of obvious appendiceal inflammation. In this study, the policy of routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology appeared to be an effective treatment for recurrent symptoms [197]. In the same way, Tartaglia et al. supported an appendectomy in patients undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection, based on the results of a study in which 90% of the removed normal-looking appendices at laparoscopy for abdominal pain and no other intra-abdominal acute disease harbored inflammatory changes at the definitive pathology [198].
根據 Grimes 等人的回顧性研究，包括 203 例組織學正常的闌尾切除術，在沒有明顯闌尾炎症的情況下，糞便結石可能是右髂窩疼痛的原因。在這項研究中，在沒有任何其他明顯病變的情況下，在腹腔鏡檢查中常規切除外觀正常的闌尾的政策似乎是治療復發癥狀的有效方法[197]。同樣，Tartaglia 等人支援對接受腹腔鏡檢查的急性右下腹痛患者進行闌尾切除術，即使闌尾在目視檢查上看起來正常，基於一項研究結果，該研究結果在腹腔鏡檢查中切除的正常闌尾中有 90%因腹痛，並且沒有其他腹腔內急性疾病在確定性病理學上存在炎症變化[198]。

Recently, Sørensen et al. performed a retrospective cohort analysis of patients who underwent a diagnostic laparoscopy due to clinical suspicion of AA where no other pathology was found, and the appendix was not removed. Of the 271 patients included, 56 (20.7%) were readmitted with right iliac fossa pain after a median time of 10 months. Twenty-two patients (8.1%) underwent a new laparoscopic procedure, and the appendix was removed in 18 patients, of which only one showed histological signs of inflammation. Based on results from this study, the authors did not consider that it is necessary to remove a macroscopic normal appendix during laparoscopy for clinically suspected AA [199]. This year, Allaway et al. published the results of a single-centre retrospective case note review of patients undergoing LA for suspected AA. Patients were divided into positive and negative appendectomy groups based on histology results. The authors reported an overall negative appendectomy rate of 36.0% among 1413 patients who met inclusion criteria (904 in the positive group and 509 in the negative group). Morbidity rates (6.3% vs 6.9%; P = 0.48) and types of morbidity were the same for negative appendicectomy and uncomplicated AA, and there was no significant difference in complication severity or length of stay (2.3 vs 2.6 days; P = 0.06) between negative appendicectomy and uncomplicated AA groups [200].
最近，Sørensen 等人對因臨床懷疑 AA 而接受診斷性腹腔鏡檢查且未發現其他病理且未切除闌尾的患者進行了回顧性佇列分析。在納入的 271 名患者中，56 名 （20.7%） 在中位時間 10 個月後因右髂窩疼痛再次入院。22 名患者 （8.1%） 接受了新的腹腔鏡手術，18 名患者切除了闌尾，其中只有 1 名患者出現炎症組織學體征。根據這項研究的結果，作者認為對於臨床疑似 AA 患者，在腹腔鏡檢查期間沒有必要切除肉眼可見的正常闌尾[199]。今年，Allaway 等人發表了對因疑似 AA 而接受 LA 的患者進行的單中心回顧性病例記錄審查的結果。根據組織學結果將患者分為闌尾切除術陽性組和陰性組。作者報告稱，在符合納入標準的 1413 名患者中，闌尾切除術的總體陰性率為 36.0%（陽性組 904 人，陰性組 509 人）。發病率（6.3% vs 6.9%;P = 0.48），陰性闌尾切除術和無併發症 AA 的發病率類型相同，併發症嚴重程度或住院時間（2.3 天 vs 2.6 天;P = 0.06），闌尾切除術陰性組和無併發症 AA 組[200]。

The 2014 Cochrane review on the use of laparoscopy for the management of acute lower abdominal pain in women of childbearing age showed that laparoscopy was associated with an increased rate of specific diagnoses. A significant difference favoring the laparoscopic procedure in the rate of removal of normal appendix compared to open appendectomy was found [201].
2014 年關於使用腹腔鏡治療育齡婦女急性下腹痛的 Cochrane 綜述顯示，腹腔鏡檢查與特定診斷率的提高有關。與開放式闌尾切除術相比，腹腔鏡手術在正常闌尾切除率方面存在顯著差異[201]。

Statement 5.3 Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable. The variability in the intra-operative classification of appendicitis influences the decision to prescribe postoperative antibiotics and should be therefore prevented/avoided. Recommendation 5.3 We suggest appendix removal if the appendix appears “normal” during surgery and no other disease is found in symptomatic patients [QoE: Low; Strength of recommendation: Weak; 2C].
聲明 5.3 外科醫生對早期急性闌尾炎的巨集觀判斷不準確且變化很大。闌尾炎術中分類的差異會影響術后抗生素處方的決定，因此應預防/避免。建議 5.3 如果闌尾在手術中表現「正常」，且有癥狀的患者未發現其他疾病，則建議切除闌尾[QoE：低;推薦強度：弱;2C]。

Topic 6: Management of perforated appendicitis with phlegmon or abscess
主題 6：穿孔性闌尾炎伴蜂窩蜂組織炎或膿腫的治療

Q.6.1: Is early appendectomy an appropriate treatment compared with delayed appendectomy for patients with perforated acute appendicitis with phlegmon or abscess?
Q.6.1：對於伴有痰或膿腫的穿孔性急性闌尾炎患者，與延遲闌尾切除術相比，早期闌尾切除術是否是一種合適的治療方法？

The optimal approach to complicated AA with phlegmon or abscess is a matter of debate.
伴有蜂窩織物或膿腫的複雜 AA 的最佳方法存在爭議。

