Dramatic decrease of surgical emergencies during COVID-19 outbreak

Evaluating the impact of the COVID-19 pandemic on outcomes of conversion and revisional bariatric surgery: a Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) study

BACKGROUND

The COVID-19 pandemic significantly impacted healthcare delivery worldwide, including bariatric surgery. While revisional procedures remained essential for weight recurrence and complications, practice patterns evolved during different phases of the pandemic.

OBJECTIVES

To evaluate the effect of COVID-19 on revisional bariatric procedures by comparing trends across pandemic (2020), vaccination rollout (2021), and postpandemic (2022) periods.

SETTING

Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, United States.

METHODS

Retrospective analysis of 72,189 bariatric surgeries (of which 55,854 conversions and 16,335 revisions) from 2020 to 2022. Outcomes included surgical volume, indications, complications, and mortality.

RESULTS

Of 609,240 bariatric procedures, 72,189 (11.8%) were revisional or conversion procedures, with conversions representing 9.2% (55,854) and revisions 2.7% (16,335). The combined proportion remained stable (12.1%, 12.1%, 11.5%, P < .001), but urgent revision rates were higher during the pandemic (3.1% versus 2.2% versus 1.8%, P < .001). Pandemic-era cases focused on severe complications (fistula, perforation, stricture), shifting postpandemic toward weight recurrence and reflux. Sleeve-to-bypass conversions increased from 41.2% to 53.6%. Serious complications were highest in 2020-2021 (6.6%, 6.4%) compared to 2022 (5.8%, P < .001), while mortality remained unchanged (.15%).

CONCLUSIONS

The study demonstrates distinct trends throughout pandemic periods, reflecting Centers for Disease Control and Prevention guidance on surgical urgency . While complication rates were slightly higher during the pandemic, procedures remained safe with stable mortality. Postpandemic shifts toward elective indications and increasing conversion procedures suggest adaptation to accumulated surgical needs.

Home care visits: The key to reducing loss to follow-up in emergency colorectal surgery

BACKGROUND

Emergency colorectal surgery has a high incidence of postdischarge complications, and loss to follow-up can delay the identification of complications. Amid evolving postdischarge care practices, it is important to assess predictors of loss to follow-up. We aimed to characterize the predictors of loss to follow-up.

METHODS

We conducted a retrospective institutional cohort study of patients ≥18 years undergoing emergency colorectal surgery at a tertiary hospital from 2016 to 2022. We excluded patients with in-hospital or 30-day mortality or a postoperative stay >30 days. We defined loss to follow-up as the absence of a postdischarge 30-day in-person or telehealth visit. The predictors of loss to follow-up were evaluated using stepwise regression analysis. We performed a subgroup analysis evaluating predictors of loss to follow-up among patients discharged post-telehealth availability at our institution (March 2020).

RESULTS

We included 426 patients, of whom 95 (22.3%) were loss to follow-up and 58.9% were discharged post-telehealth availability. Almost one half of patients were female (52.3%), and the majority were of White race (89.2%), and non-Hispanic (92.0%). Being male, being discharged to a skilled nursing facility, and prolonged hospitalization were risk factors for loss to follow-up, whereas receiving home care visits was protective. Post-telehealth availability, being male, and prolonged hospitalization were risk factors for loss to follow-up, whereas receiving homecare visits was protective. Patients who had a follow-up visit were less likely to be readmitted to the hospital and have a visit to the emergency department.

CONCLUSION

Receiving home care visits was the most protective factor for preventing loss to follow-up. Living far from the hospital remained a risk factor even post-telehealth availability. High-risk patients may benefit from targeted interventions that include scheduled home care visits.

Increased use of damage control laparotomy for emergency small bowel or colon surgery: does it affect patient outcomes?

PURPOSE

Evidence to guide the application of damage control laparotomy (DCL) in emergency surgery patients is limited. We assessed whether DCL use for emergent small bowel or colon surgery increased over time and its impact on outcomes. We hypothesized that DCL would be utilized more often in patients with significant comorbidities or septic shock with improved outcomes.

METHODS

National Surgical Quality Improvement Program (NSQIP) data on DCL patients from 2014 to 2020 were used. Endpoints were incidence of DCL, in-hospital mortality, hospital length of stay (LOS), complications, and 30-day readmission over time. P-values < 0.05 were considered statistically significant.

RESULTS

DCL incidence increased over time (OR = 1.07 [1.05-1.08], p < 0.001). Presence of pre-operative septic shock increased over the years (OR = 1.04 [1.01-1.07], p = 0.007). Mortality, readmission, and post-operative septic complications did not change over the study period. Average LOS significantly decreased over time (OR = 0.93 [0.92-0.95], p < 0.001).

CONCLUSION

The odds of a surgeon using DCL increased by 7% each year. Although pre-operative septic shock incidence increased, LOS decreased over time while mortality remained unchanged.

Enhancing the Understanding of Abdominal Trauma During the COVID-19 Pandemic Through Co-Occurrence Analysis and Machine Learning

BACKGROUND

This study examines the impact of the COVID-19 pandemic on abdominal trauma management by comparing pre-pandemic (17 February 2018-26 February 2020) and pandemic periods (27 February 2020-7 March 2022).

