COVID-19 and the treatment of acute appendicitis in Ireland: a new era or short-term pivot?

Operative Management of Acute Appendicitis is Safe During the COVID-19 Pandemic Shutdown

INTRODUCTION

In the spring of 2020, New York City was one of the first epicenters of the COVID outbreak. In this study, we evaluate the incidence and treatment of appendicitis in two New York City community hospitals during the COVID pandemic.

METHODS

This retrospective study focused on the incidence and outcome of acute appendicitis in the adult population (>18 y old) during peak-COVID periods (March 16, 2020,-June 15, 2020) compared to pre-COVID and post-COVID periods. We compared the number of patients who underwent operative versus nonoperative management, patient demographics, length of stay (LOS), complications, and readmission rates within these time periods. Data are presented as mean ± standard deviation (analysis of variance).

RESULTS

From January 1, 2020 to December 31, 2020, 393 patients presented with acute appendicitis and 321 (81.7%) were treated operatively, compared to 441 total and 366 treated operatively (83%) in 2019 (P = 0.88). During the COVID outbreak, fewer patients presented with appendicitis (mean 6.9 ± 1 pre-COVID case/week, 4.4 ± 2.4 peak-COVID cases/week and 7.6 ± 0.65 post-COVID cases/week, P = 0.018) with no significant difference in the pre-COVID and post-COVID period. There was no difference in LOS between the pre-, peak-, and post-COVID periods with a median of 1 for all the three, (interquartile range (IQR): 0.8-2, 0.6-2, 0.6-2, respectively, P = 0.43). Additionally, there was no difference in 30-day readmission rates (4.2%, 0%, 3.9%, P = 0.99) and postoperative complications (4.2%, 0%, 2.9%, P = 0.98).

CONCLUSIONS

During peak-COVID, there was a significant reduction in the number of patients who presented with acute appendicitis without a post rebound increase in presentation. Those who presented during peak-COVID were able to undergo operative management safely, without affecting LOS or postoperative complications.

COVID-19 outbreak and acute appendicitis: Does the lockdown has a influence on appendectomies?-A single center retrospective cohort study

OBJECTIVES

Healthcare systems have been negatively affected from COVID-19 pandemic worldwide. Elective surgical procedures were postponed and conservative treatment options were considered even in urgent conditions. This study aimed to explore the influence of the COVID-19 pandemic on urgent appendectomy in a pandemic hospital.

MATERIAL AND METHODS

Patients on whom appendectomy was performed between March 2020- June 2020 were included into the study (pandemic group). For comparison, control group patients were selected in the same period of 2019 (control group). Patients' demographics, laboratory and radiological findings, length of hospital stay, complications and histopathological findings of the groups were compared.

RESULTS

Forty-six patients were included in pandemic group and and one hundred-one in the control group. Patient characteristics were similar in both groups. There were no significant differences in type of surgery, complications, laboratory and histopathological findings. In the control group, length of hospital stay was longer when compared with the pandemic group.

CONCLUSION

Although the number of appendectomies performed decreased significantly during the COVID-19 pandemic, perioperative parameters were similar in both groups.

Impact of coronavirus disease on acute appendicitis cases

BACKGROUND

Disease profiles have changed in the COVID-19 pandemic. In this study, we aimed to compare acute appendicitis cases before and during the COVID-19 pandemic.

METHODS

A total of 130 patients were diagnosed with AA and operated between the days of first COVID-19 case on March 11, 2020, and May 11, 2020, and the same period of the previous year. Data of the patients were extracted from electronic archive of the hospital. Those patients were stratified into two groups; pandemic group and pre-pandemic group. The pandemic group comprised 46 patients and the pre-pandemic group, 84 patients. The two groups were compared in terms of age, gender, duration of symptoms, length of hospital stay, white blood cell count, C-reactive protein levels, and post-operative complications.

RESULTS

The median days passed from onset of abdominal pain to submission were 6.5 days in the pandemic period. However, it was 3 days in the pre-pandemic group (p<0.001). Other parameters were not statistically different between the groups (p>0.05).

CONCLUSION

During the COVID-19 pandemic period, delay in hospital submissions has attracted attention. However, delayed treatment did not reflect to the clinic as more severe disease.

