Changes in appendicitis treatment during the COVID-19 pandemic - A systematic review and meta-analysis

The Severity of Appendicitis During the COVID-19 Pandemic: A Single Institution Experience

IntroductionThe COVID-19 pandemic led to nationwide stay at home orders, leading to delays in medical care. We sought to identify if the severity of appendicitis changed during the pandemic due to these delays and if there were differences in appendicitis severity in patients with simultaneous COVID-19 infection. We hypothesized that pandemic-related restrictions led to more severe cases of appendicitis.MethodsWe performed a retrospective study (4/2018-4/2022) of all patients ≥ 5y with appendicitis. Patients with a malignant appendiceal specimen were excluded. Clinical outcomes and characteristics were compared in those with appendicitis prior to the COVID-19 (PC) era to those in the COVID-19 (C) era, as well as between COVID-19 positive (C+) and negative (C-) individuals. Univariate analyses were conducted. A P-value <0.05 was considered to be statistically significant.ResultsA total of 1665 patients met inclusion criteria, 806 (48.4%) in PC era, and 859 (51.6%) in C era. Age and gender did not differ from PC era to C era, nor did they differ from the C- group to the C+ group. The C era had significantly higher 30-day readmissions than the PC era (C 6.29% (n = 54) v. PC 2.73% (n = 22), P = 0.001). The C era also had more greater than 30-day readmissions than the PC era (C 3.26% (n = 28) v. PC 1.74% (n = 14), P = 0.048). There was no significant difference in the reason for 30-day or greater than 30-day readmissions for the PC vs C eras. Of the C era, 833 (97.0%) were C- and 26 (3.0%) were C+. Rates of nonoperative management at index admission were not different between groups. The white blood cell (WBC) count was significantly lower in C+, 11.9 (8.55-13.35 IQR), vs C- group, 12.85 (9.9-15.3 IQR), P = 0.0336. There was no significant difference in the severity of appendicitis nor readmission status in C+ vs C- groups during the C era.ConclusionOur data indicates that the PC era had more severe cases of appendicitis as shown by higher rates of perforated and gangrenous appendicitis on pathology reports compared to the C era. Interestingly, readmissions were more prevalent in the C era as opposed to the PC era, which coincided with an increase in complications requiring readmission following laparoscopic appendectomies. In evaluating appendicitis patients according to COVID-19 status, we saw no significant differences in the severity of appendicitis in C- and C+ individuals.

Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review

Appendectomy as the standard treatment for acute appendicitis has been challenged by accumulating evidence supporting nonoperative management with antibiotics as a potential primary treatment. This review aimed to summarize the clinical outcomes and the optimal indications for nonoperative management of acute appendicitis in adults. Current evidence suggests that uncomplicated and complicated appendicitis have different pathophysiologies and should be treated differently. Nonoperative management for uncomplicated appendicitis was not inferior to appendectomy in terms of complications and length of stay, with less than a 30% failure rate at 1 year. The risk of perforation and postoperative complications did not increase even if nonoperative management failed. Complicated appendicitis with localized abscess or phlegmon could also be treated conservatively, with a success rate of more than 80%. An interval appendectomy following successful nonoperative management is recommended only for patients over the age of 40 years to exclude appendiceal malignancy. The presence of appendicoliths increased the risk of treatment failure and complications; thus, it may be an indication for appendectomy. Nonoperative management is a safe and feasible option for both uncomplicated and complicated appendicitis. Patients should be informed that nonoperative management may be a safe alternative to surgery, with the possibility of treatment failure.

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis

BACKGROUND

Randomised controlled trials (RCTs) have found antibiotics to be a feasible and safe alternative to appendicectomy in adults with imaging-confirmed acute appendicitis. However, patient inclusion criteria and outcome definitions vary greatly between RCTs. We aimed to compare antibiotics with appendicectomy for the treatment of acute appendicitis using individual patient data and uniform outcome definitions.

METHODS

In this individual patient data meta-analysis, we searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials without language restrictions between database inception and June 6, 2023, for RCTs comparing appendicectomy with antibiotics for the treatment of adults (≥18 years) with imaging-confirmed acute appendicitis. Studies without 1-year follow-up data on complications were excluded, as were patients. Corresponding authors of eligible studies were contacted and invited to share data; individual patient data were merged after validation. One-stage meta-analyses were conducted using a generalised, mixed-effects linear regression model, accounting for clustering of patients within studies. The primary outcome was the complication rate at 1-year follow-up, uniformly harmonised across trials using the Clavien-Dindo classification. Complications were further divided into minor (grade 1-2 or equivalent) and major (grade 3-5 or equivalent) complications. Appendicectomy rate during 1 year was a key secondary outcome but not considered a complication for the antibiotics group. Outcomes were described separately for patients with and without an appendicolith. This study is registered with PROSPERO, CRD42023391676.

FINDINGS

Of 887 potentially relevant articles, eight were eligible for inclusion, of which six RCTs could provide data for 2101 eligible patients (1050 assigned to antibiotics and 1051 assigned to appendicectomy; 830 [39·5%] women and 1271 [60·5%] men). All studies raised some bias concerns due to absence of blinding. One study was judged to have a high risk of bias due to the exclusion of eligible patients after randomisation, but these patients were eligible for inclusion in our meta-analysis. At 1 year, 57 (5·4%) of 1050 patients randomly assigned to antibiotics had a complication compared with 87 (8·3%) of 1051 patients randomly assigned to appendicectomy (odds ratio [OR] 0·49 [95% CI 0·20 to 1·20]; risk difference -4·5 percentage points [95% CI -11·6 to 2·6]). At 1 year, 1025 (97·5%) patients in the appendicectomy group had undergone appendicectomy compared with 356 (33·9%) patients in the antibiotics group. In patients with an appendicolith at pre-interventional imaging, there were more complications at 1 year among patients who received antibiotic treatment than among those who underwent appendicectomy (29 [15·0%] of 193 patients vs 12 [6·3%] of 190 patients; OR 2·82 [95% CI 1·11 to 7·18]; risk difference 13·2 percentage points [95% CI 2·3 to 24·2]). In the antibiotics group, 94 (48·7%) of 193 patients with an appendicolith underwent appendicectomy within 1 year versus 262 (30·6%) of 857 patients without an appendicolith.

INTERPRETATION

This meta-analysis showed that antibiotic treatment in adults with imaging-confirmed acute appendicitis was a safe alternative to surgery and resulted in around two-thirds of patients avoiding appendicectomy during the first year. In patients with an appendicolith, initial antibiotic treatment increased the risk of complications compared with appendicectomy, and around half of these patients assigned to antibiotics underwent step-up appendicectomy within 1 year. These data should be key components in shared decision making.

FUNDING

None.

Perioperative severity of acute appendicitis during the confinement related to SARS COVID-19: a retrospective comparative cohort

OBJECTIVE

To evaluate the perioperative severity of acute appendicitis during the COVID-19 pandemic compared to the same periods in 2018 and 2019 in the Nancy-Metz region, France. Acute appendicitis is a common surgical emergency that can lead to severe complications if not treated promptly. The COVID-19 pandemic and subsequent lockdowns resulted in reduced hospital visits, potentially delaying treatment for appendicitis and increasing perioperative severity.

METHODS

This retrospective, bicentric cohort study included 634 adult patients who underwent emergency appendectomy at the Nancy University Hospital and Metz Regional Hospital. The study compared patients from the pandemic period (March 17, 2020, to December 14, 2020) with those from the same periods in 2018 and 2019. The primary outcome was perioperative severity, defined by a Gomes score ≥ 3 and/or a Clavien-Dindo classification ≥ 3. Secondary outcomes included time to treatment, severity of biological inflammatory syndrome, postoperative complications, and hospitalization metrics. Logistic regression analyses were performed with adjustments for ASA scores.

RESULTS

The study included 194 patients from the COVID-19 cohort and 440 from the non-COVID cohort. The perioperative severity was higher during the COVID period (33.5% vs. 25.9%), though this difference was not statistically significant (p = 0.0845). Secondary outcomes such as time to treatment, severity of the inflammatory syndrome, and postoperative complications did not show significant differences between cohorts. However, the duration of postoperative antibiotic therapy was longer during the COVID period (6 days vs. 5 days, p = 0.0410).