In the past, immediate surgery has been associated with a higher morbidity if compared with conservative treatment, while the non-surgical treatment of appendicular abscess or phlegmon has been reported to succeed in over 90% of patients, with an overall risk of recurrence of 7.4% and only 19.7% of cases of abscess requiring percutaneous drainage [202].
過去，與保守治療相比，立即手術的發病率更高，而據報導，闌尾膿腫或蜂窩織炎的非手術治療在超過 90%的患者中成功，總體復發風險為 7.4%，只有 19.7%的膿腫病例需要經皮引流[202]。

The meta-analysis by Similis et al. (including 16 non-randomized retrospective studies and one non-randomized prospective study for a total of 1572 patients, of whom 847 treated with conservative treatment and 725 with appendectomy) revealed that conservative treatment was associated with significantly less overall complications (wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and re-operations) if compared to immediate appendectomy [203].
Similis 等的 meta 分析（包括 16 項非隨機回顧性研究和 1 項非隨機前瞻性研究，共納入 1572 例患者，其中 847 例接受保守治療，725 例接受闌尾切除術）顯示，與立即闌尾切除術相比，保守治療與總體併發症（傷口感染、腹部/盆腔膿腫、腸梗阻/腸梗阻和再次手術）的相關性明顯較少[203]。

In the large series from the National Inpatient Sample (NIS) by Horn et al., 25.4% of a total of 2,209 adult patients with appendiceal abscesses who received drains failed conservative management and underwent operative intervention [204].
在 Horn 等研究的全國住院患者樣本（National Inpatient Sample， NIS）大型系列研究中，2,209 例接受引流的闌尾膿腫成年患者中，25.4%的患者保守治療失敗，並接受了手術干預[204]。

Current evidence shows that surgical treatment of patients presenting with appendiceal phlegmon or abscess is preferable to NOM with antibiotic oriented treatment in the reduction of the length of hospital stay and need for readmissions when laparoscopic expertise is available [205]. In the retrospective study by Young et al., early appendectomy has shown superior outcomes compared with initial NOM. Of 95 patients presenting with complicated AA, 60 underwent early appendectomy, and 35 initially underwent NOM. All patients who experienced failed NOM (25.7%) had an open operation with most requiring bowel resection. Early appendectomy demonstrated a lower incidence of bowel resection (3.3% vs 17.1%, P = 0.048) when compared to all patients initially undergoing NOM [206].
目前有證據表明，在腹腔鏡專業知識可縮短住院時間和再入院需要方面，對闌尾痰或膿腫患者的手術治療優於抗生素治療 NOM[205]。在 Young 等人的回顧性研究中，與初始 NOM 相比，早期闌尾切除術顯示出更好的結果。在 95 例出現複雜性 AA 的患者中，60 例接受了早期闌尾切除術，35 例最初接受了 NOM。所有經歷過 NOM 失敗的患者 （25.7%） 都接受了開放手術，其中大多數需要腸切除術。與所有最初接受 NOM 的患者相比，早期闌尾切除術的腸切除發生率較低（3.3% vs 17.1%，P = 0.048）[206]。

Recently, the cumulative meta-analysis by Gavriilidis et al. has shown a more widespread use of the laparoscopic approach for the management of complicated AA. Although overall complications, abdominal/pelvic abscesses, wound infections, and unplanned procedures were significantly lower in the conservative treatment cohort in the general analysis, on the contrary, the subgroup analysis of three RCTs revealed no significant difference in abdominal/pelvic abscesses (OR 0.46). High-quality RCTs demonstrated shorter hospital stay by 1 day for the LA cohort compared to conservative treatment [207].
最近，Gavriilidis 等人的累積薈萃分析表明腹腔鏡方法在複雜 AA 的治療中得到了更廣泛的應用。雖然在一般分析中，保守治療佇列的總體併發症、腹部/盆腔膿腫、傷口感染和計劃外手術顯著降低，但相反，3 項隨機對照試驗的亞組分析顯示腹部/盆腔膿腫無顯著差異（OR 0.46）。高品質的隨機對照試驗表明，與保守治療相比，LA 佇列的住院時間縮短了 1 天[207]。