METHODS

Analyzing data from 118 patients at the Emergency County Clinical Hospital of Craiova, we identified significant shifts in clinical practices affecting patient outcomes.

RESULTS

During the pandemic, a moderate increase in surgical interventions for specific abdominal traumas indicated the effective adaptation of the medical system. Prioritizing critical cases and deferring non-urgent procedures optimized limited resources. Demographic and clinical factors-including age, sex, body mass index (BMI), and red cell distribution width (RDW)-significantly influenced the hospitalization duration and recovery outcomes. Gender disparities in mortality lessened during the pandemic, possibly due to standardized interventions and the physiological effects of SARS-CoV-2. The link between occupation and obesity highlighted how work environments impact trauma severity, especially as lifestyle changes affect BMI. While age remained a major predictor of mortality, its influence slightly decreased, potentially due to improved protocols for elderly patients. RDW emerged as an important prognostic marker for disease severity and mortality risk.

CONCLUSIONS

Employing advanced co-occurrence analysis enhanced with machine learning, we uncovered complex relationships between clinical and demographic variables often overlooked by traditional methods. This innovative approach provided deeper insights into the collective impact of various factors on patient outcomes. Our findings demonstrate the healthcare system's rapid adaptations during the pandemic and offer critical insights for optimizing medical strategies and developing personalized interventions in global crises.

Risk of appendiceal neoplasm in patients with appendix disorders

The most common appendicular disease is acute appendicitis, with a lifetime risk of 7%-8%. Complicated cases, which can occur in 2%-7% of patients, can significantly impact the severity of the condition and may require different management approaches. Nonoperative management with possible delayed appendectomy has been suggested for selected patients, however, there is a non-negligible risk of missing an underlying malignancy, which is reported to be as high as 11%. Diagnostic work-up is paramount to achieve optimal treatment with good results.

Retrospective registry-based nationwide analysis of the COVID-19 lockdown effect on the volume of general and visceral non-malignant surgical procedures

Introduction

Coronavirus disease 2019 (COVID-19) is an acute virus infection, which was declared a pandemic by the World Health Organization. The Swiss government decreed a public lockdown to reduce and restrict further infections. The aim of this investigation was to analyze the impact of the first COVID-19 lockdown on the performance of general and visceral surgery procedures.

Materials and Methods

A retrospective study was performed on the basis of the surgical registry of the working group for quality assurance in surgery ("Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie" or AQC). All patients with specific surgical diagnoses (complicated gastric or duodenal ulcer, acute appendicitis, hernia, diverticular disease, gallstone disease, pilonidal sinus, cutaneous and perianal abscess) were analyzed during 2019 and the corresponding lockdown period of March 14 through April 26, 2020. Data regarding patients' characteristics, diagnoses, and treatments were analyzed.

Results

In total, 3,330 patients were analyzed, with 2,203 patients treated in 2019 and 1,127 patients treated in 2020. There was a reduction in the number of all investigated diagnoses during the pandemic period, with statistically significant differences in acute appendicitis, hernia, diverticular disease, gallstone disease, pilonidal sinus (all p < 0.001), and cutaneous abscess (p = 0.01). The proportion of complicated appendicitis (p = 0.02), complicated hernia (p < 0.001), and complicated gallstone disease (choledocholithiasis p = 0.01; inflammation, p = 0.001) was significantly higher during the lockdown period. The surgical urgency rate in all patients was higher during the lockdown period compared to the control period (p < 0.001).

Conclusions

The socioeconomic lockdown significantly impacted the number of general and visceral surgery procedures in Switzerland. The reasons for the reduction are multifactorial.

A Correlation Study to Comprehend the SAR-CoV-2 Viral Load, Antiviral Antibody Titer, and Severity of COVID-19 Symptoms Post-infection Amongst the Vaccinated Population in Kamrup District of As sam, Northeast India

BACKGROUND

As per the recommendation of the United States Food and Drug Administration, more research is needed to determine the antibody titer against COVID-19 vaccination.

OBJECTIVE

The study aimed to understand the relationship between the antibody titer to the demographics, infection severity, and cycle threshold (CT) values of confirmed COVID-19 patients.

METHODS

Initially, we obtained consent from 185 populations and included sixty RT-PCRpositive COVID-19 patients from Kamrup District in the Northeast State of Assam, India. The vaccination status was recorded and tested for the level of serum immunoglobulin (IgG). The CT values, gender, and clinical symptoms-based scoring (CSBS) correlated with their IgG value.

RESULTS

Around 48% of participants gained an antibody titer more than the threshold value and showed CT values between 18-25. Moreover, the maximum distributed score above the average was found between the CT values 18-25.

CONCLUSION

The IgG titer value differs significantly amongst the vaccinated population, which may depend upon their genetic and demographic variability.