CONCLUSION

The COVID-19 pandemic led to a non-significant increase in perioperative severity of acute appendicitis. Despite the challenges posed by the pandemic, the French healthcare system maintained effective management of surgical emergencies, with no significant increase in postoperative complications. Further research is required to explore the broader impact of the pandemic on the management of appendicitis.

Acute appendicitis and its treatment: a historical overview

PURPOSE

Acute appendicitis (AA) is the leading cause of acute abdomen worldwide, with an incidence of 90-100 cases per 100,000 individuals annually and a lifetime risk of 7-12%. Despite its prevalence, historical accounts of AA are limited, particularly when compared to conditions like haemorrhoids, likely due to the appendix's internal location. This article traces the historical evolution of AA treatment from ancient times to the present, highlighting key contributions.

METHODS

A review of common research databases and relevant literature on AA was conducted.

RESULTS

Evidence from ancient Egypt suggests early recognition of the appendix, referring to it as the "worm of the bowel." However, detailed anatomical descriptions and treatment approaches for AA did not emerge until the Renaissance, particularly with contributions from Leonardo da Vinci and Berengario da Carpi. The article traces the progression of AA management, including the first autopsies and surgeries, the development of surgical techniques predating anaesthesia and antisepsis, and advancements achieved from the nineteenth to the twenty-first century. The shift from conservative to surgical approaches is discussed, alongside innovations such as laparoscopic appendicectomy, single-incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES), and endoscopic retrograde appendicitis therapy (ERAT). The impact of the COVID-19 pandemic on AA treatment, including adaptations in medical practices, is also explored.

CONCLUSIONS

This review highlights the significant historical developments in AA treatment and its pivotal role in advancing abdominal surgery.

The Impact of COVID-19 on Acute Surgeries in England Among the Under-25s: A Retrospective Study of 61,360 Appendicitis and 15,850 Testicular Torsion Admissions

BACKGROUND

Little is known about how COVID-19 impacted acute surgical activity for children and young people (CYP) across England. Appendicitis and testicular torsion are common surgical conditions where treatment delays can lead to avoidable complications. We undertook a retrospective national cohort study.

PRIMARY AIM

To describe monthly acute surgical activity in CYP during the COVID-19 pandemic. Secondary aim: To investigate evidence of delayed diagnosis and adverse outcomes, describing variations by age and socioeconomic deprivation.

METHODS

Acute hospital admissions with appendicitis or testicular pain for those under 18 were extracted using Hospital Episode Statistics. Interrupted time series modelling, Mann-Whitney and Pearson's Chi-Squared tests compared the first 14 pandemic months with the previous five years. Results were stratified by age (0-4s, 5-9s and 10-17s) and appendicitis type (all, simple and complex).

RESULTS

Admissions for appendicitis and testicular torsion fell significantly early in the COVID-19 pandemic. The proportion of children with complex appendicitis also increased during this time. Orchidectomy rates rose in April 2020 for the 0-4s (+15.6% (95% CI 7.9-23.3)) and 10-17s (+11.5% (4.9-18.2)), but when the pre-pandemic period was compared with the pandemic period as a whole, there were no overall statistically significant differences in orchidectomy rates between the study periods. Overall, there was a statistically significant rise in the orchidopexy rate during the pandemic period for the 10-17s when compared with the pre-pandemic period (Pre-pandemic: 17.0% vs Pandemic: 20.9%, p < 0.0001).

CONCLUSION

A consistent reduction in activity, with short-lived periods of delayed presentations during COVID-19 pandemic peaks, occurred without persisting overall increased complication rates. These results provide useful national context for smaller sized studies that reported complications due to delays in surgery. Future research could examine how reduced activity impacted other healthcare settings and treatment pathways.

LEVEL OF EVIDENCE

II.

Less Dose, Same Care: Evaluating Computed Tomography Utilization for Pediatric Appendicitis

BACKGROUND

An ultrasonography-first, magnetic resonance imaging-second protocol, and attention to dose reduction was implemented to reduce computed tomography rates for appendicitis at our institution. We aimed to compare current computed tomography usage and report radiation doses at our children's associated system hospitals and referring nonsystem hospitals.

METHODS

A retrospective study of pediatric patients who underwent appendectomy and had a preoperative computed tomography scan between June 2020 and June 2023 was performed. Demographics and imaging details were abstracted from the medical record. Size-specific dose estimates and effective dose estimates were calculated for each computed tomography. Size-specific dose estimates were compared with American College of Radiology Dose Index Registry diagnostic reference levels.

RESULTS

Of 1,419 patients, 409 (29%) received a computed tomography for appendicitis, a 56% reduction from previous years (2012-2015) (P < .001). Overall, 352 computed tomography scans had dose data available, of which 291 (83%) were performed at system hospitals and 61 (17%) at nonsystem hospitals. The median size-specific dose estimate per computed tomography was 11.0 mGy (interquartile range 7.0, 17.4) for nonsystem hospitals and 9.1 mGy (interquartile range 6.6, 14.0) for system hospitals. The median effective dose per computed tomography was 6.7 mSv (interquartile range 4.3, 12.9) at nonsystem hospitals and 5.1 mSv (interquartile range 3.3, 9.4) at system hospitals. Nienty-three (n = 273) computed tomography scans performed at system hospitals and 30 computed tomography scans (n = 61) at nonsystem hospitals exceeded American College of Radiology Dose Index Registry age-based diagnostic reference levels.

CONCLUSION

The ultrasonography-first, magnetic resonance imaging-second protocol resulted in a significant decrease in computed tomography use for appendicitis diagnosis. Comparison of doses to American College of Radiology Dose Index Registry reference levels suggests that computed tomography protocol optimization may allow for dose reduction at some facilities.

Changes in the frequency, presentation and surgical outcomes of complicated appendicitis during the pandemic

OBJECTIVE

Coronavirus Disease 2019 (COVID-19) has affected every aspect of human life and all health care systems globally. The aim of this study was to investigate the effect of COVID-19 pandemic on the frequency, presentation and surgical outcomes of complicated appendicitis.

METHODS

Patients who underwent appendectomy for acute appendicitis one year before and one year after the declaration of the pandemic were investigated. Demographics and diagnostic findings as well as surgical and histopathological outcomes were recorded and statistically analyzed.

RESULTS

The study group of 409 patients was composed of 241 cases in the pre-pandemic group and 168 cases in the pandemic group revealing that the weekly total number of appendectomies decreased during the pandemic [pre-pandemic, median (IQR): 5 (3-6); pandemic, median (IQR): 3 (2-5); p=0.005]. The pandemic group was significantly associated with a longer time from emergency department admission to hospitalization, increased mean blood C-reactive protein levels and increased rate of postoperative complications (p=0.024, p=0.038 and p=0.004, respectively). Most importantly, pathological examinations revealed a higher number of complicated appendicitis cases in the pandemic group when compared to the pre-pandemic group [26 (15.5%) vs. 19 (7.9%), respectively] which corresponded to a 2.1-fold higher risk of being diagnosed with complicated appendicitis during the pandemic [OR: 2.1 (95% CI: 1.1-4.1), p=0.024].

CONCLUSION

While fewer appendectomies were performed during the pandemic, the incidence of complicated appendicitis and postoperative complications increased considerably.

Clinical management and complications of acute appendicitis in 3 children with SARS-CoV-2 infection: Case report

RATIONALE

Sporadic cases of acute appendicitis (AA) in children with SARS-CoV-2 infection were still recorded at the end of COVID-19 pandemics. We consider that analyses of clinical courses and outcomes is useful to improve the clinical management of such cases in the setting of a general hospital.

PATIENT CONCERNS

Patient #1 was a 14-year-old girl who presented with nausea, right lower quadrant (RLQ) pain, myalgia, ad low-grade fever for 24 hours. Patient #2 was a 7-year-old boy with a 3-day history of abdominal pain, nausea and vomiting, and fever lasting for 4 days. Patient # 3 was a 16-year-old girl RLQ pain, nausea and vomiting, and fever lasting for 7 days.

