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

Abstract

Background/Aim: Covid-19 pandemic (Cov19) has affected the world since December 2019. The management of acute appendicitis (AA) has also changed distinctly during the Cov19 outbreak. The aim of this study is to evaluate and compare the results of AA during the pre-pandemic period and the first wave of the Cov19 outbreak. Methods: Patients diagnosed with AA from March to July 2019 (pre-pandemic, 2019), and from March to July 2020 (first wave of the pandemic, 2020) were included in this study, and evaluated for age, gender, nationality, length of stay (LOS), ultrasonography (USG), computed tomography (CT) findings, C-reactive protein level (CRP), white blood cell count (WBC), treatment results, operation type, and pathological examination results retrospectively. Results: One hundred patients from 2019, and seventy-seven patients from 2020 were included in the study. The male ratio, false negative USG, number of CTs performed (especially among conservatively treated patients), CRP levels, the rate of conservative treatment were higher, and LOS was longer among patients treated in 2020 (P<0.05 for all). In 2019, 91.8% of the AA operations were performed laparoscopically, whereas in 2020, 73.2% of them were open operations (P<0.001). Complicated AA was more frequent in 2019 than in 2020 (12.2% vs 9.8%). Conclusion: During the Cov19 pandemic, a longer LOS, and a higher ratio of male to female AA patients were observed. CT was more useful during the Cov19 pandemic for diagnosing AA and especially for choosing the suitable patients for conservative treatment. Conservative treatment was preferred more frequently than surgery with a lower recurrence rate in selected uncomplicated patients; and for surgery, the open technique was preferred more frequently during the Cov19 pandemic.

Keywords

• Acute appendicitis
• Covid-19 pandemic
• Conservative treatment
• Appendectomy

References

1. 1. Orthopoulos G, Santone E, Izzo F, Tirabassi M, Pérez-Caraballo AM, Corriveau N, et al. Increasing incidence of complicated appendicitis during COVID-19 pandemic. Am J Surg. 2021 May;221(5):1056-60. doi: 10.1016/j.amjsurg.2020.09.026.
2. 2. Coimbra R, Edwards S, Kurihara H, Bass GA, Balogh ZJ, Tilsed J, et al. European Society of Trauma and Emergency Surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection. Eur J Trauma Emerg Surg. 2020 Jun;46(3):505-10. doi: 10.1007/s00068-020-01364-7.
3. 3. Zhou Y, Cen LS. Managing acute appendicitis during the COVID-19 pandemic in Jiaxing, China. World J Clin Cases. 2020 Oct 6;8(19):4349-59. doi: 10.12998/wjcc.v8.i19.4349.
4. 4. Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016 Nov;30(11):4668-90. doi: 10.1007/s00464-016-5245-7.
5. 5. Ielpo B, Podda M, Pellino G, Pata F, Caruso R, Gravante G, et al.; ACIE Appy Study Collaborative. Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study. Br J Surg. 2020 Oct 8:10.1002/bjs.11999. doi: 10.1002/bjs.11999.
6. 6. Hardin DM Jr. Acute appendicitis: review and update. Am Fam Physician. 1999 Nov 1;60(7):2027-34.
7. 7. Hernigou J, Condat B, Giaoui A, Charlier A. Resolution of appendiceal colic following migration of an appendicolith. J Visc Surg. 2014 Sep;151(4):323-5. doi: 10.1016/j.jviscsurg.2014.04.008.
8. 8. Perez KS, Allen SR. Complicated appendicitis and considerations for interval appendectomy. JAAPA. 2018 Sep;31(9):35-41. doi: 10.1097/01.JAA.0000544304.30954.40.