Impact of COVID-19 Vaccination on General Surgical Emergencies in Al-Qassim Region, Saudi Arabia: A Single-Center Retrospective Chart Review

Background This study sought to determine the COVID-19 pandemic and vaccination's effects on the number of patients presenting with emergent surgical illnesses or requiring emergency general surgical procedures. We compared the number of presenting cases and surgical emergencies before the pandemic, in 2019, and during the pandemic, before and after the COVID-19 vaccination's introduction. Method This observational retrospective chart review was conducted at a tertiary hospital in Al-Qassim, Saudi Arabia. The data were retrospectively collected for three periods (July 1 to September 30) in 2019, 2020, and 2021 using a data collection sheet for demographic data, visit date, comorbidities, emergency procedure type, COVID-19 test result, length of hospitalization, ICU admission status, and surgical case mortality. Results The study included 152 participants with a mean age of 36.1 (SD: 16) years, and 69.7% of them were male. Common surgical conditions were identified as acute appendicitis (49.3%), skin abscesses and pilonidal sinus (21.7%), and diabetic foot (9.2%) across all three years. The most frequent (48.7%) surgical procedure was appendectomy. A decrease in surgical emergencies rate was observed during the year 2020, as compared to 2019 and 2021. The general surgery emergency rate was highest in 2021 among patients admitted for procedures post-vaccination (38.8%). Conclusion Common surgical emergencies were most frequent in 2021, after the COVID-19 vaccine's introduction. Future research areas include the impact of the pandemic on delays or the severity and complication of surgical or medical cases.

Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

The Course and Surgical Treatment of Acute Appendicitis during the First and Second Wave of the COVID-19 Pandemic: A Retrospective Analysis in University Affiliated Hospital in Latvia

Background and Objectives: Acute appendicitis is the most common abdominal emergency requiring surgery and it has an estimated lifetime risk of 6.7 to 8.6%. The COVID-19 pandemic has transformed medical care worldwide, influencing diagnostic tactics, treatment modalities and outcomes. Our study aims to compare and analyze management of acute appendicitis before and during the first and second waves of the pandemic. Materials and Methods: Patients suffering acute appendicitis were enrolled retrospectively in a single-center study for a 10-month period before the pandemic (pre-COVID-19 period: 1 March to 31 December 2019) and during the pandemic (COVID-19 period: 1 March to 31 December 2020). The total number of patients, disease severity, diagnostic methods, complications, length of hospitalization and outcomes were analyzed. Results: A total number of 863 patients were included, 454 patients in the pre-COVID-19 period and 409 patients in the COVID-19 period. Compared to the pre-COVID-19 period, the number of complicated appendicitis increased in the COVID-19 period (24.4% to 37.2%; p < 0.001). The proportion of laparoscopic appendectomies increased during the COVID-19 period but did not show statistically significant differences between periods. In both time periods, we found that open technique was the chosen surgical approach more frequently in elderly patients (p < 0.001). Generalized peritonitis was significantly more common during the COVID-19 period (3.5% vs. 6.1%, p < 0.001). The postoperative course of patients was similar in the pre-COVID-19 period and during the COVID-19 period, with no significant differences in ICU admissions, overall hospital stay or morbidity. Conclusions: The COVID-19 pandemic has led to a significant increase in complicated forms of acute appendicitis; however, no significant impact was observed in terms of diagnostic or treatment approach.

Perioperative management of emergency and elective surgeries during the pandemic

The effects of the 2019 novel coronavirus, SARS-CoV-2, and its associated pandemic are complex and widespread. It has permeated all aspects of daily life around the world. Unsurprisingly, it also had significant impacts on proceedings within hospitals around the world as well. Most notably, the multiple waves of the pandemic have each had untoward effects on surgical productivity within hospital systems. More specifically, the disruption of surgical procedures has impacted both emergent and elective cases. In the context of emergent procedures, hospital systems have had to reevaluate how they define 'emergent,' forcing them to determine which cases could not be rescheduled versus those that could. Elective procedures, on the other hand, were nearly halted altogether in the initial pandemic waves. If these were not completely stopped in some places, then they were greatly reduced. This paper will serve to describe the effect the pandemic has had on the proceedings of both elective and emergent surgeries. It will also describe how we have reevaluated and changed the way we define 'emergent' surgeries and describe the potential implications of this. We will also describe literature that speaks to the implications of the delay of elective procedures. Additionally, the cost implications of fewer surgical procedures performed will be discussed. Finally, we will describe literature that has established protocols for scheduling surgeries in waves of the pandemic, how these have evolved over time, and how they have created confusion for hospital systems navigating the pandemic.

The impact of the COVID-19 outbreak on emergency general surgery in the first German "hotspot region" Aachen-Heinsberg-A multicentre retrospective cohort study