According to the results of the Cochrane review published by Cheng et al. in 2017, it is unclear whether early appendectomy shows any benefit in terms of complications compared to delayed appendectomy for people with appendiceal phlegmon or abscess. The review included only two RCTs with a total of 80 participants. The comparison between early versus delayed open appendectomy for appendiceal phlegmon included 40 participants (pediatric and adults), randomized either to early appendectomy (appendectomy as soon as appendiceal mass resolved within the same admission, n = 20) or to delayed appendectomy (initial conservative treatment followed by interval appendectomy 6 weeks later, n = 20). There was insufficient evidence to determine the effect of using either early or delayed open appendectomy on overall morbidity (RR 13.00), the proportion of participants who developed wound infection (RR 9.00), or fecal fistula (RR 3.00). Even the quality of evidence for increased length of hospital stay and time away from normal activities in the early appendectomy group was of very low quality. The comparison between early versus delayed laparoscopic appendectomy for appendiceal abscess included 40 pediatric patients, randomized either to early appendectomy (emergent laparoscopic appendicectomy, n = 20) or to delayed appendectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later, n = 20). Health-related quality of life score measured at 12 weeks after appendectomy was higher in the early appendectomy group than in the delayed appendectomy group, but the quality of evidence was very low [208].
根據 Cheng 等人於 2017 年發表的 Cochrane 綜述結果，尚不清楚與延遲闌尾切除術相比，早期闌尾切除術是否在併發症方面顯示出對闌尾痰或膿腫患者的益處。該綜述僅納入了兩項隨機對照試驗，共 80 名受試者。闌尾痰早期開放式闌尾切除術與延遲開放式闌尾切除術之間的比較包括 40 名參與者（兒童和成人），隨機分配到早期闌尾切除術（闌尾腫塊在同一入院期間立即進行闌尾切除術，n = 20）或延遲闌尾切除術（初始保守治療，然後在 6 周後進行間隔闌尾切除術，n= 20）。沒有足夠的證據來確定使用早期或延遲開放式闌尾切除術對總體發病率（RR 13.00）、發生傷口感染（RR 9.00）或糞便瘺（RR 3.00）的受試者比例的影響。甚至早期闌尾切除術組住院時間增加和遠離正常啟用時間的證據品質也非常低。闌尾膿腫早期腹腔鏡闌尾切除術與延遲腹腔鏡闌尾切除術的比較包括 40 名兒科患者，隨機分配到早期闌尾切除術（緊急腹腔鏡闌尾切除術，n = 20）或延遲闌尾切除術（初始保守治療，10 周後間隔腹腔鏡闌尾切除術，n= 20）。闌尾切除術后 12 周測量的健康相關生活質量評分在早期闌尾切除術組中高於延遲闌尾切除術組，但證據品質非常低[208]。

The high-quality RCT by Mentula et al. (not included in the Cochrane review), conversely, demonstrated that LA in experienced hands is a safe and feasible first-line treatment for appendiceal abscess. In this study, early LA was associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay. Patients in the laparoscopy group had a 10% risk of bowel resection and 13% risk of incomplete appendectomy. There were significantly fewer patients with unplanned readmissions following LA (3% versus 27%, P = 0.026). Additional interventions were required in 7% of patients in the laparoscopy group (percutaneous drainage) and 30% of patients in the conservative group (appendectomy). Conversion to open surgery was required in 10% of patients in the laparoscopy group and 13% of patients in the conservative group. The rate of uneventful recovery was 90% in the laparoscopy group versus 50% in the conservative group (P = 0.002) [209].
相反，Mentula 等人（未納入 Cochrane 系統綜述）的高品質隨機對照試驗表明，在有經驗的手中，LA 是闌尾膿腫的一線治療方法。在這項研究中，與保守治療相比，早期 LA 與更少的再入院和更少的額外干預相關，住院時間相當。腹腔鏡組患者腸切除的風險為 10%，闌尾切除不全的風險為 13%。LA 後計劃外再入院的患者顯著減少（3% vs 27%，P = 0.026）。腹腔鏡組（經皮引流）和保守組（闌尾切除術）中 7% 的患者需要額外的干預。腹腔鏡檢查組 10% 的患者和保守組 13% 的患者需要轉為開放手術。腹腔鏡組的順利康復率為 90%，保守組為 50%（P = 0.002）[209]。

Luo et al. analyzed the outcomes of 1,225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in Taiwan. The authors compared outcomes of percutaneous drainage with antibiotics or antibiotics alone. Of 6,190 children having an appendiceal abscess, 1,225 patients received non-operative treatment. Patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent AA, significantly smaller chance of receiving an interval appendectomy, and significantly fewer postoperative complications after the interval appendectomy than those without percutaneous drainage treatment. In addition, patients treated with percutaneous drainage were significantly less indicated to receive an interval appendectomy later [210].
Luo 等分析了 2007 年至 2012 年間臺灣 1,225 名接受闌尾膿腫非手術治療的 1,225 名 18 歲以下患者的結局。作者比較了經皮引流與抗生素或單獨使用抗生素的結果。在 6,190 名患有闌尾膿腫的兒童中，有 1,225 名患者接受了非手術治療。與未接受經皮引流治療的患者相比，接受經皮引流和抗生素治療的患者 AA 復發率顯著降低，接受間歇闌尾切除術的機會顯著降低，術后併發症顯著減少。此外，接受經皮引流治療的患者晚期接受間歇闌尾切除術的指征明顯較少[210]。

Two recent meta-analyses addressed the role of early appendectomy in children with appendiceal phlegmon or abscess. The meta-analysis by Fugazzola et al. found that children with appendiceal abscess/phlegmon reported better results in terms of complication rate and readmission rate if treated with NOM [211]. Similarly, the meta-analysis by Vaos et al. reported that NOM was associated with lower rates of complications and wound infections, whereas the development of IAA and postoperative ileus was not affected by the treatment of choice [212]. In both the meta-analyses, early appendectomy was associated with reduced length of hospital stay.
最近的兩項薈萃分析探討了早期闌尾切除術在闌尾痰或膿腫兒童中的作用。Fugazzola 等人的 meta 分析發現，如果接受 NOM 治療，闌尾膿腫/痰患兒在併發症發生率和再入院率方面報告的結果更好[211]。同樣，Vaos 等人的 meta 分析報告稱，NOM 與較低的併發症和傷口感染發生率相關，而 IAA 和術后腸梗阻的發展不受所選治療的影響[212]。在這兩項薈萃分析中，早期闌尾切除術與住院時間縮短有關。

