Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Abstract

IntroductionThe COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. MethodAll patients presenting to our centre with AA between March and July 2020 were included. Six-month followup data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. ResultsFifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). ConclusionsCOVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

The effect of the Covid-19 outbreak on the management of acute appendicitis: A retrospective comparative cohort study

“…Some studies reported no differences in LOS between these periods [16][17]; however, Kvasnovsky et al [18] reported a significantly higher LOS for AA during the pandemic. Conservatively treated AA patients had longer LOS than the operated patients in both periods [14,19]. In our study, LOS was significantly higher among all AA patients during the pandemic.…”

“…Also, there was no difference in the mean age of acute care surgery patients between the pre-pandemic and pandemic periods; however, there was a significant change in the most common gender between the periods with female being the most common gender with 50.9% before the pandemic, but male being the most common gender with 66.6% during pandemic [9]. There was no difference in terms of age and gender (higher male ratio) between the conservatively treated or operated patients by period [13,14]. The rate of noncitizen AA patients our previous study was 15.1% (95/628) from 2014 to 2018 [15].…”

“…Gannesh et al [25] reported lower levels of WBC (12.9 vs 13.2 x10 9 /L), and higher levels of CRP (82 vs 69 mg/dl), but Mai et al [26] reported higher levels of WBC (14 vs 12.2 x10 9 /L), and lower levels of CRP (43 vs 56 mg/dl) in AA during the pandemic. Lower WBC and CRP were reported for conservatively treated AA both in the pre-pandemic (14.2 vs 15.3 x10 9 /L, and 25.9 vs 64.8 mg/dl respectively), and the pandemic periods (12.5 vs 15.9 x10 9 /L, and 24.5 vs 50 mg/dl respectively) [13,14]. In our study, overall WBC levels were insignificantly lower during the pandemic, while overall CRP levels were higher.…”

“…Sixty to eighty percent of the appendectomies were performed laparoscopically in tertiary centers with 1-2 days LOS, and 1-3% complication rate [31]. Javanmard-Emamghissi et al [32] reported the OA rate as 56.1%, and conversion to open surgery rate as 10.7%; however, Lotfallah et al [14] reported the OA rate as 35.5% and conversion to open surgery rate as 3.2% during the pandemic. In our study, while 91.2% of the AA underwent LA in the prepandemic with 3.1% conversion rate, OA was performed in 72% of the AA patients during the pandemic.…”

Influence of Covid -19 on the management of Appendicitis

“…Moreover, the guidelines regarding the management of acute appendicitis were also modified towards conservative management to avoid long surgical lists. A number of recent studies across Europe, USA and India support the idea of conservative management of Appendicitis with oral or Intravenous antibiotics only with observation not only in adults but also in children 4,5,6 .…”