This study aimed to observe the impact of the COVID-19 outbreak on acute general surgery in the first German "hotspot" regions of Heinsberg and Aachen, during the first months of the pandemic. The incidence and severity of acute appendicitis, acute cholecystitis and mechanical bowel obstruction, were compared between March and May 2020 and a control period (same months of the previous three years). Pre-, intra- and postoperative data was compared between three regional hospitals of Heinsberg and the closest maximum care, university hospital. A total of 592 operated patients were included, 141 belonging to the pandemic cohort and 451 to the historic cohort. The pandemic group showed higher rates of clinical peritonitis (38% vs. 27%, p = 0.015), higher rates of mean white blood cell count (13.2±4.4 /nl vs. 12.3±4.7 /nl, p = 0.044) and mean C-reactive protein (60.3±81.1 mg/l vs. 44.4±72.6 mg/l, p = 0.015) preoperatively. Specifically in patients with acute appendicitis, there were less patients with catarrhal appendicitis (23% vs. 35%, p = 0.021) and a tendency towards more advanced histological findings in the pandemic cohort. In the university hospital, a 42% reduction in acute operated cases was observed at the onset of the pandemic (n = 30 in 2020 vs. n = 52 in 2019), whereas in the peripheral hospitals of Heinsberg there was only a 10% reduction (n = 111 in 2020 vs. n = 123 in 2019). The onset of the COVID-19 pandemic in our region was accompanied by advanced preoperative and intraoperative findings in patients undergoing emergency general surgery. A greater reduction in acute operated surgical cases was observed at the university hospital, in contrast to the smaller hospitals of Heinsberg, suggesting a possible shift of emergency patients, requiring immediate operation, from maximum care hospital to the periphery.

Estimating the potential overdiagnosis and overtreatment of acute appendicitis in Thailand using a secondary data analysis of service utilization before, during and after the COVID-19 lockdown policy

Introduction

Acute appendicitis is one of the most common surgical emergencies; however, optimal diagnosis and treatment of acute appendicitis remains challenging. We used the coronavirus disease 2019 (COVID-19) lockdown policy as a natural experiment to explore potential overdiagnosis and overtreatment of acute appendicitis in Thailand. The aim of this study was to estimate the potential overdiagnosis and overtreatment of acute appendicitis in Thailand by examining service utilization before, during, and after the COVID-19 lockdown policy.

Methods

A secondary data analysis of patients admitted with acute appendicitis under the Universal Coverage Scheme (UCS) in Thailand over a 6-year period between 2016 and 2021 was conducted. The trend of acute appendicitis was plotted using a 14-day rolling average of daily cases. Patient characteristics, clinical management, and outcomes were descriptively presented and compared among three study periods, namely pre-pandemic, lockdown, and post-lockdown.

Results

The number of overall acute appendicitis cases decreased from 25,407 during pre-pandemic to 22,006 during lockdown (13.4% reduction) and 21,245 during post-lockdown (16.4% reduction). This reduction was mostly due to a lower incidence of uncomplicated acute appendicitis, whereas cases of generalized peritonitis were scarcely affected by the pandemic. There was an increasing trend towards the usage of diagnostic computerized tomography for acute appendicitis but no significant difference in treatment modalities and complication rates.

Conclusion

The stable rates of generalized peritonitis and complications during the COVID-19 lockdown, despite fewer admissions overall, suggest that there may have been overdiagnosis and overtreatment of acute appendicitis in Thailand. Policy makers could use these findings to improve clinical practice for acute appendicitis in Thailand and support the efficient utilization of surgical services in the future, especially during pandemics.

The Challenges of Colorectal Cancer Surgery during the COVID-19 Pandemic in Romania: A Three-Year Retrospective Study

The predictions on the influence of the SARS-CoV-2 pandemic on access to medical services in Romania predicted a 35% drop in oncological hospitalizations in 2020 compared to the previous decade, raising the hypothesis that patients with colorectal cancer can become indirect victims of the ongoing pandemic. Therefore, the aim of the current research was to observe how the COVID-19 pandemic influenced colorectal cancer surgery in Romania, to determine the level of addressability towards specialized care, to compare the cancer staging between the pandemic and pre-pandemic periods, and to observe the risk factors for disease progression. This retrospective study was spread over three years, respectively, from March 2019 to March 2022, and included a total of 198 patients with a history of colorectal cancer surgery. It was decided to perform a parallel comparison of 2019, 2020, and 2021 to observe any significant changes during the pandemic. Our clinic encountered a significant decrease in all interventions during the pandemic; although the number of CRC surgeries remained constant, the cases were more difficult, with significantly more patients presenting in emergency situations, from 31.3% in 2019 to 50.0% in 2020 and 57.1% in 2021. Thus, the number of elective surgeries decreased significantly. The proportion of TNM (tumor-node-metastasis) staging was, however, statistically significant between the pre-pandemic and pandemic period. In 2019, 13.3% of patients had stage IIa, compared with 28.8% in 2020 and 13.1% in 2021. Similarly, the proportion of very advanced colorectal cancer was higher during the pandemic period of 2020 and 2021 (12.0% in 2019 vs. 12.5% in 2020 and 25.0% in 2021), which was represented by a significantly higher proportion of patients with bowel perforation. Patients with an advanced TNM stage had a 6.28-fold increased risk of disease progression, followed by lymphovascular invasion (HR = 5.19). However, the COVID-19 pandemic, represented by admission years 2020 and 2021, did not pose a significant risk for disease progression and mortality. In-hospital mortality during the pandemic also did not change significantly. After the pandemic restrictions have been lifted, it would be advisable to conduct a widespread colorectal cancer screening campaign in order to identify any instances of the disease that went undetected during the SARS-CoV-2 pandemic.

Safety of Three-Dimensional versus Two-Dimensional Laparoscopic Hysterectomy during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has resulted in a significant decrease in the number of surgical procedures performed. Therefore, it is important to use surgical methods that carry the lowest possible risk of virus transmission between the patient and the operating theater staff.