DIAGNOSES

The patients were diagnosed with acute appendicitis (AA) based on the clinical picture, labs and abdominal ultrasound (US) findings. SARS-CoV- 2 infection was diagnosed using rapid antigen test performed at admission.

INTERVENTIONS

The patients were started on i.v. Ceftriaxone and Metronidazole, antalgics and i.v. fluids at admission. Appendectomy was performed the day after admission in patients # 1 and #2, and after 48 hours in patient #3.

OUTCOMES

Patient #1 had no complications and was discharged on postoperative day (POD) #5. Patient #2 developed a cecal fistula on POD #4 which was treated conservatively with Ertapenem, i.v. fluids, and local placement of colostomy bag. The fistula closed spontaneously on POD #12. He was discharged on POD #17. Patient #3 developed a postoperative abscess on POD # 6 and required laparoscopic surgical drainage of the abscess. She was discharged after another 6 days (POD #12). No patient required ICU admission, steroids, or supplemental O2 use during their hospitalization. There were no late complications or readmissions in these patients.

LESSONS

We consider that AA in these SARS-CoV-2 positive children had a similar course with SARS-CoV-2 negative cases. Compliance to previously established COVID-19 protocols was useful to improve the outcome. The parents should bring the sick child early to the hospital in order to avoid complications related to delayed presentation and not to SARS-CoV-2 infection itself.

The Advancement of Appendicitis in Children in the Pre-Pandemic and the Pandemic Year

Background: The COVID-19 pandemic affected the health of millions of people, both directly through infection and indirectly through delayed diagnosis and treatment of non-COVID-19 illnesses. The aim of this study was to check the impact of the COVID-19 pandemic on the diagnosis and treatment of appendicitis in children. Methods: The study was carried out at the Department of Paediatric Surgery of the Marciniak Hospital (Wrocław, Poland) and covered two periods, the pre-pandemic one (P1, 01/03/2019-29/02/2020) and the pandemic one (P2, 01/03/2020-28/02/2021). Results: The number of admissions of patients with suspected appendicitis and observation-only patients decreased during the pandemic (400/289 and 226/160, respectively). Although the number of operated children was similar during both analyzed periods (P1: 174, P2: 160), the rate of surgical interventions was significantly higher during P2 (55.4%) than during P1 (43.5%) (χ2 test: p = 0.00272). The values of the variables quantifying disease progression and severity of inflammation, selected inflammation-related parameters detected by laboratory blood tests, latencies from the onset of symptoms to the admission and from the admission to the operation, and total duration of hospitalization did not differ significantly between the pre-pandemic and pandemic periods. Conclusions: These results show that the COVID-19 pandemic led to more rigorous and careful triage of pediatric patients suspected of acute appendicitis that did not have a negative impact on patient outcomes.

Analyzing the dynamics of complicated and uncomplicated appendicitis during the COVID-19 pandemic in Seoul, Korea: a multifaceted time series approach

OBJECTIVES

This study investigated the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated control strategies on the incidence of appendicitis in Seoul, using data from 2018 to 2020 from Korea's National Health Insurance.

METHODS

We analyzed records of total, complicated, and uncomplicated appendicitis cases, as well as the ratio of complicated to uncomplicated appendicitis, using natural spline and piecewise regression models to identify trends and breakpoints. Bayesian structural time-series (BSTS) models were used to evaluate the causal impact of social distancing on appendicitis incidences.

RESULTS

The spline regression analysis indicated decreasing trends in both total and uncomplicated appendicitis cases. Conversely, the incidence of complicated appendicitis and the ratio of complicated to uncomplicated cases increased. Breakpoints for a decline in uncomplicated appendicitis and a rise in the ratio occurred at 31 weeks in 2020 (95% confidence interval [CI], 23.2 to 38.8) and at 33.9 weeks (95% CI, 28.3 to 39.6), respectively. The BSTS model demonstrated a 7.8% reduction in total appendicitis cases (95% credible interval [CrI], -12.1 to -3.3). It also showed a 17.4% decrease in uncomplicated cases (95% CrI, -22.2 to -12.3) and increases of 12.8% (95% CrI, 4.9 to 22.0) in complicated cases and 39.0% (95% CrI, 27.0 to 53.3) in the ratio of complicated to uncomplicated appendicitis.

CONCLUSIONS

The COVID-19 pandemic resulted in a decrease in both total and uncomplicated appendicitis cases, while the number of complicated cases increased. Reduced medical visits likely accounted for these changes. Strategies are needed to manage changes in disease pathophysiology resulting from altered healthcare utilization during health crises.

Influence of the COVID-19 pandemic on the defined daily dose of antimicrobials in patients requiring elective and emergency surgical procedures

BACKGROUND

The COVID-19 pandemic has resulted in great incertitude and overwhelming changes in healthcare that have had a direct impact on antibiotic prescription. However, the influence of this pandemic on antibiotic consumption in patients undergoing surgery has not yet been analysed. The goal of this study was to analyse antimicrobial consumption and prescription in the same period of 2019 (pre-COVID-19), 2020 (beginning of the COVID-19 pandemic) and 2021 (established COVID-19) according to the DDD system in surgical patients at a tertiary-level hospital.

METHODS

A prospectively maintained database was analysed. All patients who underwent elective or emergency gastrointestinal surgery during the same period (2019, 2020 and 2021) were included. Those who received at least 1 of the 10 most frequently prescribed antimicrobials during those periods were analysed.

RESULTS

A total of 2975 patients were included in this study. In 2020, the number of procedures performed decreased significantly (653 versus 1154 and 1168 in 2020 versus 2019 and 2021, respectively; P = 0.005). Of all patients who underwent surgery during these periods, 45.08% received at least one of the antimicrobials studied (45.8% in 2020 versus 22.9% and 22.97% in 2019 and 2021, respectively; P = 0.005). Of these, 22.97% of the patients received a combination of these antimicrobials, with ceftriaxone/metronidazole being the most frequent. Hepato-Pancreato-Biliary and Liver Transplant, Emergency Surgery and Colorectal Surgery units had higher antibiotic consumption.

CONCLUSIONS

The COVID-19 pandemic has resulted in a significant decrease in surgical activity and higher post-operative antimicrobial prescription compared with previous and subsequent years.

Appendectomy: Cross-sectional study of the effects of COVID-19 in a hospital in South Brazil

Background

COVID-19 has further burdened the Brazilian healthcare system, especially emergencies. Patients may have delayed seeking care for surgical abdominal pain. Delays in the approach may have impacted clinical evolution and outcomes. This study evaluated appendectomies and their complications performed by the public system during one-year follow-up of COVID-19 in a hospital in southern Brazil.

Materials and methods

In this hospital-based cross-sectional study, we included adult patients who underwent appendectomy from March 2019 to April 2021 (n = 162). Patients were divided into pre-pandemic (n = 78) and pandemic (n = 84) groups based on the surgery date. The analyzed variables included hospitalization duration, intensive care unit (ICU) admission, surgical approach, histopathological findings, COVID-19 testing, patient outcomes, and 30-day survival rate.

Results

The cohorts exhibited similar epidemiology, with the sex ratio and average age being maintained. No statistical difference was found in the 30-day survival rate and clinical outcomes. Of the four patients admitted to the ICU, three belonged to the pandemic cohort and tested negative for COVID-19. Only 47.6 % of the patients in the pandemic cohort underwent COVID-19 polymerase chain reaction examination; one tested positive (2.5 %).

Conclusion

This study demonstrated that there was no increased risk for appendectomies during the first wave of the pandemic. Surgeries were safe during this period. Patients continued to access the emergency service despite surgical abdominal pain and restrictive measures imposed by health authorities. The similar results observed across cohorts are attributed to the readiness of the teams and the availability of medical surgical equipment in safe quantities.

Effects of the COVID-19 pandemic on short-term postoperative outcomes of emergency surgery for gastroduodenal perforation: A nationwide study in Japan based on the National Clinical Database

Aim

To examine the potential negative effects of the COVID-19 pandemic on short-term postoperative outcomes of emergency surgery for gastroduodenal perforation in Japan.

Methods

A total of 7973 cases of gastroduodenal perforation from 2019 to 2021 were retrieved from the National Clinical Database (NCD), which includes >95% of surgical cases in Japan. Data were analyzed nationally and in subgroups for subjects in areas with high infection levels (HILs). Postoperative 30-d mortality, surgical mortality, and complications (Clavien-Dindo (CD) grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1.

