Background As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods A retrospective cohort analysis was performed between December 2019 and April 2020 in the four highvolume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA. Results A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis. Conclusions The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

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Background The aim of this study is to investigate the outcomes of conservative management of non-complicated acute appendicitis (AA) using our unique institutional protocol, and to compare between these and the outcomes of operative management. Methods Patients admitted to our institution between March 2016 and October 2019 with non-complicated AA were grouped according to their initial management: non-operative versus surgical. Our unique protocol for non-operative management includes: pain \ 3 days; afebrile upon admission; non-gravid; WBC \15,000 (9 10 9 /L); CRP \ 5 mg/ dl; appendix diameter \ 1 cm; no appendicolith on imaging; no prior episode of AA; no history of Inflammatory Bowel Disease; no evidence of peritonitis on physical examination. The primary outcome measured was failure of non-surgical management during the index admission. Secondary outcomes included recurrence rate, readmissions, complications, length of antibiotic treatment and length of stay (LOS). Results A total of 695 patients were included, 436 in the operative group and 259 in the non-surgical treatment group. The mean follow-up time was 1004.9 ± 205.7 days. Patients initially treated conservatively rarely required surgery during their index admission (6.9%). Recurrence rate was 19.1% after a mean follow up of 33.4 months. The overall failure rate of conservative management was documented in 20.8% of the patients. The complication rate was higher in those treated with upfront surgery (1.6% vs. 0.4%, p \ 0.001). The overall LOS was not statistically different between the groups. Conclusions Our composite protocol for non-surgical management of non-complicated AA results in a low failure rate. A well calculated patient treatment allocation in non-complicated AA can advocate for wide-spread use of the conservative approach.