AIM

Safety evaluation of three-dimensional (3D) versus two-dimensional (2D) laparoscopic hysterectomy during the COVID-19 pandemic.

METHODS

44 patients were assigned to a prospective case-control study. They were divided either to 3D (n = 22) or 2D laparoscopic hysterectomy (n = 22). Fourteen laparoscopic supracervical hysterectomies (LASH) and eight total laparoscopic hysterectomies (TLH) were performed in every group. The demographic data, operating time, change in patients' hemoglobin level and other surgical outcomes were evaluated.

RESULTS

3D laparoscopy was associated with a significantly shorter operating time than 2D. (3D vs. 2D LASH 70 ± 23 min vs. 90 ± 20 min, p = 0.0086; 3D vs. 2D TLH 72 ± 9 min vs. 85 ± 9 min, p = 0.0089). The 3D and 2D groups were not significantly different in terms of change in serum hemoglobin level and other surgical outcomes.

CONCLUSIONS

Due to a shorter operating time, 3D laparoscopic hysterectomy seems to be a safer method both for both the surgeon and the patient. Regarding terms of possible virus transmission, it may be particularly considered the first-choice method during the COVID-19 pandemic.

Emergency General Surgery and COVID-19 Pandemic: Are There Any Changes? A Scoping Review

Background and Objectives: The pandemic of SARS-CoV-19 has affected the overall spectrum of General Surgery, either in the case management part, or in the type of cases. The purpose of this review is to gather all the parameters affected and to compare these changes between the pandemic period and the corresponding time frame of the previous year. Materials and Methods: A review of literature in two electronic databases (PubMed and Scopus) was performed examining studies during the pre-pandemic (March to May 2019) and pandemic (March to May 2020) period about emergency surgeries. The differences in case presentation in emergency rooms, patient characteristics, length of hospitalization, type of surgery, complications and mortality rate were compared. Results: The comparison of the studies revealed significant results highlighting the differences between the two time periods for each parameter. There has been observed an overall decrease in the number of cases presented for emergency and urgent surgery. In terms of age, sex, and BMI, there were no significant variations amongst the patients. About the length of hospitalization, the patients hospitalized longer during the pandemic period. In terms of pathologies, the most common types of surgery were appendectomy, gastrointestinal, and colorectal resection. Mortality did not differ between the two study periods. Conclusions: COVID-19 affected a large part of Emergency General Surgery mainly concerns the type of operations performed. The hospitalization of patients, the complications that may have arisen and the recognition of emergencies were the most important issues faced by health care officials in hospitals during the period of COVID-19; however, there were parameters like mortality and patients' characteristics that did not appear to differ with pre-pandemic era.

Acute Biliary Pancreatitis Management during the Coronavirus Disease 2019 Pandemic

(1) Objective: We aimed to analyze and describe the management of acute biliary pancreatitis (ABP) during the coronavirus disease 2019 (COVID-19) pandemic. (2) Methods: This was a retrospective cohort study among patients with ABP during a control period (16 March 2019 to 15 March 2020; period 1) and a COVID-19 period (16 March 2020 to 15 March 2021; period 2). (3) Results: We included 89 patients with ABP, being 58 in period 1 and 31 in period 2. The mean patient age was 62.75 ± 16.59 years, and 51 (57.3%) patients were women. The Quick Sequential Organ Failure Assessment score for sepsis and World Society of Emergency Surgery Sepsis Severity Score were significantly higher among patients in period 2. Twenty-two patients (37.9%) in period 1 and six (19.3%) in period 2 underwent cholecystectomy. There were no significant differences in surgical interventions between the two periods. The hospital mortality rate was 3.4 and 19.3% in period 1 and period 2, respectively. Mortality was significantly higher in period 2. Conclusion: During the COVID-19 pandemic, we observed a significant reduction in the number of patients with ABP but increased severity and mortality. Multicenter studies with more patients are needed to obtain additional evidence regarding ABP management during the COVID-19 pandemic.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R² = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R² = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

Acute Appendicitis During the COVID-19 Pandemic - Changes in Incidence and Clinical Presentation but not in Patients' Outcome

BACKGROUND

The COVID-19 pandemic is an ongoing severe issue. The aim of this study was to compare the incidence, severity and treatment of acute appendicitis (AA) before and during the COVID-19 pandemic.

METHODS

A retrospective cohort analysis was conducted between January 2019 and April 2020 in one high-volume center. A comparison was performed between two groups (group A: patients admitted with AA before the COVID-19 pandemic; group B: patients admitted with AA at the beginning of the pandemic) in terms of the incidence of AA and clinical and pathological outcomes. The incidence of AA was also analyzed in six surrounding peripheral hospitals.

RESULTS

A total of 94 patients were identified, 54 in group A and 40 in group B (57% vs. 43%). Demographic data was comparable between groups. AA in group B showed a significant higher rate of histological advanced cases (10 (18.5%) group A vs. 20 (50%) group B, p=0.001) and the need for postoperative antibiotic treatment (6 (11.1%) group A vs. 11 (27.5%) group B, p=0.045). During the pandemic, a higher percentage of patients was treated at peripheral hospitals (group A: 54/111 vs. 40/126).