Results

Nationally, data from 2019 vs 2020 and 2021 showed 30-d mortality of 175 (6.7%) vs 398 (7.4%), surgical mortality of 250 (9.5%) vs 537 (10.1%), and complications (CD ≥3) of 558 (21.2%) vs 1163 (21.8%). Among these data, the only significantly high SMR was found for complications in July 2020 (1.36 [95% CI: 1.001-1.80]). In areas with HILs, data from 2019 vs 2020 and 2021 indicated 30-d mortality of 91 (6.3%) vs 215 (7.3%), surgical mortality of 135 (9.4%) vs 294 (10.0%), and complications (CD ≥3) of 304 (21.1%) vs (23.1%). In these data, no month had a significantly high SMR.

Conclusion

The COVID-19 pandemic had few negative effects on outcomes after surgery for gastroduodenal perforation. These findings suggest that the emergency system for gastroduodenal perforation in Japan was generally maintained during the pandemic.

Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial

Importance

Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking.

Objective

To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up.

Design, Setting, and Participants

This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298).

Interventions

Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days.

Main Outcomes and Measures

The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design.

Results

After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave.

Conclusions and Relevance

This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03236961.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

Comparison of Clinical, Pathological, and Procedural Characteristics of Adult and Pediatric Acute Appendicitis before and during the COVID-19 Pandemic

BACKGROUND

This study aims to analyze the impact of the COVID-19 pandemic on the clinical, pathological, and surgical characteristics of acute appendicitis (AA) at the University Hospital Centre (UHC) Zagreb.

METHODS

This retrospective study analyzed demographic, clinical, and surgical data from consecutive AA patients. Data were collected from an electronic database for two periods: 1 January to 31 December 2019 (pre-COVID-19), and 11 March 2020, to 11 March 2021 (COVID-19 pandemic).

RESULTS

During the two study periods, 855 appendectomies were performed, 427 in the pre-pandemic, and 428 during the pandemic. Demographic data were comparable between groups. There was statistically no significant difference in the type of appendectomy (p = 0.33) and the median hospital length of stay (3; (2-5) days, p = 0.08). There was an increase in the conversion rate during the pandemic period (4.2% vs. 7.7%, p = 0.03). The negative appendectomy rate and the incidence of perforated AA did not differ significantly (p = 0.34 for both).

CONCLUSIONS

We did not observe a significant increase in the rate of AA complications during the COVID-19 pandemic at the UHC Zagreb. This may be attributed to two factors: (1) AA was diagnosed and treated as an emergency, which remained available during the pandemic, and (2) diagnostic and therapeutic protocols remained unaltered. We recommend a laparoscopic approach even during the COVID-19 pandemic.

Impact of COVID-19 on acute appendicitis presentation, management and pathology findings in adult and paediatric populations

BACKGROUND

We investigated the impact of the COVID-19 pandemic on trends of presentation, management and pathology findings in patients who underwent an appendicectomy for suspected acute appendicitis.

METHOD

The retrospective study reviewed patients (n = 939 adults and n = 329 children) who had an appendicectomy performed for suspected acute appendicitis and histopathology assessment in the Belfast Health and Social Care Trust, Northern Ireland. Pre-COVID-19 (March 2019 to February 2020) and COVID-19 Year 1 (March 2020 to February 2021) data were compared. Chi-squared tests were applied to compare timeframes.

RESULTS

513 adult appendicectomies were performed in the immediate year pre-COVID-19, compared to 426 in COVID-19 Year 1, representing a 17% reduction. No such reduction was seen within the paediatric population, likely related to a change in regional paediatric referral criteria during the pandemic. When comparing COVID-19 Year 1 with pre-pandemic, fewer patients presented with <24 hours of symptoms (45% v 53%, p = 0.005), and there was greater use of pre-operative computed tomography imaging in adults (63.2% v 48.7%, p<0.001). Fewer adult and paediatric cases of simple acute appendicitis and non-diagnostic specimens, with relative increased proportions of perforated acute appendicitis, were observed in COVID-19 Year 1 compared with pre-pandemic. No absolute increase in perforated acute appendicitis cases was observed in adults.

CONCLUSION

Year 1 of the COVID-19 pandemic was associated with delayed presentation of acute appendicitis in adults and children. In adults, an overall reduction in appendicectomy operations, increased use of pre-operative diagnostic imaging, and fewer specimens showing simple acute appendicitis or non-diagnostic features, collectively support appropriate restriction of surgery for those patients with a more certain acute appendicitis diagnosis.

Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study

OBJECTIVE

To describe the COVID-19 pandemic's impact on acute appendicitis management on children and young people (CYP).

DESIGN

Retrospective cohort study.

SETTING

All English National Health Service hospitals.

PATIENTS

Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5-9s, 10-24s).

EXPOSURE

Study pandemic period: February 2020-March 2021. Comparator pre-pandemic period: February 2015-January 2020.

MAIN OUTCOME MEASURES

Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared.

RESULTS

101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5-9s (-18.4% (95% CI -26.8% to -10.0%)) and 10-24s (-28.4% (-38.9% to -18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to -54 procedures (-68.4 to -39.6) and -512 (-555.9 to -467.3) for the 5-9s and 10-24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5-9s (-15.5% (-23.2% to -7.8%)) and 10-24s (-44.8% (-57.9% to -31.6%) across all types, which was equivalent to -43 (-56.1 to 30.3) and -643 (-692.5 to -593.1) procedures for the 5-9s and 10-24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic.

CONCLUSIONS

For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.

Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy

INTRODUCTION

Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy.

MATERIAL AND METHODS

Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN).

RESULTS

A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group.

CONCLUSION

ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.

Causative microbes and antibiotic susceptibility of acute appendicitis in adults and children

BACKGROUND

In recent years, some studies have found that acute uncomplicated appendicitis can be treated with antibiotics alone. Because of the lack of relevant research on treating acute appendicitis in Taiwan, this study investigated the microbiological characteristics of acute appendicitis to permit accurate empirical antibiotic use for uncomplicated appendicitis.

METHODS

In this single-center retrospective cohort study, patients listed in the Taiwan National Health Insurance Research Database with a discharge diagnosis of acute appendicitis were identified. Data for bacterial specimens and antibiotic susceptibility tests among patients treated at Tri-Service General Hospital between January 2016 and December 2021 were analyzed.

RESULTS

Among 2805 patients diagnosed with acute appendicitis, 167 (6%) were <18 years old. The culture positivity rates among children and adults were 33% and 18%, respectively. In total, 367 aerobes and 207 anaerobes were isolated. The predominant aerobic gram-positive coccus was viridans group streptococci (8.9%), the most common aerobic gram-negative bacillus was Escherichia coli (27.9%), and the most common anaerobic microorganism was Bacteroides spp. (27.7%). The results of antibiotic susceptibility testing of the predominant microorganisms revealed that 86.3% of gram-positive aerobes were susceptible to ampicillin, 76.3% of gram-negative aerobes were susceptible to gentamicin, and all anaerobic isolates were susceptible to metronidazole.

CONCLUSION

Triple first-line antibiotic combination therapy, including ampicillin, gentamicin, and metronidazole, remains highly effective against the pathogens that cause acute appendicitis.

Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study

An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study

OBJECTIVE

To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19.

METHODS

From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21).

RESULTS

A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity.

CONCLUSION

This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

Diverticulitis patient care during the Covid-19 pandemic in Germany-a retrospective nationwide population-based cohort study

PURPOSE

Coronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany.

METHODS

This is a retrospective population-wide analysis of hospital billing data (2012-2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic.

RESULTS

Of a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%).

CONCLUSION

During lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection.

Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis

INTRODUCTION

The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic.

METHODS

Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared.

RESULTS

During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001).

CONCLUSIONS

Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.

Treatment of acute mesenteric ischemia between 2010 and 2020 - a German nation-wide study

BACKGROUND

Aim of this study was to analyze long-term trends of hospitalizations, treatment regimen and in-hospital mortality of in-patients with acute mesenteric ischemia (AMI) over the past decade and effects of the SARS-CoV2-pandemic.