Did the severity of appendicitis increase during the COVID-19 pandemic?

BACKGROUND

This study aimed to assess the severity of appendicitis during the coronavirus disease 2019 (COVID-19) pandemic, as patients with appendicitis may procrastinate seeking medical attention during the pandemic.

METHODS

Information on patients with appendicitis who were treated at the Taipei City Hospital during the COVID-19 pandemic (January 1, 2020 to June 30, 2020) was retrieved. Patients who were diagnosed with appendicitis and treated at the same hospital from January 1, 2019 to July 1, 2019 were designated as the control group. Multivariate logistic regression analysis was conducted to assess changes in the severity of appendicitis (at a 2-week interval) between the two groups.

RESULTS

We identified 307 (study group: 149; control group: 158) consecutive patients with appendicitis. The mean age was 46.2 +- 19.8 years. Between the two groups, there were no significant differences in age, sex, comorbidity, surgery type (laparoscopic or open appendectomy) or surgery time. The number of patients in the study group decreased between January 29, 2020 and April 21, 2020, which paralleled the period of spikes in the confirmed COVID-19 cases and restricted daily activities. The percentage of uncomplicated and complicated appendicitis (excluding mild appendicitis or normal appendix) in the study group increased between February 26 and March 10, as well as between April 8 and April 21. In the multivariate regression analysis, the odds of uncomplicated and complicated appendicitis increased in three bi-weeks for the study group but not in the control group.

CONCLUSION

The severity of acute appendicitis might increase during the COVID-19 pandemic, because patients with mild appendicitis (or abdominal pain) may hesitate to seek help.

COVID-19 pandemic changed the management and outcomes of acute appendicitis in northern Beijing: A single-center study

BACKGROUND

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, outcomes and management of many diseases have been affected. Acute appendicitis is a common acute abdomen. The incidence rate is 0.05%-0.5%. Studies reported that the number of patients with appendicitis admitted to emergency department significantly decreased since the pandemic. People avoided going to the hospital for fear of being infected. Different countries have different epidemic prevention measures that result in different treatment outcomes. The Chinese government also published some temporary measures in order to prevent the outbreak.

AIM

To explore the changes in management and outcomes of acute appendicitis during the COVID-19 pandemic in the North of Beijing.

METHODS

Patients with acute appendicitis admitted to Beijing Tsinghua Changgung Hospital between February and June 2019 and February and June 2020 were retrospectively reviewed. Cases were grouped according to admission year. The demographic characteristics, present illnesses, medical history, symptoms and signs, comorbidities, blood test results, imaging data, appendix pathology, and treatment details were compared.

RESULTS

Overall, 74 patients received nonsurgical treatment and 113 patients underwent surgical treatment in group 2019, whereas 159 patients received nonsurgical treatment and 26 patients received surgical treatment in group 2020. Fever, thick appendix, nonsurgical management, and uncomplicated appendicitis (simple or supportive appendicitis) were more common in group 2020 (P < 0.05). Among the nonsurgical management cases, the neutrophil percentage, neutrophil-to-lymphocyte ratio, and recurrence rate were higher in group 2020 (P < 0.05). Among surgically managed cases, there were more cases with gastrointestinal symptoms, peritonitis, ascites in the image, and intraoperative adhesion or ascites in group 2020 (P < 0.05). The white blood cell count, time from diagnosis to surgery, surgical time, and intraoperative blood loss were higher in group 2020 (P < 0.05).

CONCLUSION

During the COVID-19 pandemic, patients suffering from acute appendicitis in Beijing tended to present with severe symptoms and opt for nonsurgical treatment. For patients who underwent surgical management, the operation was delayed and more difficult during the pandemic. Nevertheless, the hospital stay and the incidence of postsurgical complications did not change.

A Review of SARS-CoV2: Compared With SARS-CoV and MERS-CoV

The outbreak of coronavirus disease 2019 (COVID-19) has been spreading rapidly in China and the Chinese government took a series of policies to control the epidemic. Studies found that severe COVID-19 is characterized by pneumonia, lymphopenia, exhausted lymphocytes and a cytokine storm. Studies have showen that SARS-CoV2 has significant genomic similarity to the severe acute respiratory syndrome (SARS-CoV), which was a pandemic in 2002. More importantly, some diligent measures were used to limit its spread according to the evidence of hospital spread. Therefore, the Public Health Emergency of International Concern (PHEIC) has been established by the World Health Organization (WHO) with strategic objectives for public health to curtail its impact on global health and economy. The purpose of this paper is to review the transmission patterns of the three pneumonia: SARS-CoV2, SARS-CoV, and MERS-CoV. We compare the new characteristics of COVID-19 with those of SARS-CoV and MERS-CoV.

