Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective

Abstract

Introduction The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy. Methods Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020–May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model. Results Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications. Conclusion During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

“…Initially, concerns regarding transmission of infection to operating team members during aerosol generating procedures as well as early associations with excess post-operative mortality for patients acutely infected with SARS-CoV-2 caused surgeons to pivot from established practice patterns to pursue either delayed operative management, or for certain conditions such as appendicitis, non-operative management [ 2 – 5 ]. With the post-pandemic return to relative normalcy, and the benefit of additional outcome data,, the standard-of-care appears to have safely tracked back towards practices established before the pandemic [ 6 ]. Accordingly, the clinical intersection of acute or chronic SARS-CoV-2 and emergency surgical pathologies management is de-emphasized in contemporary research inquiries.…”

Focus on identifying and closing knowledge gaps in acute appendicitis

“…They also catalog their experience in applying this approach to achieve two specific goals: (1) identifying knowledge gaps regarding the optimal treatment for appendicitis as a hypothesis-generating launchpad for future interventional RCTs, and (2) describing the gap between evidence-based practice guidelines [6] and "real world" selective application as a lens through which to assess the variability in surgical outcomes. Tackling some of the controversies in current care of the patient with acute appendicitis, the ESTES SnapAppy collaborative explores technical aspects of surgical management (including the use of staplers and energy devices at key portions of the operation), operating surgeon experience, mentorship and graded trainee autonomy, and contemporary surgical outcomes following appendectomy across Europe, North America and the Middle East, particularly in the context of an evolving COVID pandemic [7][8][9][10].…”