CONCLUSION

During the onset of the COVID-19 pandemic there was a significant decrease of patients with AA in a high-volume center, which showed more advanced disease of AA. This significant decrease in the high-volume center correlates with an increase in patients with AA in peripheral hospitals and represents a change in patient flow during the onset of the pandemic.

Impact of the COVID-19 pandemic and the restrictions on pediatric appendicitis in Turkey: A single-center experience

BACKGROUND

In this study we investigated how the incidence and course of acute appendicitis (AA) changed in children during the pandemic.

METHODS

Children diagnosed with AA during the 1-year pandemic period after the first COVID-19 case in Turkey and the previous 1 year were included in the study. Children were divided into two groups: those hospitalized during the pandemic (group A) and those hospitalized in the year before the pandemic (group B). Furthermore, we compared the findings obtained for COVID-19-positive and COVID-19-negative children in the whole study group and within group A.

RESULTS

A significant difference was found between the two groups in terms of gender, the rate of vomiting and the number of days of vomiting. Complicated AA was more frequent in group B than in group A. In addition, the hospital stay was significantly longer, the mean number of days with fever was significantly higher, and mean body temperature was significantly higher in COVID-19-positive patients in the whole study group and within group A.

CONCLUSIONS

Contrary to most studies in the literature, in the present study the patients in the pre-pandemic period were admitted to hospital later, and this may have been associated with the higher frequency of complicated AA in these patients. During the pandemic, however, the arrangements and warnings of health authorities might have reduced the anxiety and the hesitancy of families to go to the hospital, and hence this may have been associated with the lower rate of complicated AA in this period.

Changes in volumes and severity of surgical urgencies during the first two COVID-19 pandemic waves in a regional hospital network

Background and aim This study analyses the impact of the first two pandemic waves on surgical urgencies/emergencies and their consequences on an entire provincial hospital network's surgical activities. Methods  Clinical and epidemiological data of urgent/emergent surgical admissions and interventions in the Autonomous Province of Trento's hospital network were collected from the internal common electronic database. The investigation periods were March-May 2019 (reference period), March-May 2020 (phase-I), June - August 2020 (phase-II), and October - December 2020 (phase-III). The same data were divided and grouped for the six most represented diagnoses. Results: The number of admissions for surgical emergencies in the studied periods showed a sinusoidal trend. In the reference period of 2019, 957 patients were admitted in urgency, while in the three pandemic phases, urgent admissions were 511, 888 and 633 respectively (-47% in phase I, - 8% in phase II, -34% in phase III). This trend was also observed by stratifying admissions for single disease, except for gastrointestinal perforations and pancreatitis, which showed a slight increasing trend in phase-I. Among the studied population, the surgical rate was 35.2% in phase-I and 34.3% in phase-III; these data were significantly higher than in 2019 (25.6%).  Conclusions The effect of the COVID pandemic on surgical emergencies and urgencies (SUEs) was mainly indirect, manifesting itself with a significant reduction in the number of surgical admissions, particularly in phases-I and-III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019.

Does the COVID-19 Pandemic Affect Morbidity and Mortality Rates of Emergency General Surgery? A Retrospective Study from a Single-Center Tertiary Greek Hospital

Background and Objectives: The outbreak of the COVID-19 pandemic had a major impact on all aspects of health care. Few up-to-date studies have actually assessed the impact of COVID-19 on emergency surgeries. The aim of this study was to provide an overview of the impact of the pandemic relating to the emergency surgery performed, as well as morbidity and mortality rates during the first year of the pandemic (March 2020–February 2021) and during the control period. In this period, the first propaedeutic surgery department and the third surgery department of the University General Hospital of Thessaloniki “AHEPA” in Greece provided continuous emergency general surgery services. Material and Methods: The study is in a retrospective cohort and included patients who were admitted to the Emergency Department and underwent emergency general surgery during the control period (n = 456), March 2019–February 2020 and during the first year of the pandemic (n = 223), March 2020–February 2021. Gender, age, type of surgical operation (morbidity), ICU need, the patient’s outcome, and days of hospitalization were compared. Results: A total of 679 emergency surgeries were included. Statistically significant differences emerged between the two time periods in the total number of emergency surgeries performed (p < 0.001). The most common type of surgery in the control period was associated with soft tissue infection while, during the pandemic period, the most common type of surgery was associated with the hepatobiliary system. In addition, the mortality rates nearly doubled during the pandemic period (2.2% vs. 4%). Finally, the mean age of our sample was 50.6 ± 17.5 and the majority of the participants in both time periods were males. Conclusions: The COVID-19 pandemic changed significantly the total number of emergency general surgeries performed. Mortality rates doubled and morbidity rates were affected between the control and pandemic periods. Finally, age, gender, length of hospitalization, intensive care unit hospitalization, and laparoscopy use in patients undergoing emergency surgery during the pandemic were stable.