Management of Acute Appendicitis in Children During COVID-19 and Perspectives of Pediatric Surgeons From South Asia: Survey Study

BACKGROUND

Nonoperative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and is potentially influenced by physician preferences. Owing to the effects of the COVID-19 pandemic on health care, the practice of NOT has generally increased by necessity and may, in a post-COVID-19 world, change surgeons' perceptions of NOT.

OBJECTIVE

The aim of this study was to determine whether the use of NOT has increased in South Asia and whether these levels of practice would be sustained after the pandemic subsides.

METHODS

A survey was conducted among pediatric surgeons regarding their position, institute, and country; the number of appendicitis cases they managed; and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). The survey also directly posed the question as to whether they would continue with the COVID-19-imposed level of NOT after the effect of the pandemic diminishes.

RESULTS

A total of 134 responses were collected out of 200 (67.0%). A significant increase in the practice of NOT was observed for the entire cohort, although no effect was observed when grouped by country or institute. When grouped by position, senior physicians increased the practice of NOT the most, while junior physicians reported the least change. The data suggest that only professors would be inclined to maintain the COVID-19-level of NOT practice after the pandemic.

CONCLUSIONS

Increased practice of NOT during the COVID-19 pandemic was observed in South Asia, particularly by senior surgeons. Only professors appeared inclined to consider maintaining this increased level of practice in the post-COVID-19 world.

Appendectomy during the COVID-19 pandemic in Italy: a multicenter ambispective cohort study by the Italian Society of Endoscopic Surgery and new technologies (the CRAC study)

Major surgical societies advised using non-operative management of appendicitis and suggested against laparoscopy during the COVID-19 pandemic. The hypothesis is that a significant reduction in the number of emergent appendectomies was observed during the pandemic, restricted to complex cases. The study aimed to analyse emergent surgical appendectomies during pandemic on a national basis and compare it to the same period of the previous year. This is a multicentre, retrospective, observational study investigating the outcomes of patients undergoing emergent appendectomy in March-April 2019 vs March-April 2020. The primary outcome was the number of appendectomies performed, classified according to the American Association for the Surgery of Trauma (AAST) score. Secondary outcomes were the type of surgical technique employed (laparoscopic vs open) and the complication rates. One thousand five hundred forty one patients with acute appendicitis underwent surgery during the two study periods. 1337 (86.8%) patients met the inclusion criteria: 546 (40.8%) patients underwent surgery for acute appendicitis in 2020 and 791 (59.2%) in 2019. According to AAST, patients with complicated appendicitis operated in 2019 were 30.3% vs 39.9% in 2020 (p = 0.001). We observed an increase in the number of post-operative complications in 2020 (15.9%) compared to 2019 (9.6%) (p < 0.001). The following determinants increased the likelihood of complication occurrence: undergoing surgery during 2020 (+ 67%), the increase of a unit in the AAST score (+ 26%), surgery performed > 24 h after admission (+ 58%), open surgery (+ 112%) and conversion to open surgery (+ 166%). In Italian hospitals, in March and April 2020, the number of appendectomies has drastically dropped. During the first pandemic wave, patients undergoing surgery were more frequently affected by more severe appendicitis than the previous year's timeframe and experienced a higher number of complications. Trial registration number and date: Research Registry ID 5789, May 7th, 2020.

