Management of Acute Appendicitis During the COVID-19 Pandemic is Significantly Different: A Retrospective Single UK Hospital Study

Abstract

Introduction:The COVID-19 pandemic has led to a change in the delivery of acute and emergency surgical services. With emphasis on reducing unnecessary operative intervention and performing more CT scans, there has been a shift in managing acute appendicitis conservatively. We evaluate the impact of this shift on the management of acute appendicitis. Methods: A single UK centre retrospective study evaluating patients with suspected acute appendicitis pre-COVID-19 rota (18 March 2020) and post-COVID rota implementation. Data including demographics, inflammatory markers, imaging, mode of management and operative findings were collected. Logistic regression with SPSS was used to determine which factors were associated with conservative management and treated with antibiotics. Results: A total of 161 patients were analysed, 82 pre-COVID19 and 79 post-COVID19. Of the pre-COVID-19 patients, 67.07% underwent appendicectomy while the rest were conservatively managed; 24.3% of these patients underwent a CT scan only. Post-COVID-19, 22.78% of patients underwent appendicectomy with a higher percentage of diagnostic CT scans performed, 43/79 (54.4%, p <0.001). The proportion of histologically normal appendicectomies was significantly reduced in the post-COVID-19 era (12.78% vs 0.00%; p-value 0.001). Logistic regression analysis showed a normal WCC to be associated with greater likelihood of conservative management. No conservatively managed patients returned to theatre in the 30-day follow-up period. Conclusion:Due to the restrictions imposed by the post-COVID-19 rota, a greater proportion of patients were managed conservatively with comparable patient outcomes. The approach also led to fewer negative appendicectomies owing to greater reliance on imaging.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

“…On the other hand, prolonged preoperative intervals were reported during the pre-pandemic period in two studies[ 15 , 18 ]. There were two studies that concluded that the diagnostic process was prolonged during the COVID-19 period[ 10 , 13 ]. One important point that should be emphasized regarding the reported intervals in studies is that all were self-reported intervals.…”

“…Antakia et al [ 18 ] reported that during the COVID-19 pandemic, they have used CT 2.6 times more frequently (OR: 2.6; P = 0.008), but the use of US was reduced by 1.6 fold (OR: 1.6; P = 0.227). Khan et al [ 13 ] showed that US was performed less frequently, and use of CT for the diagnosis of AAp increased during the pandemic period (OR: 3.7; P < 0.001).…”

“…In the literature, there is no consensus on the definition of complications (plastron, abscess, phlegmon, gangrene, perforation, peri-appendicular abscess, pelvic abscess, and severe peritonitis) that are related to AAp. Ten of the 25 studies that are related to the COVID-19 pandemic and AAp reported that perforation rates significantly increased during the pandemic period (5.0%-45.6%)[ 1 - 4 , 9 , 13 , 15 , 16 , 40 ]. In addition, another 2 of the 25 studies reported an increase in the perforation rates (17.5%-31.0%) that did not reach statistical significance[ 37 , 38 ].…”

“…Interestingly, perforation rates were reported to be reduced (5.0%-10.7%) during the COVID-19 pandemic in two studies[ 14 , 17 ]. Five studies in our literature review reported that peri-appendicular and pelvic abscess rates (5.6%-33.9%) increased during the pandemic period[ 2 , 13 , 17 , 18 , 35 ]. Some of the studies reported all complications as “complicated AAp”.…”

“…Ten of the 25 studies that were reviewed gave their results regarding negative appendectomy rates. The results of these studies showed that negative appendectomy rates dropped during the COVID-19 pandemic[ 1 , 6 , 13 - 16 , 18 , 33 , 34 , 39 ]. Five of the ten studies stated that this drop showed statistical significance.…”