METHODS

We analyzed fully anonymized data from the German Federal Statistical Office of patients with AMI between 2010 and 2020. Besides descriptive analyses of age, gender, in-hospital mortality, comorbidity burden and treatment regimen, multivariable logistic regression analyses were performed to identify independent variables associated with in-hospital mortality and different treatment.

RESULTS

A total of 278,121 hospitalizations (120,667 male [43.4%], mean age 72.1 years) with AMI were included in this study. The total number of hospitalizations increased from 2010 (n = 24,172) to 2019 (n = 26,684) (relative increase 10.4%). In-hospital mortality decreased over the past decade from 36.6% to 2010 to 31.1% in 2019 (rel. decrease 15.2%). Independent risk factors for in-hospital mortality were older age (OR = 1.03 per year), higher comorbidity burden (OR = 1.06 per point in van Walraven score [vWs]), male gender (OR = 1.07), AMI as a secondary diagnosis (OR = 1.44), and the need for surgical (visceral surgery: OR = 1.38, vascular surgery: OR = 3.33) and endovascular treatment (OR = 1.21). We report a decline in hospitalizations during the first wave of infection in spring 2020 (rel. decrease 9.7%).

CONCLUSION

In-hospital mortality rate has declined over the past decade, but remains high at above 30%. Older age, increased comorbidity and male gender are independent factors for in-hospital mortality. Hospitalizations requiring vascular surgery are associated with high in-hospital mortality, followed by visceral surgery and endovascular approaches. The first wave of the SARS-CoV2-pandemic in spring 2020 implied a decrease in hospital admissions.

Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review

Global pandemics cause health system disruptions. The inadvertent disruption in surgical emergency care during the Coronavirus Disease 2019 (COVID-19) pandemic has been the topic of several published studies. Our aim was to summarize the reasons that led to the delayed diagnosis of pediatric appendicitis during the COVID-19 era. This systematic literature search evaluated studies containing pediatric appendicitis patient data regarding outcomes, times to hospital admission or times from symptom onset to emergency department visit. Studies elucidating reasons for delays in the management of pediatric appendicitis were also reviewed. Ultimately, 42 studies were included. Several reasons for delayed diagnosis are analyzed such as changes to public health measures, fear of exposure to COVID-19, increased use of telemedicine, COVID-19 infection with concurrent acute appendicitis, recurrence of appendicitis after non-operative management and increased time to intraoperative diagnosis. Time to hospital admission in conjunction with patient outcomes was extracted and analyzed as an indicative measure of delayed management. Delayed diagnosis of acute appendicitis has been documented in many studies with various effects on outcomes. Suspicion of pediatric acute appendicitis must always lead to prompt medical examination, regardless of pandemic status. Telemedicine can be valuable if properly applied. Data from this era can guide future health system policies.

Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: a Systematic Review and Meta-analysis

BACKGROUND

Reports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to health care, but may be explained by a concomitant decrease in uncomplicated appendicitis. We analyze the impact of the pandemic on the incidences of complicated and uncomplicated appendicitis.

METHOD

We did a systematic literature search in the PubMed, Embase and Web Of Science databases on December 21, 2022 with the search terms (appendicitis OR appendectomy) AND ("COVID" OR SARS-Cov2 OR "coronavirus"). Studies reporting the number of complicated and uncomplicated appendicitis during identical calendar periods in 2020 and the pre-pandemic year(s) were included. Reports with indications suggesting a change in how the patients were diagnosed and managed between the two periods were excluded. No protocol was prepared in advance. We did random effects meta-analysis of the change in proportion of complicated appendicitis, expressed as the risk ratio (RR), and of the change in number of patients with complicated and uncomplicated appendicitis during the pandemic compared with pre-pandemic periods, expressed as the incidence ratio (IR). We did separate analyses for studies based on single- and multi-center and regional data, age-categories and prehospital delay.

RESULTS

The meta-analysis of 100,059 patients in 63 reports from 25 countries shows an increase in the proportion of complicated appendicitis during the pandemic period (RR 1.39, 95% confidence interval (95% CI 1.25, 1.53). This was mainly explained by a decreased incidence of uncomplicated appendicitis (incidence ratio (IR) 0.66, 95% CI 0.59, 0.73). No increase in complicated appendicitis was seen in multi-center and regional reports combined (IR 0.98, 95% CI 0.90, 1.07).

CONCLUSION

The increased proportion of complicated appendicitis during Covid-19 is explained by a decrease in the incidence of uncomplicated appendicitis, whereas the incidence of complicated appendicitis remained stable. This result is more evident in the multi-center and regional based reports. This suggests an increase in spontaneously resolving appendicitis due to the restrained access to health care. This has important principal implications for the management of patients with suspected appendicitis.

Impact of the COVID-19 Pandemic on the Severity and Early Postoperative Outcomes of Acute Appendicitis

Background The coronavirus disease 2019 (COVID-19) pandemic caused changes in surgical practice. For acute appendicitis (AA), measures to control the pandemic might hinder patients from seeking medical care timely, resulting in increasing severity, postoperative complications, and mortality. This study aimed to investigate whether the COVID-19 pandemic had a negative impact on the severity and postoperative outcomes of patients with AA. Methodology We retrospectively reviewed medical records of AA patients treated operatively at Nhan Dan Gia Dinh Hospital hospital from June 1st to September 30th in three consecutive years: pre-pandemic (2019)/Group 1, minor waves (2020)/Group 2, and major wave (2021)/Group 3 (2021). Data were collected focusing on the duration of symptoms, severity of AA, time from admission to operation, postoperative complications, and mortality. Results There were 1,055 patients, including 452 patients in Group 1, 409 in Group 2, and 194 in Group 3. The overall number of patients decreased mainly in non-complicated AA. The percentages of hospital admission after 24 hours gradually increased (20.8%, 27.9%, and 43.8%, p < 0.05). The percentages of complicated AA in Group 2 and Group 3 were statistically higher than in Group 1 (39% and 55% vs. 31%, p < 0.05). Waiting time for operation increased to five hours during the major wave. Laparoscopic appendectomy was performed in 98-99% of AA patients during the pandemic, with an early postoperative complication rate of 5-9% and a mortality rate of 0.2-1%. Conclusions Although the percentages of hospital admission after 24 hours and complicated AA increased, laparoscopic appendectomy was still feasible and effective and should be maintained as the standard management for AA during the COVID-19 pandemic.

Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.

METHODS

We searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.

RESULTS

Twelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73-0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31-0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41-1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70-2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36-1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69-1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28-6.74; z = 2.55; p = 0.011).

CONCLUSIONS

Although the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

The impact of the COVID-19 pandemic on the number of patients presenting with appendicitis to the emergency department

INTRODUCTION

The COVID-19 pandemic has had an influence on the number of patients presenting to the emergency department (ED) with surgical conditions.

AIM

To evaluate the number of patients presenting with acute appendicitis (AA) and the percentage of complicated appendicitis before and after the COVID-19 disease outbreak.

MATERIAL AND METHODS

This is a retrospective study based on the data of all patients presenting with AA to the ED of a tertiary COVID referral university hospital in Greece. We analysed the number of patients treated with AA, patient characteristics, and the proportion of patients with complicated appendicitis, and we compared the 2 groups of patients treated 12 months before and 12 months after COVID-19 onset in Greece.

RESULTS

A total of 152 patients were included in this study. There was a significant decrease in the number of patients presenting with AA after COVID-19 onset in Greece. Respectively, 91 and 61 patients were subjected to appendectomy 12 months before and after COVID-19 onset. Comparing the 2 groups of patients, there was a statistically significant increase in the operation time (p = 0.01) after COVID-19 onset, whereas the percentage of complicated appendicitis, the duration of symptoms before presenting to the ED (< 24 h, > 24 h), and the type of operation (laparoscopic, open, converted) did not differ significantly between the 2 groups of patients.

CONCLUSIONS

The number of patients presenting to the ED with AA decreased after COVID-19 onset, most likely because patients hesitated to seek help in a COVID-19 referral hospital.