The SARS-CoV-2 first wave impact in the acute inflammatory surgical pathologies

Anecdotal evidence suggests that community infection control measures during the COVID-19 outbreak have modified the number and natural history of acute surgical inflammatory processes (ASIP—appendicitis, cholecystitis, diverticulitis and perianal abscesses) admissions. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation and treatment ASIP and quantify the effect of COVID-19 infection on the outcomes of ASIP patients. This was a multicentre, comparative study, whereby ASIP cases from 2019, 2020 and 2021 (March 14th to May 2nd) were analyzed. Data regarding patient and disease characteristics as well as outcomes, were collected from sixteen centres in Madrid, and one in Seville (Spain). The number of patients treated for ASIP in 2019 was 822 compared to 521 in 2020 and 835 in 2021. This 1/3rd reduction occurs mainly in patients with mild cases, while the number of severe cases was similar. Surgical standards suffered a step back during the first wave: Lower laparoscopic approach and longer length of stay. We also found a more conservative approach to the patients this year, non-justified by clinical circumstances. Luckily these standards improved again in 2021. The positive COVID-19 status itself did not have a direct impact on mortality. Strikingly, none of the 33 surgically treated COVID positive patients during both years died postoperatively. This is an interesting finding which, if confirmed through future research with a larger sample size of COVID-19 positive patients, can expedite the recovery phase of acute surgical services.

Conservative management of acute appendicitis in the era of COVID 19: A multicenter prospective observational study at the United Arab Emirates

Background & Aims

Since its emergence in December 2019, the COVID-19 pandemic resulted in a profound impact on the health care system worldwide. We propose herein to evaluate the impact of implementing conservative management as an alternative approach to surgical appendectomy during COVID19 pandemic.

Materials and Methods

Our study is a prospective multicenter study that includes a cohort of 158 patients admitted to the surgical departments in both Tawam Hospital and SSMC hospital, Abu Dhabi, UAE, from February 2020 till July 2020.

Results

Our results showed a significant decrease in length of hospital stay (LOS) (2.32 ± 0.83 days) among conservatively treated group compared to the surgically treated group (2.8 ± 1.47 days). Also, short term follow-up showed that 90% of those patients did not require further operative intervention or developed complications. Out of the 110 patients that were swapped for COVID19, nine (8.18%) were confirmed to be positive. Our protocol was to avoid surgical management for COVID19 positive patients unless indicated. This resulted in (8/9) of COVID19 positive patients to be treated conservatively.

Conclusions

In conclusion, our results showed that the implementation of conservative management in treating patients with acute appendicitis who were COVID19 positive maybe essential in reducing viral transmission risks as well as avoiding operative risks on COVID19 positive patients.

The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access

Background

The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March–May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March–May 2020, group 2).

Methods

A comparison (groups 1 versus 2) and subgroup analysis were performed between patients’ demographic, medical history, surgical, clinical and management characteristics.

Results

Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08–4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33–5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89–11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05–25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01–63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11).

Conclusions

This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a “filter effect” induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

Concurrent COVID-19 infection in children with acute appendicitis: A report of three cases

Literature describing patients with concomitant COVID-19 infection with acute appendicitis in pediatric patients is growing, and understanding the clinical picture of such patients is relevant in their treatment. We report 3 male children who were surgically treated for acute appendicitis and had concomitant SARS-CoV-2 infection. Our first patient was a 12-year-old male who presented with symptoms indicative of appendicitis but no respiratory symptoms associated with COVID-19 (eg cough, shortness of breath). Laboratory evaluation revealed leukopenia and an elevated C-reactive protein; imaging was consistent with acute appendicitis and an acute pulmonary viral infection. Though he lacked diffuse peritonitis on physical examination or a leukocytosis, he was found to have perforated appendicitis in the operating room. Our second patient was another 12-year-old male whose suspected appendicitis was confirmed via ultrasound and surgery. He tested positive for COVID-19 1 month prior and he continued to test positive for infection on admission without any associated respiratory symptoms. Our third patient was a 13-year-old patient who also presented with symptomatic acute appendicitis without apparent COVID-19 manifestations. These cases provide further examples of pediatric patients with concomitant acute appendicitis and COVID-19 infection, namely an unusual presentation of perforated appendicitis with asymptomatic COVID-19-related pulmonary infection and the more common acute appendicitis with asymptomatic COVID-19 infection.

Successful maintenance of process and outcomes for oesophageal cancer surgery in Ireland during the first wave of the COVID-19 pandemic

Introduction

The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019.

Methods

Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared.

Results

In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period.

Conclusions

Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.

Acute Appendicitis in Children During the COVID-19 Pandemic: Neither Delayed Diagnosis Nor Worse Outcomes

AIM

The aim of this study was to describe the incidence of complicated appendicitis during the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic lockdown.