Statement 6.1 Non-operative management is a reasonable first-line treatment for appendicitis with phlegmon or abscess. Percutaneous drainage as an adjunct to antibiotics, if accessible, could be beneficial, although there is a lack of evidence for its use on a routine basis. Laparoscopic surgery in experienced hands is a safe and feasible first-line treatment for appendiceal abscess, being associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay. Recommendation 6.1 We suggest non-operative management with antibiotics and—if available—percutaneous drainage for complicated appendicitis with a periappendicular abscess, in settings where laparoscopic expertise is not available [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 6.1 非手術治療是闌尾炎伴痰或膿腫的合理一線治療。經皮引流作為抗生素的輔助手段（如果可獲得的話）可能是有益的，儘管缺乏證據表明其常規使用。有經驗的手進行腹腔鏡手術是闌尾膿腫的一線治療方法，與保守治療相比，再入院率和額外干預措施更少，住院時間相當。建議 6.1 對於伴有闌尾周圍膿腫的複雜性闌尾炎，我們建議在沒有腹腔鏡專業知識的情況下，使用抗生素進行非手術治療，如果有的話，經皮引流[QoE：中度;推薦強度：弱;2B]。

Statement 6.2 Operative management of acute appendicitis with phlegmon or abscess is a safe alternative to non-operative management in experienced hands and may be associated with shorter LOS, reduced need for readmissions, and fewer additional interventions than conservative treatment. Recommendation 6.2 We suggest the laparoscopic approach as treatment of choice for patients with complicated appendicitis with phlegmon or abscess where advanced laparoscopic expertise is available, with a low threshold for conversion. [QoE: Moderate; Strength of recommendation: Weak; 2B].
聲明 6.2 對於有經驗的手來說，伴有痰或膿腫的急性闌尾炎的手術治療是非手術治療的安全替代方法，並且可能與保守治療相比，LOS 更短、再入院需求更少以及額外干預措施更少。建議 6.2 對於伴有痰或膿腫的複雜性闌尾炎患者，我們建議將腹腔鏡入路作為首選治療方法，因為這些患者具有先進的腹腔鏡專業知識，並且轉化閾值較低。[QoE：中等;推薦強度：弱;2B]。

Q.6.2: Is interval appendectomy always indicated for patients with acute appendicitis following successful NOM?
Q.6.2：NOM 成功后急性闌尾炎患者是否總是需要進行間歇闌尾切除術？

The reported rate of recurrence after non-surgical treatment for perforated AA and phlegmon is up to 12% [213]. In order to avoid this quite high chance of recurrence, some authors recommend routine elective interval appendectomy following initial conservative management. However, this procedure is associated with a non-negligible rate of morbidity of 12.4% [202]. The systematic review by Hall et al., including three retrospective studies for a total of 127 cases of non-surgical treatment of appendix mass in children, showed that after successful non-operative treatment the risk of recurrent AA was found to be 20.5%. Overall, the complications reported included SSI, prolonged postoperative ileus, hematoma formation, and small bowel obstruction, but the incidence of any individual complication was not determined [23].
據報導，AA 穿孔和痰非手術治療后的復發率高達 12%[213]。為了避免這種相當高的復發機會，一些作者建議在初始保守治療後進行常規選擇性間歇闌尾切除術。然而，該手術的發病率為 12.4%，不可忽視[202]。Hall 等人的系統評價，包括 3 項回顧性研究，共納入 127 例兒童闌尾腫塊非手術治療病例，結果顯示，非手術治療成功后，AA 復發風險為 20.5%。總體而言，報告的併發症包括 SSI、術后腸梗阻延長、血腫形成和小腸梗阻，但未確定任何個體併發症的發生率[23]。

In the recent systematic review by Darwazeh et al., interval appendectomy and repeated NOM in the case of recurrence of appendiceal phlegmon were associated with similar morbidity. However, elective interval appendectomy was related to additional operative costs to prevent recurrence in only one of eight patients, such as not to justify the routine performance of appendectomy [213].
在 Darwazeh 等人最近的系統評價中，闌尾痰復發情況下的間期闌尾切除術和重複 NOM 與類似的發病率相關。然而，選擇性間歇闌尾切除術與額外的手術費用有關，以防止 8 例患者中只有 1 例患者復發，例如無法證明常規實施闌尾切除術的合理性[213]。

In the same way, Rushing et al., who found a risk of recurrence of 24.3% in patients, managed with NOM for appendiceal abscess or phlegmon and recommended against routine interval appendectomy in otherwise asymptomatic patients [214]. The CHINA RCT recently compared the outcomes of active observation versus interval appendectomy after successful NOM of an appendix mass in children. Results showed that more than three-quarters of children could avoid appendectomy during early follow-up after successful NOM of an appendix mass. The proportion of children with histologically proven recurrent AA under active observation was 12%, and the proportion of children with severe complications related to interval appendicectomy was 6%.
同樣，Rushing 等發現患者復發風險為 24.3%，對闌尾膿腫或蜂窩蜂窩織炎採用 NOM 治療，並建議對其他無癥狀患者進行常規間歇闌尾切除術[214]。CHINA RCT 最近比較了兒童闌尾腫塊成功 NOM 後主動觀察與間歇闌尾切除術的結果。結果顯示，超過四分之三的兒童在闌尾腫塊成功 NOM 後的早期隨訪期間可以避免闌尾切除術。經組織學證實復發性 AA 的患兒在積極觀察下佔比為 12%，發生間歇闌尾切除術相關嚴重併發症的患兒佔比為 6%。

Although the risk of complications after interval appendectomy was low, adoption of a wait-and-see approach, reserving appendectomy for patients who develop AA recurrence or recurrent symptoms, should be considered a most cost-effective management strategy compared with routine interval appendectomy [215].
雖然間歇闌尾切除術后併發症的風險較低，但與常規間歇闌尾切除術相比，採用觀望方法，將闌尾切除術留給出現 AA 復發或復發癥狀的患者，應被視為最具成本效益的治療策略[215]。