The impact of COVID-19 pandemic on AMI and stroke mortality in Lombardy: Evidence from the epicenter of the pandemic

BACKGROUND

The first Covid-19 epidemic outbreak has enormously impacted the delivery of clinical healthcare and hospital management practices in most of the hospitals around the world. In this context, it is important to assess whether the clinical management of non-Covid patients has not been compromised. Among non-Covid cases, patients with Acute Myocardial Infarction (AMI) and stroke need non-deferrable emergency care and are the natural candidates to be studied. Preliminary evidence suggests that the time from onset of symptoms to emergency department (ED) presentation has significantly increased in Covid-19 times as well as the 30-day mortality and in-hospital mortality.

METHODS

We check, in a causal inference framework, the causal effect of the hospital's stress generated by Covid-19 pandemic on in-hospital mortality rates (primary end-point of the study) of AMI and stroke over several time-windows of 15-days around the implementation date of the State of Emergency restrictions for COVID-19 (March, 9th 2020) using two quasi-experimental approaches, regression-discontinuity design (RDD) and difference-in-regression-discontinuity (DRD) designs. Data are drawn from Spedali Civili of Brescia, one of the most hit provinces in Italy by Covid-19 during March and May 2020.

FINDINGS

Despite the potential adverse effects on expected mortality due to a longer time to hospitalization and staff extra-burden generated by the first wave of Covid-19, the AMI and stroke mortality rates are overall not statistically different during the first wave of Covid-19 than before the first peak. The obtained results provided by RDD models are robust also when we account for seasonality and unobserved factors with DRD models.

INTERPRETATION

The non-statistically significant impact on mortality rates for AMI and stroke patients provides evidence of the hospital ability to manage -with the implementation of a dual track organization- the simultaneous delivery of high-quality cares to both Covid and non-Covid patients.

Acute appendicitis severity during the early COVID-19 pandemic period

Background

The early COVID-19 pandemic period significantly strained the US healthcare system. During this period, consultations and admissions for acute medical conditions decreased, which was associated with an increase in disease-specific morbidity and mortality. Therefore, we sought to determine what, if any, effect the early COVID-19 pandemic period had on the presentation, management, and histopathologic severity of acute appendicitis.

Methods

We performed a retrospective, observational study to compare the frequencies with which patients presented with acute appendicitis, the proportion of whom were managed surgically, and the distribution of histopathologic disease severity among all resected appendix specimens during the early COVID-19 pandemic period (March 6-June 30, 2020) to equivalent time periods for the 3 preceding/pre-pandemic years (2017-2019).

Results

Compared with equivalent pre-pandemic time periods, during the COVID-19 pandemic period there was no significant difference in the number of patients who presented for acute appendicitis, there was a decreased rate of surgical management (81% vs 94%; p=0.014), and there was an overall increase in the incidence of perforated appendicitis (31% vs 16%; p=0.004), including by histopathologic diagnosis (25% vs 11%; p=0.01).

Discussion

Despite potential patient hesitancy to present for care, the early COVID-19 pandemic period was associated with no significant change in the number of patients presenting with acute appendicitis; however, there was a significant increase in the incidence of perforated appendicitis. This study highlights the need to encourage patients to avoid late presentation for acute surgical conditions and for the robust planning for the medical management of otherwise surgical abnormalities during episodes of restricted or limited resources.

Level of evidence

Level III.

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic? A scoping review

BACKGROUND

Acute colonic diverticulitis (ACD) is common in Western countries, with its prevalence increasing throughout the world. As a result of the coronavirus disease 2019 (COVID-19), elective surgery and in-patients' visits have been cancelled or postponed worldwide.

AIM

To systematically explore the impact of the pandemic in the management of ACD.

METHODS

MEDLINE, Embase, Scopus, MedxRiv, and the Cochrane Library databases were searched to 22 December 2020. Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible. For cross sectional studies, outcomes of interest included the number of hospital admission for ACD, as well as key features of disease severity (complicated or not) across two time periods (pre- and during lockdown).

RESULTS

A total of 69 papers were inspected, and 21 were eligible for inclusion. Ten papers were cross sectional studies from seven world countries; six were case reports; three were qualitative studies, and two review articles. A 56% overall decrease in admissions for ACD was observed during lockdown, peaking 67% in the largest series. A 4%-8% decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase. An initial non-operative management was recommended for complicated diverticulitis, and encouraged to an out-of-hospital regimen. Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination, societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.

CONCLUSION

During the COVID-19 pandemic, fewer patients presented and were diagnosed with ACD. Such decline may have likely affected the spectrum of uncomplicated disease. Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.

How have casemix, cost and hospital stay of inpatients in the last year of life changed over the past decade? Evidence from Italy

Healthcare utilisation and expenditure are highly concentrated in hospital inpatient services, in particular in end-of-life care with the peak occurring in the very last year of life, regardless of patient age. Few scientific studies have investigated hospital costs and stays of patients at the end of life, and even fewer studies have analysed their evolution over time. In this paper, we exploit hospitalisation data for the Lombardy region of Italy with the aim of studying the evolution of hospital casemix, costs and stays of chronic patients, and compare the last year of life of two cohorts of patients who died in 2005 and 2014. Despite an overall three-year increase in the age at death, the results showed a significant decrease in hospital costs and use due to reduced interventions and length of hospital stays. However, this was not associated with an increase in quality of life/conditions (as indicated by clinical casemix as a proxy) for end-of-life patients; patients' casemix characteristics and clinical condition, as measured by the number of comorbidities, disease severity, prevalence of pulmonary disease and heart failure diagnosis, significantly worsened over the decade. This gives rise to important health policy concerns on how to identify effective policies and possible changes in healthcare system organisation to move from hospital-centred care to a community-centred approach whose value has been demonstrated during the COVID-19 pandemic.