METHODS

This was a retrospective study of pediatric patients diagnosed with acute appendicitis in a single pediatric institution that assumed care responsibility for most of the pediatric emergencies during the lockdown period in Madrid (Spain). A control group was made up of the same number of patients diagnosed the previous year.

RESULTS

One hundred fifty-one patients diagnosed with acute appendicitis were included (77 during self-quarantine and 74 during the previous year). The incidence of complicated appendicitis was 38.9% versus 28.3%, showing no significant differences. The 2 groups were homogeneous, with no differences in time elapsed between symptom onset and first emergency department visit, laboratory test results, median length of stay, intensive care admissions, or patients correctly diagnosed on their first visit.

CONCLUSIONS

COVID-19 (coronavirus disease 2019) self-quarantine has not increased the incidence of complicated appendicitis, and children who developed complicated appendicitis did not have worse clinical outcomes. Parents did not delay presenting for medical attention, and emergency department pediatricians did not fail to diagnose this condition. Reorganization of hospital resources, fast-track treatment protocols for noncomplicated appendicitis, and extended use of home-stay hospitalization for complicated appendicitis could have contributed to these favorable outcomes.

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

Background

In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period.

Methods

All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison.

Results

There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR).

Discussion

The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

Effect of the COVID-19 pandemic on CT scans ordered from the emergency department for abdominal complaints

Purpose

The COVID-19 pandemic has affected healthcare systems and patients alike across the USA. We seek to elucidate changes in abdominal imaging ordered from the emergency department (ED) in a healthcare system undergoing non-surge conditions in April 2020 compared to April 2019.

Methods

We performed a retrospective, observational study comparing patients undergoing CT scans of the abdomen and pelvis ordered from the ED in April 2020 vs. April 2019 at a single healthcare center. Via review of the radiology report and electronic medical record, we determined the positive or negative status of these scans. We evaluated percentages of positive CT scans and differences in outcomes, including admission rates, interventions, and mortality.

Results

Comparing 2020 to 2019, there was a 31.6% decrease in the number of CT scans performed from the ED. We found a higher percentage of positive CT findings, 58.2% vs. 50.8% (p = 0.025), and increased admission rates, 40.8% vs. 34.1% (p = 0.036). Differences were found in rates of appendicitis, colitis, and cholangitis. No difference was found in ICU admissions, interventions, or in-hospital mortality.

Conclusion

During the COVID-19 pandemic in a region undergoing non-surge conditions, we found increased rates of positive CT scans performed from the ED for abdominal complaints with an increased percentage of hospital admissions compared to a control year. No differences in ICU admissions or rates of procedural intervention were found to suggest higher acuity of pathology on presentation. Our findings suggest appropriately decreased healthcare utilization in our study period, driven by pre-hospital patient self-selection.

Rate of Application and Outcome of Non-operative Management of Acute Appendicitis in the Setting of COVID-19: Systematic Review and Meta-analysis

BACKGROUND

Non-operative management (NOM) of acute appendicitis has been assessed in several studies before COVID-19 pandemic. This systematic review aimed to assess the extent of adoption, efficacy, and safety of NOM of acute appendicitis in the setting of COVID-19.

METHODS

This was a PRISMA-compliant systematic review of the literature. Electronic databases and Google Scholar were queried for studies that applied NOM of acute appendicitis during COVID-19. The main outcome measures were the rates of NOM application during the pandemic as compared to the pre-pandemic period, failure and complication rates of NOM. Failure was defined as the need for appendectomy during NOM and complications included development of appendicular mass or abscess.

RESULTS

Fourteen studies (2140 patients) were included. The male to female ratio was 1.44:1 and median age was 34. Nine hundred fifty-nine (44.8%) patients had a trial of NOM. The weighted mean rate of NOM application was 50.1% (95%CI: 29.8-70.5%). The application of NOM during the pandemic was significantly more likely than its application before COVID-19 (OR = 6.7, p < 0.001). The weight mean failure rate of NOM was 16.4% (95%CI: 9.4-23.4). NOM failure was more likely in children and patients with complicated appendicitis. The weighted mean complication rate after NOM was 4.5% (95%CI: 1.4-7.7). NOM had significantly lower odds for complications than appendectomy (OR = 0.36, p = 0.03). There was no mortality after application of NOM.