In the study by Renteria et al., unexpected malignancy was 3% in the elderly (mean age 66 years) and 1.5% in the young (mean age 39 years) cohorts of patients who underwent appendectomy as primary treatment for AA [216]. Adult patients with complicated AA treated with interval appendectomy can be diagnosed with appendiceal neoplasm in up to 11% of cases, in contrast to 1.5% of the patients who have early appendectomy [217]. Recently, the RCT by Mällinen et al. comparing interval appendectomy and follow-up with MRI after initial successful nonoperative treatment of periappendicular abscess was prematurely terminated owing to ethical concerns following the unexpected finding at the interim analysis of a high rate of neoplasm (17%), with all neoplasms in patients older than 40 years [218]. If this significant rate of neoplasms after periappendicular abscess is validated by future studies, it would argue for routine interval appendectomy in this setting.
在 Renteria 等的研究中，接受闌尾切除術作為 AA 主要治療的患者組的老年人（平均年齡 66 歲）和年輕（平均年齡 39 歲）患者組的意外惡性腫瘤發生率分別為 3%和 1.5%[216]。接受間歇性闌尾切除術治療的複雜性 AA 成人患者，高達 11%的病例可診斷為闌尾腫瘤，而早期闌尾切除術的患者中這一比例為 1.5%[217]。最近，Mällinen 等人比較闌尾周圍膿腫初始成功非手術治療後間期闌尾切除術和 MRI 隨訪的隨機對照試驗，由於中期分析中意外發現腫瘤發生率高（17%），所有腫瘤均發生在 40 歲以上的患者中，出於倫理問題而提前終止[218].如果闌尾周圍膿腫后腫瘤的顯著發生率被未來的研究驗證，那麼在這種情況下將支援常規間歇闌尾切除術。

Statement 6.3 The reported rate of recurrence after non-surgical treatment for perforated AA and phlegmon ranges from 12% to 24%. Interval appendectomy and repeated NOM in case of recurrence of appendiceal phlegmon are associated with similar morbidity. However, elective interval appendectomy is related to additional operative costs to prevent recurrence in only one of eight patients, such as not to justify the routine performance of appendectomy. Recommendation 6.3 We recommend against routine interval appendectomy after NOM for complicated appendicitis in young adults (< 40 years old) and children. Interval appendectomy is recommended for those patients with recurrent symptoms [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 6.3 據報導，穿孔 AA 和痰的非手術治療后的復發率在 12% 至 24% 之間。闌尾痰復發時的間隔闌尾切除術和重複 NOM 與相似的發病率相關。然而，擇期間歇闌尾切除術與額外的手術費用有關，以防止八名患者中只有一名患者復發，例如不能證明闌尾切除術的常規執行是合理的。建議 6.3 對於年輕成人（<，40 歲）和兒童的複雜性闌尾炎，我們建議不要在 NOM 後進行常規間歇闌尾切除術。對於癥狀反覆發作的患者，建議進行間歇闌尾切除術 [QoE：中度;推薦強度：強;1B]。

Statement 6.4 The incidence of appendicular neoplasms is high (3–17%) in adult patients ≥ 40 years old) with complicated appendicitis. Recommendation 6.4 We suggest both colonic screening with colonscopy and interval full-dose contrast-enhanced CT scan for patients with appendicitis treated non-operatively if ≥ 40 years old [QoE: Low; Strength of recommendation: Weak; 2C].
聲明 6.4 在患有複雜性闌尾炎的成年患者中，闌尾腫瘤的發生率很高（3-17≥40%）。建議 6.4 對於 40 歲以上的非手術治療闌尾炎患者，我們建議同時進行結腸鏡檢查和間隔全劑量對比增強 CT 掃描，如果年齡≥ 40 歲 [QoE： 低;推薦強度：弱;2C]。

Topic 7: Perioperative antibiotic therapy
主題 7：圍手術期抗生素治療

Q.7.1: Is preoperative antibiotic therapy recommended for patients with acute appendicitis?
Q.7.1：急性闌尾炎患者是否建議術前抗生素治療？

In 2001, a Cochrane meta-analysis supported that broad-spectrum antibiotics given preoperatively are effective in decreasing SSI and abscesses. RCTs and non-randomized comparative studies in which any antibiotic regime was compared to placebo in patients undergoing appendectomy were analyzed. Forty-four studies including 9,298 patients were included in this review. Antibiotics were superior to placebo for preventing wound infection and intra-abdominal abscess, with no apparent difference in the nature of the removed appendix [219]. The same final results have been obtained by the 2005 updated version of the review, including 45 studies with 9,576 patients [220]. The timing of pre-operative antibiotics does not affect the frequency of SSI after appendectomy for AA. Therefore, the optimal timing of preoperative antibiotic administration may be from 0 to 60 min before the surgical skin incision [221].
2001 年，一項 Cochrane 薈萃分析支援術前給予廣譜抗生素可有效減少 SSI 和膿腫。分析了隨機對照試驗和非隨機比較研究，其中將任何抗生素方案與安慰劑在接受闌尾切除術的患者中進行了比較。本綜述納入了 44 項研究，包括 9,298 名患者。抗生素在預防傷口感染和腹腔內膿腫方面優於安慰劑，切除闌尾的性質沒有明顯差異[219]。2005 年更新版的綜述也獲得了相同的最終結果，包括 45 項研究，涉及 9,576 例患者[220]。術前抗生素的使用時間不影響 AA 闌尾切除術後 SSI 的頻率。因此，術前抗生素給葯的最佳時間可能是手術切開皮膚前 0-60 分鐘[221]。

