Global practices and attitudes in acute appendicitis management: the PAMAP-W international survey and Delphi consensus study on the WSES appendicitis grading system

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BACKGROUND: Despite the availability of several appendicitis grading systems and ongoing efforts toward standardization, substantial variability persists worldwide in the management of acute appendicitis. Differences are particularly evident in operative approach, stump closure, postoperative antibiotic use and duration, drainage, interval appendectomy after non operative management and follow-up strategies. The PAMAP-W project was designed as a sequential mixed-method study to explore real-world practice patterns and to develop grade-linked expert statements to support clinical and surgical decision-making. METHODS: The study consisted of two complementary phases. First, an international cross-sectional web-based survey was conducted among surgeons involved in emergency and acute care surgery to assess practices and attitudes regarding appendicitis severity classification and grade-linked management. The questionnaire explored demographics, surgical approach, appendiceal stump management, intra-abdominal lavage and drainage, postoperative antibiotic therapy, and follow-up strategies according to acute appendicitis severity. Second, a Delphi consensus process involving an international expert panel was carried out to review and refine candidate grade-linked management statements derived from areas of heterogeneity identified in the survey. Consensus thresholds were predefined for each Delphi round. RESULTS: A total of 467 surgeons from 64 countries completed the survey, providing an international snapshot of contemporary appendicitis management. Laparoscopy was the preferred approach across all grades, although increasing disease severity was associated with greater variability in operative choices and postoperative management. Considerable heterogeneity was observed in stump closure techniques, use of drainage, duration of antibiotic therapy, and follow-up strategies, particularly in complicated appendicitis. Fifty international experts were invited to participate in the Delphi process, 37 and 33 completed rounds 1 and 2, respectively. Most candidate statements achieved consensus after two rounds, resulting in a set of grade-linked expert statements intended to support more consistent interpretation and management of appendicitis severity. CONCLUSIONS: Marked international heterogeneity persists in the intraoperative and postoperative management of acute appendicitis, particularly in complicated disease. The PAMAP-W project combines real-world practice mapping with expert consensus refinement to support a pragmatic, grade-linked framework for clinical and surgical decision-making. The WSES Acute Appendicitis grading system is intended to complement, not replace, formal evidence-based recommendations. Further studies are needed to assess its reproducibility, implementation, and impact on clinical outcomes.

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