CONCLUSION

NOM of acute appendicitis in the setting of COVID-19 may be a safe, short-term alternative to surgery with acceptably low failure and complication rates.

The role of a pediatric tertiary care center in avoiding collateral damage for children with acute appendicitis during the COVID-19 outbreak

PURPOSE

To evaluate the impact of the COVID-19 pandemic-related lockdown on management and outcomes of children with acute appendicitis.

METHODS

A retrospective cohort study was conducted, including children treated for acute appendicitis (January 20th-May 11th, 2020). The data regarding the severity of appendicitis and outcome were collected and compared for two time periods, before and after the nationwide lockdown (March 17th, 2020).

RESULTS

The number of cases of acute appendicitis increased by 77% during the lockdown (n = 39 vs. n = 69, p = 0.03). During the lockdown, children treated for appendicitis were older (11.1 vs. 8.9 years, p = 0.003), and were more likely to live more than 5 km away from our institution (77% vs. 52%, p = 0.017). Less children had previously consulted a general practitioner (15% vs. 33%, p = 0.028), whereas more children were transferred from other hospitals (52% vs. 31%, p = 0.043). There was no difference in terms of length of hospital stay, rate of postoperative intra-abdominal abscess, ER visits, and readmissions between both periods. Three children (4%) were diagnosed with COVID-19 and appendicitis.

CONCLUSIONS

Despite an increase in the number of children with appendicitis managed at our hospital during the COVID-19-related lockdown, management, and outcome remained similar. Although our pediatric center was strongly affected by this pandemic, maintaining our prior practice strategies for acute appendicitis avoided the occurrence of collateral damage for those children.

The impact of COVID-19 on emergency general surgery admissions and operative volumes: A single centre experience

Introduction

The COVID-19 pandemic has placed a significant strain on healthcare resources and utilisation globally. The appearance of the disease in the Republic of Ireland resulted in a broad postponement of scheduled and routine surgical care. The influence of the novel coronavirus, and the associated imposition of public health measures such as school closures and social distancing, on the burden of emergency surgical disease is less clear.

Aim

The aim of this study was to examine the impact of COVID-19 on the number of patients presenting to our institution with emergent surgical illnesses or requiring emergency general surgical procedures.

Methods

All patients attending our service between March 1st 2020 and April 30th 2020 were identified retrospectively by examining electronic handover and electronic discharge summaries, and data were collected relating to demographics, presenting illness, critical care utilisation, length of stay, operative or endoscopic procedure performed, and in-hospital mortality. Similar data were collected March 1st to April 30th 2019, 2018, and 2017 respectively to allow direct comparison.

Results

151 patients were admitted during the study period, compared to a total of 788 during the proceeding three years (mean 2.49 admissions per night versus 4.35 per night, 42.8% reduction, p < 0.001). Median age of admitted patients was 51.8 years, compared to 50.3 years formerly (p = 0.35). 53 emergency procedures were performed, compared to a median of 70 over the same period in the previous years (mean 0.87 per day versus 1.16 per day, 25.4% reduction, p = 0.05).

Conclusion

A significant overall reduction in the number of patients being admitted to our unit and requiring emergency surgical procedures during March and April 2020 was seen, in line with patterns reported internationally.

[Surgical care during the new coronavirus (Covid-19) pandemic]

Safe and reasonable surgical care in the context of COVID-19 pandemic is difficult task. The main current issues are selection of patients for surgical treatment, principles of surgical treatment in cancer patients, possibilities of endoscopic surgery, organization of surgical department and operating theatre, surgical strategy in infected patients. Own experience and rational implementation of the recommendations developed by international research and practical communities are extremely important for optimizing surgical treatment of patients in a pandemic, as well as for ensuring the safety of patients and medical staff.

Managing acute appendicitis during the COVID-19 pandemic in Jiaxing, China

BACKGROUND

Coronavirus disease 19 (COVID-19) is a global pandemic and has had a profound impact on our routine surgical activities. Acute appendicitis is the most common abdominal emergency worldwide. Therefore, it is highly essential to assess the influence the pandemic has on acute appendicitis.

