Do young patients with high clinical suspicion of appendicitis really need cross-sectional imaging? Proceedings from a highly controversial debate among the experts' panel of 2020 WSES Jerusalem guidelines.

The widespread use of cross-sectional imaging in suspected appendicitis is debated. Recent guidelines have demonstrated conflicting views and the debate continues. In April 2020 the World Society of Emergency Surgery (WSES) published the update of the Jerusalem Guidelines on the diagnosis and treatment of acute appendicitis. The role of pre-operative imaging was a particular difficult point to reach a definitive decision, leading to pro-con arguments and an ad hoc Delphi survey with a consensus statement. The systematic review of the literature performed during the guidelines development, which has been summarized in this current opinion paper, demonstrated that the use of AIR and AAS scores as clinical predictors of acute appendicitis is a cost-effective method to reduce the negative appendectomy rate and can stratify patients into high-risk group with specificity of up to 94%. There are currently two principal management strategies for patients with suspected appendicitis: the score-based risk-stratification followed by a diversified management depending on the estimated risk of appendicitis, and the imaging-based strategy advocating routine diagnostic imaging in all patients except those deemed having low probability of appendicitis. In patients younger than 40 years old who have been scored for high probability for acute appendicitis (AIR score 9-12, Alvarado score 9-10, and AAS ≥ 16), CT scan adds little value in the diagnosis. A high-probability score of acute appendicitis may be used to select patients younger than 40 years old in which imaging is not needed.Evidence LevelII (Systematic Reviews and Meta-analyses).