Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

Abstract

Background In early 2020, the COVID‐19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown versus a non-pandemic period. Methods All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. Results There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%)( P =0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P<0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5%( P =0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 ( P =0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 ( P <0.001) – a 0% negative appendicectomy rate (NAR). Discussion The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

Delayed presentation of children to the emergency department during the first wave of COVID‐19 pandemic in Italy: Area‐based cohort study

“…An additional analysis restricted to cases of appendicitis who underwent surgery showed a tendency to a larger percentage of appendiceal perforation in 2020 incomparison with the two previous years. Our results confirmed previous ones obtained in most 10–14 but not all 15 countries in Europe, Israel, USA and China of an increase, sometimes a borderline/not significant one, in complications rates for appendicitis during pandemic which has been attributed to late presentations.…”

“…Our results confirmed previous ones obtained in most [10][11][12][13][14] but not all 15 countries in Europe, Israel, USA and China of an increase, sometimes a borderline/not significant one, in complications rates for appendicitis during pandemic which has been attributed to late presentations.…”

Did the COVID-19 Pandemic Prolong the Time Till Diagnosis and Worsen Outcomes for Children with Acute Appendicitis?

“…A similar trend was also observed nationwide in the lesser number of performed appendectomies in children for the yearly statistics of 2020 and 2019 as presented by the Lithuanian Institute of Hygiene. It was also observed nationwide in Germany, UK, US, and Israel, with a decrease of 4-8 times being seen in Bosnia and Herzegovina [15][16][17][18][19][20][21]. We can clearly say that the majority of the number drop was due to elective surgery prohibition, which was one of the preventive measures issued by the government seeking to minimize possible spread of the pandemic.…”

Perioperative considerations for acute appendicitis in patients with COVID-19 infection: two case reports

“…It also showed a decrease in histologic severity and overall complication. This would be able to reduce the risk of perioperative viral transmission [6]. As the incidence of delayed diagnosis and complicated appendicitis has increased in the pandemic, abdominal CT should be considered for rapid and accurate diagnosis and treatment.…”