AIM

To assess the efficacy of the management of acute appendicitis during the COVID-19 pandemic.

METHODS

We retrospectively analyzed 90 patients who presented with acute appendicitis during the outbreak of COVID-19 in Jiaxing, China. Clinical data regarding appendectomies patients were also collected for the corresponding time frame from 2019. Preoperative management, intraoperative protective measures, and postoperative management were conducted.

RESULTS

After screening, six patients were identified as unqualified due to fever and were then referred to the COVID-19 expert group. The results of the nucleic acid test were negative. Of the 76 patients enrolled in the simple group, nine patients received medication therapy, and all others underwent surgery. From this same group, 66 patients were diagnosed with suppurative appendicitis, and one patient was diagnosed with perforated appendicitis after surgery. There were 14 patients in the complex group, for which the postoperative diagnosis indicated perforated appendicitis. The proportion of men with perforated appendicitis was higher than that in 2019 (P < 0.05). The chief complaint duration for perforated appendicitis patients in 2020 was longer than that in 2019 (P < 0.05). The routine blood test showed that white blood cell counts and neutrophil ratios were higher in perforated appendicitis patients in 2020 than in 2019 (P < 0.05). The ratio of open appendectomies to the amount of mean blood loss during surgery was greater in 2020 than in 2019 (P < 0.05). Online consultation after discharge was selected in 59 cases (65.6%). No perioperative infection with COVID-19 or long-term postoperative complications were found.

CONCLUSION

The management of acute appendicitis from Jiaxing effectively reduced the influence of the pandemic and minimized the risk of nosocomial infection.

A single-centre observational cohort study to evaluate volume and severity of emergency general surgery admissions during the COVID-19 pandemic: Is there a "lockdown" effect?

INTRODUCTION

The COVID-19 pandemic has led to changes in NHS surgical service provision, including reduced elective surgical and endoscopic activity, with only essential emergency surgery being undertaken. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. The aim of this study was to investigate a possible 'lockdown' effect on the volume and severity of surgical admissions and their outcomes.

METHODS

Two separate cohorts of adult emergency general surgery inpatient admissions 30 days immediately before (February 16, 2020 to March 15, 2020), and after UK government advice (March 16, 2020 to April 15, 2020). Data were collected relating to patient characteristics, severity of disease, clinical outcomes, and compared between these groups.

RESULTS

Following lockdown, a significant reduction in median daily admissions from 7 to 3 per day (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of acute kidney injury, and also were significantly more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality.

CONCLUSION

There appears to be a "lockdown" effect on general surgical admissions with a profound impact; fewer surgical admissions, more acutely unwell surgical patients, and an increase in all cause 30-day mortality. Patients should be advised to present promptly with gastrointestinal symptoms, and this should be reinforced for future lockdowns during the pandemic.

Current opinions and practices for the management of acute appendicitis: an international survey

BACKGROUND

In recent decades the management of acute appendicitis has evolved significantly. Improved access to early imaging and better clinical scoring algorithms have resulted in less negative appendicectomy rates. In addition, non-operative management has become increasingly utilized. The aim of this study was to assess the variability of management of acute appendicitis globally.

METHODS

This was a multi-national targeted survey of general surgeons across 39 countries. A structured set of questions was utilized to delineate nuances between management styles of consultants and trainees. Opinions on the pathological diagnosis of appendicitis, acceptable negative appendicectomy rates, and the role of non-operative treatment of appendicitis (NOTA) were surveyed.

RESULTS

A total of 304 general surgeons responded to this survey, 42% of which were consultants/attendings. Sixty-nine percent advocated that a histologically normal appendix was the most appropriate definition of a negative appendicectomy, while 29% felt that anything other than inflammation, necrosis, gangrene, or perforation was more appropriate. Forty-three percent felt that negative appendicectomy rates should be less than 10%, with 41% reporting that their own negative appendicectomy rate was < 5%. Interestingly, only 17% reported routinely using NOTA for uncomplicated appendicitis, with one-fifth stating that they would undergo NOTA if they themselves had uncomplicated appendicitis.

CONCLUSION

This study represents the largest sampling of management strategies for acute appendicitis. It shows substantial global heterogeneity between clinicians regarding what constitutes a negative appendicectomy as well as the appropriateness of non-operative management.