Statement 7.1 A single dose of broad-spectrum antibiotics given preoperatively (from 0 to 60 min before the surgical skin incision) has been shown to be effective in decreasing wound infection and postoperative intra-abdominal abscess, with no apparent difference in the nature of the removed appendix. Recommendation 7.1 We recommend a single preoperative dose of broad-spectrum antibiotics in patients with acute appendicitis undergoing appendectomy. We recommend against postoperative antibiotics for patients with uncomplicated appendicitis [QoE: High; Strength of recommendation: Strong; 1A].
聲明 7.1 術前（手術皮膚切口前 0 至 60 分鐘）給予單劑量廣譜抗生素已被證明可有效減少傷口感染和術后腹腔內膿腫，切除闌尾的性質沒有明顯差異。建議 7.1 我們建議對接受闌尾切除術的急性闌尾炎患者進行單次術前劑量的廣譜抗生素。我們建議對無併發症的闌尾炎患者不要使用術后抗生素[QoE：高;推薦強度：強;1A]。

Q.7.2: Are postoperative antibiotics always indicated in adult patients following appendectomy?
Q.7.2：闌尾切除術后的成年患者是否總是需要術後抗生素？

Prospective trials demonstrated that patients with perforated AA should receive postoperative antibiotic treatment, especially if complete source control has not been achieved. Cho et al. recently demonstrated in a large cohort of patients that the role of antibiotic treatment for preventing post-appendectomy IAA seems to be related with achieving intraperitoneal infectious source control. The authors found that the mean durations of postoperative antibiotic therapy were 3.1 days for the non-IAA group and 3.3 days for the IAA group, with no significant difference between the groups [222].
前瞻性試驗表明，穿孔 AA 患者應接受術後抗生素治療，尤其是在尚未實現完全源控制的情況下。Cho 等人最近在一大群患者中證明，抗生素治療在預防闌尾切除術后 IAA 方面的作用似乎與實現腹膜內感染源控制有關。作者發現，非 IAA 組和 IAA 組術后抗生素治療的平均持續時間分別為 3.1 天和 3.3 天，兩組之間差異無統計學意義[222]。

In the large observational study by McGillen et al., patients with complicated AA were significantly more likely to be started on antibiotics after surgery (83.9% versus 33.3%; P < 0.001) compared with patients with simple AA. The development of a SSI was significantly associated with a clinical diagnosis of diabetes, the presence of free fluid, abscess, or perforation on pre-operative imaging [223].
在 McGillen 等人的大型觀察性研究中，複雜 AA 患者在手術後開始使用抗生素的可能性明顯更高（83.9%對 33.3%;P < 0.001）與單純性 AA 患者相比。SSI 的發生與糖尿病的臨床診斷、術前影像學檢查中存在遊離液體、膿腫或穿孔顯著相關[223]。

The optimal course of antibiotics remains to be identified, but current evidence suggests that longer postoperative courses do not prevent SSI compared with 2 days of antibiotics.
抗生素的最佳療程仍有待確定，但目前的證據表明，與 2 天的抗生素相比，較長的術後療程並不能預防 SSI。

The meta-analysis by Van den Boom et al., including nine studies with more than 2,000 patients with complicated AA, revealed a statistically significant difference in IAA incidence between the antibiotic treatment of ≤ 5 vs > 5 days (OR 0.36), but not between ≤ 3 vs > 3 days (OR 0.81) [224].
Van den Boom 等的 meta 分析納入了 9 項研究，納入了 2,000 多名複雜性 AA 患者，結果顯示，抗生素治療 5≤ vs > 5 d（OR 0.36）的 IAA 發生率差異有統計學意義，但 3≤ vs > 3 d（OR 0.81）之間沒有統計學意義[224]。

A total of 80 patients were enrolled in a recent RCT comparing the outcomes of short (24 h) and the extended (> 24 h) postoperative antibiotic therapy in complicated AA. The overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (P = 0.23). Mean complication index did not differ between the study groups (P = 0.29), whereas hospital length of stay was significantly reduced in the short therapy group (61 ± 34 h vs 81 ± 40 h, P = 0.005). Based on the results of this RCT, 24 h of antibiotic therapy following appendectomy does not result in worse primary outcomes in complicated AA, but results in a significant reduction in length of hospitalization, with a major cost-saving and antibacterial stewardship benefits [225].
最近一項隨機對照試驗共納入了 80 名患者，比較了複雜 AA 術后短期（24 小時）和延長（> 24 小時）抗生素治療的結果。短組和延長組的總體併發症發生率分別為 17.9%和 29.3%（P = 0.23）。研究組之間的平均併發症指數沒有差異（P = 0.29），而短期治療組的住院時間顯著縮短（61 ± 34 小時 vs 81 ± 40 小時，P = 0.005）。根據本 RCT 結果，闌尾切除術后 24 h 抗生素治療不會導致複雜 AA 的主要結局較差，但可顯著縮短住院時間，並顯著節省成本並具有抗菌管理益處[225]。