Acute Appendicitis During The COVID-19 Pandemic: A Multicenter, Retrospective Analysis From The US Epicenter

BACKGROUND

Acute appendicitis (AA) is the most common surgical emergency, with a relatively stable yearly incidence. During the first wave of the COVID-19 pandemic, as New York City (NYC) emerged as the US epicenter, hospitals saw a marked reduction in patients presenting with non-COVID-related diseases. The objective of this study was to characterize the effects of the pandemic on the incidence, presentation, and management of AA.

METHODS

A retrospective analysis of patients with AA who presented to two academic medical centers during the NYC COVID peak (March 22nd-May 31st, 2020) was performed. This group was compared to a control cohort presenting during the same period in 2019. Primary outcomes included the incidence of AA, complicated disease, and management. Secondary outcomes included duration of symptoms, hospital length of stay, and complication rates. Statistical analyses were performed using Mann-Whitney U, Chi-square, and Fisher's exact tests.

RESULTS

A 49.1% reduction in the incidence of AA was seen between 2019 (n = 114) and 2020 (n = 58). Median duration of symptoms doubled from 1 day in 2019 to 2 days in 2020 (P < .02). Proportionally, the incidence of complicated appendicitis rose from 19.3% to 41.4% (P < .005). 32.4% of patients with uncomplicated AA underwent non-operative management in 2020, compared to 12% in 2019 (P < .02). Hospital length of stay and complication rates were similar between years.

DISCUSSION

Significantly fewer AA patients presented during the initial phase of the pandemic. Patients presented later, which may have contributed to a higher proportion of complicated disease. Surgeons were also more likely to treat uncomplicated AA nonoperatively than they were prior. Further research is needed to understand the long-term consequences of these changes.

Management of acute appendicitis during COVID-19 pandemic. Single center data from a tertiary care hospital in Germany

Objectives

The unexpected global overload of the health system during COVID-19 pandemic has caused changes in management of acute appendicitis worldwide. Whereas conservative treatment was widely recommended, the appendicectomy remained standard therapy in Germany. We aimed to investigate the impact of COVID-19 pandemic on treatment routine for acute appendicitis at University Hospital of Magdeburg.

Methods

Adult patients with clinical and/or radiological diagnosis of acute appendicitis were included in the single center retrospective study. Data was collected to patient demographics, treatment modality and outcomes including morbidity and length of stay. The patient data related to COVID-19 period from March 22, 2020 to December 31, 2021 (649 days) were compared to the Non-COVID-19 period from June 12, 2018 to March 21, 2020 (649 days). Subgroup analysis related to conservative or surgical treatment has been performed.

Results

A total of 385 patients was included in the study, 203 (52.73 %) during Non-COVID-19 period and 182 (47.27 %) during COVID-19 period. Mean age of entire collective was 43.28 years, containing 43.9 % female patients (p=0.095). Conservative treatment was accomplished in 49 patients (12.7 % of entire collective), increasing from 9.9 % to 15.9 % during COVID-19 period (p=0.074). Laparoscopic appendicectomy was performed in 99.3 % (n=152) of operated patients during COVID-19 period (p=0.013), followed by less postoperative complications compared to reference period (23.5 % vs. 13.1 %, p=0.015). The initiation of antibiotic therapy after the diagnosis increased from 37.9 % to 53.3 % (p=0.002) during COVID-19 period regardless the following treatment modality. Antibiotic treatment showed shorter duration during pandemic period (5.57 days vs. 3.16 days, p<0.001) and it was given longer in the conservative treatment group (5.63 days vs. 4.26 days, p=0.02). The overall length of stay was shorter during COVID-19 period (4.67 days vs. 4.12 days, p=0.052) and in the conservative treatment group (3.08 days vs. 4.47 days, p<0.001). However, the overall morbidity was lower during the COVID-19 period than before (17.2 % vs. 7.7 %, p=0.005) and for conservative therapy compared to appendicectomy (2 % vs. 14.3 %, p=0.016). There was no mortality documented.

Conclusions

According to our findings the COVID-19 pandemic had a relevant impact on treatment of acute appendicitis, but it was possible to maintain the traditional diagnostic and treatment pathway. Although laparoscopic appendicectomy remains a recommended procedure, the conservative treatment of uncomplicated appendicitis with excellent short-term outcome can be a safe alternative to surgery during potential new wave of COVID-19 pandemic and in the daily routine.

Increased Complications of Emergent Surgical Procedures During the First Wave of COVID-19

INTRODUCTION

Based on recommendations by CMS elective surgery was stopped during the first wave of COVID-19. Despite hospitals being open for emergent surgery, there were some studies that showed a decrease in surgical volume.

METHODS

A retrospective analysis for all surgeries from 185 affiliated hospitals from the first wave of the COVID-19 pandemic (March 2020 to May 2020) and as a comparison the previous year, March 2019 to May 2019 were obtained. Five surgeries were further analyzed: appendectomies, cholecystectomies, craniotomies, exploratory laparotomies, and endoscopic retrograde cholangiopancreatographies (ERCPs).

RESULTS

Between March 2019 and May 2019, 326,726 surgeries were performed, and between March 2020 and May 2020, 237,809 surgeries were performed. The highest specialty for both years was gastroenterology. In 2020, 15.7% of the patients were admitted to the ICU versus 13.7% in 2019. For appendectomies, cholecystectomies, craniotomies, exploratory laparotomies and ERCPs, there was an increase from 2019 to 2020 in acute kidney injuries rate, infection, systemic inflammatory response syndrome (SIRS), and sepsis. All the changes in surgical volumes for the five surgeries from 2019 to 2020 were significant. For appendectomy, the statistically significant complications were infection and SIRS and sepsis.

CONCLUSIONS

Across the board, there was a decrease in surgical volume during the COVID-19 pandemic first wave. There was a statistically significant decrease in appendectomy, cholecystectomy, exploratory laparotomy, craniotomy, and ERCP. For all five surgeries, we did see an increase in mortality rates and several complications. The only statistically significant complications were infection and SIRS and sepsis, for appendectomy.

Association of the Bacteria of the Vermiform Appendix and the Peritoneal Cavity with Complicated Acute Appendicitis in Children

BACKGROUND

Primary infection has been questioned as the pathogenetic cause of acute appendicitis. We attempted to identify the bacteria involved and to investigate if their species, types, or combinations affected the severity of acute appendicitis in children.

METHODS

Samples from both the appendiceal lumen and the peritoneal cavity of 72 children who underwent appendectomy were collected to perform bacterial culture analysis. The outcomes were studied to identify if and how they were associated with the severity of the disease. Regression analysis was performed to identify any risk factors associated with complicated appendicitis.

RESULTS

Escherichia coli, Pseudomonas aeruginosa, and Streptococcus species were the most common pathogens found in the study population. The same microorganisms, either combined or separate, were the most common in the appendiceal lumen and the peritoneal cavity of patients with complicated appendicitis. Gram-negative bacteria and polymicrobial cultures in the peritoneal fluid and in the appendiceal lumen were associated with complicated appendicitis. Polymicrobial cultures in the peritoneal cavity presented a four times higher risk of complicated appendicitis.

CONCLUSIONS

Polymicrobial presentation and Gram-negative bacteria are associated with complicated appendicitis. Antibiotic regimens should target the combinations of the most frequently identified pathogens, speculating the value of early antipseudomonal intervention.