9. 9. Cano-Valderrama O, Morales X, Ferrigni CJ, Martín-Antona E, Turrado V, García A, et al. Acute Care Surgery during the COVID-19 pandemic in Spain: Changes in volume, causes and complications. A multicentre retrospective cohort study. Int J Surg. 2020 Aug; 80:157-61. doi: 10.1016/j.ijsu.2020.07.002. 10.
10. 10. Tankel J, Keinan A, Blich O, Koussa M, Helou B, Shay S, et al.. The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study. World J Surg. 2020 Aug;44(8):2458-63. doi: 10.1007/s00268-020-05599-8.
11. 11. Romero J, Valencia S, Guerrero A. Acute Appendicitis During Coronavirus Disease 2019 (COVID-19): Changes in Clinical Presentation and CT Findings. J Am Coll Radiol. 2020 Aug;17(8):1011-3. doi: 10.1016/j.jacr.2020.06.002.
12. 12. Finkelstein P, Picado O, Muddasani K, Wodnicki H, Mesko T, Unger S, et al. A Retrospective Analysis of the Trends in Acute Appendicitis During the COVID-19 Pandemic. J Laparoendosc Adv Surg Tech A. 2021 Mar;31(3):243-6. doi: 10.1089/lap.2020.0749.
13. 13. Talan DA, Saltzman DJ, Mower WR, Krishnadasan A, Jude CM, Amii R, et al.; Olive View–UCLA Appendicitis Study Group. Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management. Ann Emerg Med. 2017 Jul;70(1):1-11.e9. doi: 10.1016/j.annemergmed.2016.08.446.
14. 14. Lotfallah A, Aamery A, Moussa G, Manu M. Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study. Cureus. 2021 Mar 24;13(3):e14095. doi: 10.7759/cureus.14095.
15. 15. Karakaş D, Yeşiltaş M, Gökçek B, Eğin S, Hot S. Is language disability a risk factor for complicated appendicitis? A retrospective cohort study. J Surg Med. 2020;4(8):631-5. doi:10.28982/josam.770774
16. 16. Antakia R, Xanthis A, Georgiades F, Hudson V, Ashcroft J, Rooney S, et al. Acute appendicitis management during the COVID-19 pandemic: A prospective cohort study from a large UK centre. Int J Surg. 2021 Feb;86:32-7. doi: 10.1016/j.ijsu.2020.12.009.
17. 17. Kumaira Fonseca M, Trindade EN, Costa Filho OP, Nácul MP, Seabra AP. Impact of COVID-19 Outbreak on the Emergency Presentation of Acute Appendicitis. Am Surg. 2020 Nov;86(11):1508-12. doi: 10.1177/0003134820972098.
18. 18. Kvasnovsky CL, Shi Y, Rich BS, Glick RD, Soffer SZ, Lipskar AM, et al.. Limiting hospital resources for acute appendicitis in children: Lessons learned from the U.S. epicenter of the COVID-19 pandemic. J Pediatr Surg. 2021 May;56(5):900-4. doi: 10.1016/j.jpedsurg.2020.06.024.
19. 19. Horn CB, Tian D, Bochicchio GV, Turnbull IR. Incidence, demographics, and outcomes of nonoperative management of appendicitis in the United States. J Surg Res. 2018 Mar;223:251-8. doi: 10.1016/j.jss.2017.10.007.
20. 20. Gans SL, Pols MA, Stoker J, Boermeester MA; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31. doi: 10.1159/000371583.
21. 21. Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27. doi: 10.1186/s13017-020-00306-3.
22. 22. Ashcroft J, Hudson VE, Davies RJ. COVID-19 gastrointestinal symptoms mimicking surgical presentations. Ann Med Surg (Lond). 2020 Jun 24;56:108-9. doi: 10.1016/j.amsu.2020.06.025.
23. 23. Somers K, Abd Elwahab S, Raza MZ, O'Grady S, DeMarchi J, Butt A, et al. Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm? Surgeon. 2021 Feb 12:S1479-666X(21)00030-5. doi: 10.1016/j.surge.2021.01.009.
24. 24. Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am. 2018 Oct;98(5):1005-23. doi: 10.1016/j.suc.2018.05.006.
25. 25. Ganesh R, Lucocq J, Ekpete NO, Ain NU, Lim SK, Alwash A, et al. Management of appendicitis during COVID-19 pandemic; short-term outcomes. Scott Med J. 2020 Nov;65(4):144-8. doi: 10.1177/0036933020956316.
26. 26. Mai DVC, Sagar A, Menon NS, Claydon O, Park JY, Down B, et al. A local experience of non-operative management for an appendicitis cohort during COVID-19. Ann Med Surg (Lond). 2021 Mar;63:102-60. doi: 10.1016/j.amsu.2021.02.006.
27. 27. Hansson J, Khorram-Manesh A, Alwindawe A, Lundholm K. A model to select patients who may benefit from antibiotic therapy as the first line treatment of acute appendicitis at high probability. J Gastrointest Surg. 2014 May;18(5):961-7. doi: 10.1007/s11605-013-2413-0.
28. 28. Ehmann MR, Zink EK, Levin AB, Suarez JI, Belcher HME, Daugherty Biddison EL, et al. Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis. Chest. 2021 Mar;159(3):1076-83. doi: 10.1016/j.chest.2020.09.246.
29. 29. Iftikhar M, Shah S, Shah I, Shah JA, Faisal M. Outcomes of Conservative Management of Acute Appendicitis during COVID-19 Pandemic. J Coll Physicians Surg Pak. 2021 Jan;30(1):S50-S54. doi: 10.29271/jcpsp.2021.01.S50.
30. 30. Emile SH, Hamid HKS, Khan SM, Davis GN. Rate of Application and Outcome of Non-operative Management of Acute Appendicitis in the Setting of COVID-19: Systematic Review and Meta-analysis. J Gastrointest Surg. 2021 Mar 26:1–11. doi: 10.1007/s11605-021-04988-1.
31. 31. Flum DR. Clinical practice. Acute appendicitis--appendectomy or the "antibiotics first" strategy. N Engl J Med. 2015 May 14;372(20):1937-43. doi: 10.1056/NEJMcp1215006. Erratum in: N Engl J Med. 2015 Jun 4;372(23):2274.
32. 32. Javanmard-Emamghissi H, Boyd-Carson H, Hollyman M, Doleman B, Adiamah A, Lund JN, et al. COVID: HAREM (Had Appendicitis, Resolved/Recurred Emergency Morbidity/Mortality) Collaborators Group. The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study. Tech Coloproctol. 2021 Apr;25(4):401-11. doi: 10.1007/s10151-020-02297-4.
33. 33. Gao Z, Li M, Zhou H, Liang Y, Zheng C, Li S, et al. Complicated appendicitis are common during the epidemic period of 2019 novel coronavirus (2019-nCoV). Asian J Surg. 2020 Oct;43(10):1002-5. doi: 10.1016/j.asjsur.2020.07.01.