Although discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria, a period of 3–5 days for adult patients is generally sufficient following appendectomy for complicated AA. The 2015 “STOP-IT” RCT by Sawyer et al. on 518 patients with complicated intra-abdominal infection, including also complicated AA, undergoing adequate source control demonstrated that outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities [226].
雖然應根據臨床和實驗室標準停止抗菌治療，但對於複雜 AA，成年患者在闌尾切除術后通常 3-5 天就足夠了。Sawyer 等在 2015 年對 518 例複雜性腹腔內感染（包括複雜性 AA）患者進行了“STOP-IT”RCT 研究，結果顯示，固定持續時間抗生素治療（約 4 日）後的結局與延長至生理異常消退後的較長療程（約 8 日）的結局相似[226]。

Statement 7.2 In patients with complicated acute appendicitis, postoperative broad-spectrum antibiotics are suggested, especially if complete source control has not been achieved. For adult patients deemed to require them, discontinuation of antibiotics after 24 h seems safe and is associated with shorter length of hospital stay and lower costs. In patients with intra-abdominal infections who had undergone an adequate source control, the outcomes after fixed-duration antibiotic therapy (approximately 3–5 days) are similar to those after a longer course of antibiotics. Recommendation 7.2 We recommend against prolonging antibiotics longer than 3–5 days postoperatively in case of complicated appendicitis with adequate source control [QoE: High; Strength of recommendation: Strong; 1A].
聲明 7.2 對於複雜性急性闌尾炎患者，建議術后使用廣譜抗生素，特別是在尚未實現完全源控制的情況下。對於被認為需要抗生素的成年患者，24 小時後停用抗生素似乎是安全的，並且與更短的住院時間和更低的成本相關。在接受充分源控制的腹腔內感染患者中，固定持續時間抗生素治療（約 3-5 天）后的結局與長期抗生素治療后的結局相似。建議 7.2 我們建議不要將抗生素延長術后 3-5 天以上，以防複雜性闌尾炎且來源控制充分 [QoE：高;推薦強度：強;1A]。

Q.7.3: Are postoperative antibiotics always indicated in pediatric patients following appendectomy?
Q.7.3：闌尾切除術后的兒科患者是否總是需要使用術后抗生素？

A retrospective review conducted by Litz et al. demonstrated that antibiotic administration within 1 h of appendectomy in pediatric patients with AA who receive antibiotics at diagnosis did not change the incidence of postoperative infectious complications [227].
Litz 等進行的一項回顧性評價表明，對於診斷時接受抗生素治療的 AA 兒科患者，闌尾切除術后 1h 內給予抗生素治療不會改變術后感染併發症的發生率[227]。

Children with non-perforated AA should receive a single broad-spectrum antibiotic. Second- or third-generation cephalosporins, such as cefoxitin or cefotetan, may be used in uncomplicated cases.
患有非穿孔 AA 的兒童應接受單一廣譜抗生素治療。第二代或第三代頭孢菌素類藥物，如頭孢西丁或頭孢替坦，可用於無併發症的病例。

In complicated AA, intravenous antibiotics that are effective against enteric gram-negative organisms and anaerobes including E. coli and Bacteroides spp. should be initiated as soon as the diagnosis is established. Broader-spectrum coverage is obtained with piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate, or imipenem-cilastatin. For perforated AA, the most common combination is ampicillin, clindamycin (or metronidazole), and gentamicin. Alternatives include ceftriaxone-metronidazole or ticarcillin-clavulanate plus gentamicin, in accordance with the epidemiology of bacteria [228]. Metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used [229]. In a recent retrospective cohort study of 24,984 children aged 3 to 18 years, Kronman et al. compared the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with AA. The exposure of interest was receipt of systemic extended-spectrum antibiotics (piperacillin ± tazobactam, ticarcillin ± clavulanate, ceftazidime, cefepime, or a carbapenem) on the day of appendectomy or the day after. The primary outcome was 30-day readmission for SSI or repeat abdominal surgery. The authors reported that extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated AA [230].
在複雜性 AA 中，一旦確診，應立即開始靜脈注射對腸道革蘭氏陰性菌和厭氧菌（包括大腸桿菌和擬桿菌屬）有效的抗生素。哌拉西林-他唑巴坦、氨苄西林-舒巴坦、替卡西林-克拉維酸鹽或亞胺培南-西司他丁可獲得更廣譜的覆蓋率。對於穿孔 AA，最常見的組合是氨苄西林、克林黴素（或甲硝唑）和慶大黴素。根據細菌流行病學，替代藥物包括頭孢曲松-甲硝唑或替卡西林-克拉維酸鹽加慶大黴素[228]。當使用廣譜抗生素（如氨基青黴素類、β-內醯胺類抑製劑或碳青霉烯類藥物）和部分頭孢菌素類時，不適用於甲硝唑[229]。在最近一項針對 24,984 名 3 至 18 歲兒童的回顧性佇列研究中，Kronman 等人比較了廣譜抗生素與窄譜抗生素對 AA 兒童的有效性。感興趣的暴露是在闌尾切除術當天或第二天接受全身性超譜抗生素（哌拉西林±他唑巴坦、替卡西林±克拉維酸鹽、頭孢他啶、頭孢吡肟或碳青霉烯類藥物）。主要結果是 30 天再入院 SSI 或重複腹部手術。作者報告說，對於手術治療的急性無併發症或複雜性 AA 兒童，廣譜抗生素似乎沒有優勢於窄譜藥物[230]。