Epidemiology and Outcome of Acute Appendicitis during and before the COVID-19 Pandemic: A Retrospective Single-Center Analysis

Background and Objectives: We investigated epidemiological factors and outcomes, including the development of complications, for patients with appendicitis according to three sequential coronavirus disease 2019 (COVID-19) pandemic periods, divided by specific time points. Materials and Methods: This observational study included patients with acute appendicitis who arrived at a single-center between March 2019 and April 2022. The study divided the pandemic into three periods: period A as the first phase of the pandemic (from 1 March 2020 to 22 August 2021), period B as the time period the medical system stabilized (from 23 August 2021 to 31 December 2021), and period C as the time period of the exploration of patients with COVID-19 in South Korea (from 1 January 2022 to 30 April 2022). Data collection was based on medical records. The primary outcome was presence or absence of complications and the secondary outcomes were the time taken from ED visit to surgical intervention, the presence and time of the first administration of antibiotics, and the hospital stay time. Results: Of 1,101 patients, 1,039 were included, with 326 and 711 patients before and during the pandemic, respectively. Incidence of complications was not affected during the pandemic (before the pandemic 58.0%; period A 62.7%; period B,55.4%; and period C 58.1%; p = 0.358). Time from symptom onset to emergency department (ED) arrival significantly decreased during the pandemic (before the pandemic 47.8 ± 84.3 h; pandemic 35.0 ± 54 h; p = 0.003). Time from ED visit to the operating room was statistically significantly increased during the pandemic (before the pandemic 14.3 ± 21.67 h; period A 18.8 ± 14.02 h; period B 18.8 ± 8.57 h; period C 18.3 ± 12.95 h; p = 0.001). Age and time from symptom onset to ED arrival were variables affecting the incidence of complications; however, they were not affected during the pandemic (age, OR 2.382; 95% CI 1.545-3.670; time from symptom onset to ED arrival, OR 1.010, 95% CI 1.006-1.010; p < 0.001). Conclusions: This study found no differences in postoperative complications or treatment durations between pandemic periods. The incidence of appendicitis complications was significantly influenced by age and the duration between the onset of symptoms and arrival at the emergency department, but not by the pandemic period itself.

Impact of the COVID-19 pandemic on the outcomes of laparoscopic appendectomy for acute appendicitis

Purpose

This retrospective study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the time interval from symptom onset to surgery and on the operative outcomes of laparoscopic appendectomy for patients with acute appendicitis.

Methods

Between October 2018 and July 2021, laparoscopic appendectomy was performed in 502 patients with acute appendicitis admitted to Hallym University Chuncheon Sacred Heart Hospital in Chuncheon, Korea. We compared demographic data, serum levels of inflammatory markers, time to event of appendicitis, and operative outcomes between the pre-COVID-19 and post-COVID-19 pandemic groups.

Results

Laparoscopic appendectomy was performed in 271 patients in the pre-COVID-19 group and in 231 patients in the post-COVID-19 group. There were no differences in baseline characteristics, serum inflammatory marker levels, or the proportions of complicated appendicitis between the groups (25.1%, pre-COVID-19 vs. 31.6%, post-COVID-19; P = 0.106). The time intervals between symptom onset and hospital arrival (24.42 hours vs. 23.59 hours, P = 0.743) and between hospital arrival and the start of surgery (10.12 hours vs. 9.04 hours, P = 0.246) did not increase post-COVID-19. The overall 30-day postoperative complication rate did not differ significantly between the groups (9.6% vs. 10.8%, P = 0.650), and the severity of 30-day postoperative complications was also similar in both groups (P = 0.447).

Conclusion

This study demonstrates that hospitalization and surgeries were not delayed in patients with acute appendicitis and that the operative outcomes of laparoscopic appendectomy did not worsen despite the COVID-19 pandemic.

Comparing the 30-Day Mortality for Hip Fractures in Patients with and without COVID-19: An Updated Meta-Analysis

We conducted an updated meta-analysis to evaluate the 30-day mortality of hip fractures during the COVID-19 pandemic and assess mortality rates by country. We systematically searched Medline, EMBASE, and the Cochrane Library up to November 2022 for studies on the 30-day mortality of hip fractures during the pandemic. Two reviewers used the Newcastle-Ottawa tool to independently assess the methodological quality of the included studies. We conducted a meta-analysis and systematic review including 40 eligible studies with 17,753 patients with hip fractures, including 2280 patients with COVID-19 (12.8%). The overall 30-day mortality rate for hip fractures during the pandemic was 12.6% from published studies. The 30-day mortality of patients with hip fractures who had COVID-19 was significantly higher than those without COVID-19 (OR, 7.10; 95% CI, 5.51-9.15; I2 = 57%). The hip fracture mortality rate increased during the pandemic and varied by country, with the highest rates found in Europe, particularly the United Kingdom (UK) and Spain. COVID-19 may have contributed to the increased 30-day mortality rate in hip fracture patients. The mortality rate of hip fracture in patients without COVID-19 did not change during the pandemic.

Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children's hospitals

BACKGROUND

Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups.

METHODS

A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management.

RESULTS

Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients.

CONCLUSION

Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.

Impact of the COVID pandemic on major abdominal cancer resections in Germany: a retrospective population-based cohort study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is estimated to have claimed more than 6 million lives globally since it started in 2019. Germany was exposed to two waves of coronavirus disease 2019 in 2020, one starting in April and the other in October. To ensure sufficient capacity for coronavirus disease 2019 patients in intensive care units, elective medical procedures were postponed. The fraction of major abdominal cancer resections affected by these measures remains unknown, and the most affected patient cohort has yet to be identified.

METHODS

This is a register-based, retrospective, nationwide cohort study of anonymized 'diagnosis-related group' billing data provided by the Federal Statistical Office in Germany. Cases were identified using diagnostic and procedural codes for major cancer resections. Population-adjusted cancer resection rates as the primary endpoint were compared at baseline (2012-2019) to those in 2020.

RESULTS

A change in resection rates for all analyzed entities (esophageal, gastric, liver, pancreatic, colon, rectum, and lung cancer) was observed from baseline to 2020. Total monthly oncological resections dropped by 7.4% (8.7% normalized to the annual German population, P =0.011). Changes ranged from +3.7% for pancreatic resections ( P =0.277) to -19.4% for rectal resections ( P <0.001). Reductions were higher during lockdown periods. During the first lockdown period (April-June), the overall drop was 14.3% (8.58 per 100 000 vs. 7.35 per 100 000, P <0.001). There was no catch-up effect during the summer months except for pancreatic cancer resections. In the second lockdown period, there was an overall drop of 17.3%. In subgroup analyses, the elderly were most affected by the reduction in resection rates. There was a significant negative correlation between regional SARS-CoV-2 incidences and resections rates. This correlation was strongest for rectal cancer resections (Spearman's r : -0.425, P <0.001).

CONCLUSIONS

The pandemic lockdowns had a major impact on the oncological surgical caseload in Germany in 2020. The elderly were most affected by the reduction. There was a clear correlation between SARS-CoV-2 incidences regionally and the reduction of surgical resection rates. In future pandemic circumstances, oncological surgery has to be prioritized with an extra focus on the most vulnerable patients.

A critical appraisal on the treatment of acute appendicitis in pediatric population during the COVID-19 pandemic

Acute appendicitis is one of the most common causes of abdominal pain in children. During the coronavirus disease 2019 (COVID-19) pandemic, a delay in presentation to the emergency department and a higher rate of complicated appendicitis were observed. Traditionally, operative management (laparoscopic or open appendectomy) was thought to be the best treatment strategy for acute appendicitis. However, nonoperative management with antibiotics has gained popularity in managing pediatric appendicitis during the COVID-19 era. The pandemic has posed significant challenges in the management of acute appendicitis. Cancellation of elective appendectomies, delay in seeking care due to fear of contracting COVID-19 infection, and impact of COVID-19 infection in the pediatric population have resulted in higher rates of complications. Furthermore, multiple studies have reported multisystem inflammatory syndrome in children mimicking acute appendicitis, subjecting patients to unnecessary surgery. Therefore, it is imperative to update the treatment guidelines for the management of acute appendicitis in the pediatric population during and after COVID-19 times.

Variations in clinical course and surgical outcomes of acute appendicitis during COVID-19 Pandemic: a multicenter cohort study

BACKGROUND

COVID-19 pandemic has led to changes in the presentation and treatment of surgical pathologies. Therefore, we aim to describe the influence of the COVID-19 pandemic on the clinical presentation and management of acute appendicitis (AAp) and its surgical outcomes.

STUDY DESIGN

A multicenter cohort study with prospectively collected databases. Three high-volume centers were included and all patients over 18 years of age who underwent appendectomy for AAp were included. Multiple logistic regression and multinomial logistic regression were performed, and odds ratio, relative risk, and B-coefficient were reported when appropriate, statistical significance was reached with p-values < 0.05.