Impact of COVID-19 on surgical emergencies: nationwide analysis

Background

The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality.

Methods

This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region.

Results

During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40).

Conclusion

A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak

Purpose

To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak.

Methods

A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08).

Conclusions

During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons ‘decision making’ process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.

The decrease of non-complicated acute appendicitis and the negative appendectomy rate during pandemic

Background

During pandemic, admissions for surgical emergencies dropped down dramatically. Also acute appendicitis decreased. The aim of the present study was to evaluate the change in volume and clinical presentation of patients with acute appendicitis during pandemic and the variation in treatment.

Methods

This is a retrospective study of patients admitted in 11 Italian hospital for acute appendicitis during the lockdown period (March–April 2020) compared with the same period of the previous 2 years (2018–2019). The number and the rate of complicated and non-complicated acute appendicitis were recorded and compared between the two study periods; non-operative vs operative treatment and negative appendectomy rate were also recorded.

Results

The study included 532 patients, 112 in the study period and 420 in the control period; Hospital admission for acute appendicitis dropped by 46% (OR 0.516 95% CI 0.411–0.648 p < 0.001) during the 2020 lockdown. The number of complicated acute appendicitis did not change (− 18%, OR 0.763 95% CI 0.517–1.124 p = 0.1719), whereas the number of non-complicated acute appendicitis significantly decreased (− 56%, OR 0.424 95% CI 0.319–0.564 p < 0.001). Non-operative treatment rate remained similar (12.1% vs. 11.6% p = 0.434). The negative appendectomy rate also significantly decreased (6.1% vs. 17.3%, p = 0.006).

Conclusions

The present study found a significant reduction of both admissions for non-complicated acute appendicitis and negative appendectomy rate during the pandemic period. Conversely, admissions for complicated acute appendicitis did not change.

Trial registration: NCT04649996.

"Safer at home": The effect of the COVID-19 lockdown on epidemiology, resource utilization, and outcomes at a large urban trauma center

BACKGROUND

The COVID-19 pandemic has affected the entire global health care system. In California, because of a high burden of cases, a lockdown order was announced on March 19, 2020. This study investigated the impact of the lockdown on the epidemiology and outcomes of trauma admissions at the largest trauma center in Los Angeles.

METHODS

A retrospective study comparing epidemiological and clinical characteristics and outcomes of trauma admissions during the lockdown period (March 20, 2020, to June 30, 2020) to a similar period in the previous year (March 20, 2019, to June 30, 2019) was performed. Data collection included demographics, mechanism of injury, prehospital transportation, substance use, injury severity, resource utilization, and outcomes.

FINDINGS

There were 1,202 admissions during the lockdown period in 2020 and 1,143 during the same calendar period in 2019. Following the lockdown, there was a reduction in the automobile versus pedestrian admissions by 42.5%, motorcycle injuries by 38.7%, and bicycle accidents by 28.4% but no significant effect on the number of motor vehicle accident admissions. There was an increase in ground level falls by 32.5%, especially in the elderly group. The absolute number of gunshot wounds increased by 6.2% and knife injuries by 39.3%. Suicides increased by 38.5%. Positive testing for substance use increased by 20.9%. During the lockdown, patients suffered less severe trauma, with Injury Severity Score of <9 (p < 0.001), as well as less severe head (p = 0.001) and severe chest trauma (p < 0.001). Trauma deaths were reduced by 27.9%, and the crude overall mortality was significantly lower during the lockdown period (4.1% vs. 5.9%, p = 0.046). Intensive care unit admission rates, mechanical ventilation, and intensive care unit length of stay were all reduced.

CONCLUSION

The COVID-19 lockdown in 2020 had a significant effect on the epidemiology, clinical characteristics, and critical care resource utilization of trauma admissions in a large academic trauma center. These findings may help in planning and optimization of hospital resources during the pandemic.

LEVEL OF EVIDENCE

Epidemiological study, level III; Retrospective observational, level III.

A Community-Based Model to the COVID-19 Humanitarian Crisis

A multidisciplinary group, mainly from Bergamo region - the epicenter of the COVID-19 pandemic crisis in Italy on march 2020- has developed concept of creating intermediate care facilities and proposes a three-tier model of community-based care, with the goal of reducing hospital admissions, contagion and mortality related to hospital overloading and optimizing human resources.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand

Background

The New Zealand government instituted escalating public health interventions to prevent the spread of COVID‐19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity.

Results

There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length‐of‐stay, 30‐day mortality and admission diagnosis were comparable.

Conclusion

Despite a significant reduction in ED presentations, interventions for COVID‐19 did not result in a difference in the rate or severity of acute general surgical admissions.