Broad-spectrum, single, or double agent therapy is equally efficacious as but more cost-effective than triple agent therapy. It was reported that dual therapy consisting of ceftriaxone and metronidazole only offers a more efficient and cost-effective antibiotic management compared with triple therapy, but prospective studies are required to determine whether this policy is associated with higher rates of wound infections and change in antibiotic therapy [231].
廣譜、單藥或雙藥治療與三藥治療同樣有效，但更具成本效益。據報導，與三聯治療相比，頭孢曲松和甲硝唑聯合治療只能提供更有效、更具成本效益的抗生素管理，但需要前瞻性研究來確定該政策是否與更高的傷口感染率和抗生素治療的變化有關[231]。

Postoperative antibiotics can be administered orally if the patient is otherwise well enough to be discharged. Arnold et al. conducted a RCT of 82 pediatric patients to compare the effect of home intravenous versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated AA. Fosrty-four patients (54%) were randomized to the IV group and 38 (46%) to the oral group. The study showed no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days), postoperative abscess rate (11.6% vs 8.1%), or readmission rate (14.0% vs 16.2%), whereas hospital and outpatient charges were higher in the IV group [232].
如果患者身體狀況良好，可以口服術后抗生素出院。Arnold 等人對 82 名兒科患者進行了一項隨機對照試驗，以比較家庭靜脈注射抗生素治療與口服抗生素治療對穿孔 AA 闌尾切除術后併發症發生率和資源利用率的影響。Fosrty-4 患者 （54%） 被隨機分配到靜脈注射組，38 名 （46%） 被隨機分配到口服組。研究顯示，住院時間（4.4 ± 1.5 vs 4.4 ± 2.0 d）、術后膿腫率（11.6% vs 8.1%）或再入院率（14.0% vs 16.2%）沒有差異，而 IV 組的住院和門診費用更高[232]。

Other retrospective cohort studies have confirmed that after apspendectomy for perforated AA in children, oral antibiotics show equivalent outcomes compared with intravenous antibiotics, but with shorter length of hospitalizations and less medical encounters required [233].
其他回顧性佇列研究證實，在兒童穿孔 AA 的末端切除術后，口服抗生素的結局與靜脈注射抗生素相當，但住院時間更短，醫療次數更少[233]。

Compared to pediatric patients who receive intravenous antibiotics, those who are treated with oral antibiotics have statistically lower rates of repeated US imaging (49.6% vs 35.1%) and PICC placement (98.3% vs 9.1%), whereas the rates of IAA are similar (20.9% vs 16.0%). Moreover, early transition to oral antibiotics allows shorter hospital times and decreased hospital charges, with similar total antibiotic days and readmission rate [234].
與接受靜脈抗生素治療的兒科患者相比，接受口服抗生素治療的兒科患者重複超聲成像（49.6% vs 35.1%）和 PICC 置入率（98.3% vs 9.1%）在統計學上較低，而 IAA 的比率相似（20.9% vs 16.0%）。此外，早期過渡到口服抗生素可以縮短住院時間並降低住院費用，抗生素總使用天數和再入院率相似[234]。

Statement 7.3 Administering postoperative antibiotics orally in children with complicated appendicitis for periods shorter than 7 days postoperatively seems to be safe and it is not associated with increased risk of complications. Early transition to oral antibiotics is safe, effective, and cost-efficient in the treatment of complicated appendicitis in the child. Recommendation 7.3 We recommend early switch (after 48 h) to oral administration of postoperative antibiotics in children with complicated appendicitis, with an overall length of therapy shorter than seven days [QoE: Moderate; Strength of recommendation: Strong; 1B].
聲明 7.3 對患有複雜性闌尾炎的兒童術後口服抗生素術后少於 7 天似乎是安全的，並且與併發症風險增加無關。早期過渡到口服抗生素在治療兒童複雜性闌尾炎方面是安全、有效且具有成本效益的。建議 7.3 對於複雜性闌尾炎患兒，我們建議儘早（48 小時后）改用術後口服抗生素，總治療時間短於 7 日[QoE：中度;推薦強度：強;1B]。

Statement 7.4 Postoperative antibiotics after appendectomy for uncomplicated acute appendicitis in children seems to have no role in reducing the rate of surgical site infection. Recommendation 7.4 In pediatric patients operated for uncomplicated acute appendicitis, we suggest against using postoperative antibiotic therapy [QoE: Low; Strength of recommendation: Weak; 2C].
聲明 7.4 兒童無併發症急性闌尾炎闌尾切除術后使用抗生素似乎對降低手術部位感染率沒有作用。建議 7.4 對於因無併發症的急性闌尾炎而接受手術的兒科患者，我們建議不要使用術后抗生素治療[QoE：低;推薦強度：弱;2C]。

Conclusions  結論

The current evidence-based guidelines are the updated 2020 International Comprehensive Clinical Guidelines for the diagnosis and management of acute appendicitis. After reaching consensus on each of the above mentioned, the panel experts and the scientific committee members developed two WSES flow-chart algorithm for the diagnosis and management of acute appendicits to be used for adults and pediatric patient population, reported respectively in Figs. 1 and 2.
目前的循證指南是更新的 2020 年急性闌尾炎診斷和管理國際綜合臨床指南。在就上述每一項達成共識後，專家組專家和科學委員會成員開發了兩種用於成人和兒童患者群體的急性闌尾診斷和管理的 WSES 流程圖演算法，分別如圖所示。1 和 2。

Fig. 1  圖1

Practical WSES algorithm for diagnosis and treatment of adult patients with suspected acute appendicitis
用於疑似急性闌尾炎成人患者診治的實用 WSES 演算法

Fig. 2  圖2

Practical WSES algorithm for diagnosis and treatment of pediatric patients with suspected acute appendicitis
用於疑似急性闌尾炎兒科患者診治的實用 WSES 演算法