Is nonoperative management of appendicitis inferior in the COVID-19 era?

Abstract

Background Previous studies on non-operative management of acute appendicitis indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between non-operative and operative management groups, regardless of COVID-19 status. Methods We queried the National COVID Cohort Collaborative from 2020-2023 to identify adults with acute appendicitis who underwent operative or non-operative management. COVID-19 status was denoted: COVID-negative, -active, or -recovered. Intention to treat was utilized for non-operative management. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities. Results A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and -recovered less-often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of non-operative management between COVID groups. Adjusted analysis indicated, compared with operative, non-operative management carried higher odds of mortality and readmission for COVID-negative and -active patients. Conclusions This study demonstrates higher odds of mortality amongst non-operative management of appendicitis, and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that non-operative management of appendicitis is associated with worse outcomes for COVID-active and -negative patients. Additionally, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patients from appendectomy for acute appendicitis. Surgeon clinical judgement of a patient’s physiology and surgical risk should, of course, inform the decision to proceed to the operating room. Level of Evidence III, therapeutic/care management