RESULTS

1.468 patients were included (709 in the pre-pandemic group and 759 in the COVID-19 group). Female patients constituted 51.84%. Mean age was 38.13 ± 16.96 years. Mean Alvarado's score was 7.01 ± 1.59 points. Open surgical approach was preferred in 90.12%. Conversion rate of 1.29%. Mortality rate was 0.75%. There was an increase of perforated and localized peritonitis (p 0.01) in the COVID-19 group. Presence of any postoperative complication (p 0.00), requirement of right colectomy and ileostomy (p 0.00), and mortality (p 0.04) were higher in the COVID-19 group. Patients in the pre-pandemic group have a lesser risk of mortality (OR 0.14, p 0.02, 95% CI 0.02-0.81) and a lesser relative risk of having complicated appendicitis (RR 0.68, p 0.00, 95% CI 0.54-0.86).

CONCLUSION

Complicated appendicitis was an unexpected consequence of the COVID-19 pandemic, due to surgical consultation delay, increased rates of morbidity, associated procedures, and mortality, influencing the clinical course and surgical outcomes of patients with AAp.

Risk of colorectal cancer after appendectomy: A systematic review and meta-analysis

BACKGROUND AND AIM

Appendectomy is associated with various diseases, but whether it increases the risk of colorectal cancer (CRC) remains uncertain. We conducted a systematic review and meta-analysis aimed at investigating the suggested correlation between appendectomy and CRC.

METHODS

Systematic retrieval was performed using the PubMed, Embase, Cochrane library, Web of Science, and ClinicalTrials.gov databases up to May 4, 2022, for studies reported the influence of appendectomy on CRC, colon cancer (CC) or rectal cancer (RC). Odd ratios (ORs) and 95% confidence intervals (CIs) of CRC after appendectomy were pooled using the random effects model. Subgroup analyses were carried on by region, sex, and tumor location.

RESULTS

Our search identified 1743 articles, of which 22 studies from three continents published between 1964 and 2022 were eligible for inclusion. Overall, people with appendectomy had a higher risk of CRC (OR = 1.31; 95% CI [1.05, 1.62]). But the risk for Europeans was not significant (OR = 0.94; 95% CI [0.87, 1.02]; I²  = 0%), while for Americans and Asians, appendectomy would increase the risk of CRC (OR = 1.68; 95% CI [1.15, 2.44]; I²  = 65% and OR = 1.46; 95% CI [1.04, 2.05]; I²  = 98%), especially in females and in developing countries. It is worth noting that appendectomy might be a protective factor for CC in European women (OR = 0.87; 95% CI [0.77, 0.98]; I²  = 0%).

CONCLUSIONS

Appendectomy may be a risk factor for CRC, with varying degrees in different populations. More high-quality cross-regional studies are needed for better clinical decision making.

Were surgical outcomes for acute appendicitis impacted by the COVID-19 pandemic?

BACKGROUND

The COVID-19 pandemic disrupted healthcare systems throughout the world. We examine whether appendectomy outcomes in 2020 and 2021 were affected by the pandemic.

METHODS

We conducted a retrospective cohort study of 30-day appendectomy outcomes using the ACS-NSQIP database from 2019 through 2021. Logistic regression and linear regression analyses were performed to create models of post-operative outcomes.

RESULTS

There were no associations between the time period of surgery and death, readmission, reoperation, deep incisional SSI, organ space SSI, sepsis, septic shock, rate of complicated appendicitis, failure to wean from the ventilator, or days from admission to operation. During the first 21 months of the pandemic (April 2020 through December 2021), there was a decreased length of hospital stay (p = 0.016), increased operative time (p < 0.001), and increased likelihood of laparoscopic versus open surgery (p < 0.001) in compared to 2019.

CONCLUSIONS

There were minimal differences in emergent appendectomy outcomes during the first 21 months of the pandemic when compared to 2019. Surgical systems in the US successfully adapted to the challenges presented by the COVID-19 pandemic.

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

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.

Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables

INTRODUCTION

Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process.

METHODS

Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created.

RESULTS

18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed.

CONCLUSION

Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.

The role of IL-6, thiol-disulfide homeostasis, and inflammatory biomarkers in the prediction of acute appendicitis in children: a controlled study

PURPOSE

This study aimed to examine the diagnostic value of IL-6, thiol-disulfide homeostasis, complete blood count and inflammatory biomarkers in the prediction of acute appendicitis in children.

METHODS

The study was designed as a prospective and controlled study in children-the study was conducted at a tertiary referential university hospital between May 2020 and April 2021. Patients were divided between study groups and one control group (CG): 1: confirmed acute appendicitis group (AAP); 2: perforated appendicitis group (PAP); and 3: non-specified abdominal pain (NAP). The age and gender of the patients were determined. The following listed laboratory parameters were compared between groups: TOS: total oxidative status, TAS: total antioxidant status, OSI: oxidative stress index, TT: total thiol, NT (µmol/L): native thiol, DIS: disulfide, IL-6: interleukin 6, TNF-a: tumor necrosis factor-alpha, WBC: white blood cell, NEU: neutrophil, NEU%: neutrophil percentage, LY: lymphocyte, LY%: lymphocyte percentage, PLT: platelet, MPV: mean platelet volume NLR: neutrophil lymphocyte ratio, CRP: C-reactive protein, LCR: lymphocyte CRP ratio, and serum lactate.

RESULTS

The TOS level of the PAP group was found to be significantly higher than that in the AAP, NAP and control groups (p = 0.006, < 0.001 and p < 0.001). TAS, TT, and NT levels in the PAP group were significantly lower than those in the AAP, NAP and control groups. OSI was significantly higher in the PAP group than in the other groups. The TT and NT levels of the NAP group were both similar to those of the control group. Serum DIS level was similar between the AAP and PAP groups, AAP and NAP groups, and NAP and control groups. Serum IL-6 and TNF-α levels were found to be significantly higher in the PAP group compared to those in all groups. The WBC, NEU, and NEU% values were found to be significantly higher in the PAP group than those in the NAP and control groups, while LY and LY% values were found to be significantly lower. PAP and AAP groups were found to be similar in terms of WBC, NEU, LYM, NEU%, and LYM% values. PLT and MPV values and serum lactate values did not show a significant difference between the groups. NLR was similar in the AAP and PAP groups. A significant increase in CRP versus a decrease in LCR was detected in the PAP group compared to that in the AAP group. Multivariate analysis demonstrated that only IL-6 has significant estimated accuracy rates as 80% for the control group, 78.8% for AAP, 96.9% for PAP, and 81.6% for NAP.

CONCLUSION

Rather than AAP, PAP caused significantly higher oxidative stress (increased TOS and OSI), and lower antioxidation capacity (decreased TT and NT). IL-6 levels can provide a significant stratification. Nevertheless, simply detecting WBC or CRP is not enough to distinguish the specific pathology in acute appendicitis and related conditions.

Effects of COVID-19 Pandemic on the Frequency of Complicated Appendicitis in Pediatric Populations

Background: The clinical course of acute appendicitis, one of the most common diseases needing surgical intervention in children, was affected by the coronavirus disease 2019 (COVID-19) pandemic. The global fear and panic about the outbreak and governmental decisions on lockdowns and restrictions led to an increasing number of complicated forms of appendicitis. Objectives: This study aimed to compare different aspects of appendicitis and its complications between the pre-pandemic and pandemic periods. Methods: In a retrospective cross-sectional analytical study, we enrolled all patients with a diagnosis of acute appendicitis for two consecutive years. Only children under 14 years of age were included in the study. The patients were divided into two groups based on the time of disease presentation, the pre-pandemic and pandemic periods. Demographic features, as well as clinical, laboratory, and imaging findings, were compared between the two groups. Results: Out of 369 patients included in the study, 173 were placed in the pre-pandemic group. There was no significant change in the incidence of appendicitis between the two periods (P = 0.232). However, the incidence of complicated appendicitis increased remarkably during the pandemic (27% vs. 11%, P < 0.001). No substantial differences were found in parameters like age, sex, laboratory findings, and the length of hospital stay between the two groups (P > 0.005). The patients who tested positive for COVID-19 had a significantly higher hospitalization duration (P < 0.001). Conclusions: Our results suggested that the rate of complicated appendicitis was substantially higher during the pandemic compared to the pre-pandemic time. Also, the proportion of midline laparotomy was significantly higher after the outbreak. These findings suggested that delays in care provision during the COVID-19 outbreak could have probably contributed to the rise in the incidence of complicated appendicitis in children.