Impact of the COVID-19 pandemic on incidence and severity of acute appendicitis: a comparison between 2019 and 2020

Acute Appendicitis in Children in the Era of Covid-19

BACKGROUND

Abdominal pain is a common complaint encountered by paediatric surgeons. This complaint could be related to surgical or non-surgical causes. With coronavirus disease 2019 (COVID-19), the incidence of abdominal pain has increased and mimicked acute appendicitis in paediatric patients.

OBJECTIVE

The objective of this study was to assess the impact of the COVID-19 pandemic on paediatric acute appendicitis in terms of demographic data (age and sex), and operative findings, specifically, the complicated appendicitis and negative appendectomy rates.

MATERIALS AND METHODS

This retrospective cohort study reviewed the records of children aged 5-15 years, who were diagnosed with acute appendicitis and underwent surgery between January 2018 and December 2021. The patients were divided into pre-pandemic and pandemic groups. Demographic, operative and histopathological findings were compared between the two groups.

RESULTS

A significant increase in the incidence of acute abdominal pain amongst the admitted children (39.8% vs. 32.7%, P < 0.0001) and a significant decrease in the incidence of acute appendicitis (27% vs. 33%, P < 0.013) were observed in the pandemic group. An associated non-significant increase in the rates of complicated appendicitis (30% vs. 26%, P = 0.299) and negative appendectomy (5.8% vs. 3.8%, P = 0.359) was noted. During the pandemic period, no statistically significant differences were found between polymerase chain reaction (PCR)-positive and PCR-negative patients in complicated appendicitis or negative appendectomy rates (30% vs. 29.7%, P = 0.841, and 6.7% vs. 4.2%, P = 0.424, respectively).

CONCLUSION

COVID-19 is associated with an increased incidence of acute abdominal pain in children but a decreased rate of acute appendicitis. The latter tends to present at a younger age than usual. The rates of complicated appendicitis and negative appendectomy increased but were not significantly affected by the pandemic or severe acute respiratory syndrome coronavirus 2 infection status.

Unchanged Faces of Acute Appendicitis: Exploring Presentation and Treatment Amidst the COVID-19 Pandemic

Introduction The emergence of the COVID-19 pandemic necessitated the implementation of novel guidelines for managing appendicitis, prompting an evaluation of its effects on patient presentation and treatment at a district general hospital. Healthcare facilities worldwide have adapted protocols to meet the unique challenges of the pandemic, ensuring safe and efficient care. Our study assesses the pandemic's influence on patient demographics, clinical outcomes, surgical procedures, and adherence to guidelines among individuals undergoing emergency appendicitis surgery. Through this investigation, we aimed to determine whether significant deviations occurred in managing acute appendicitis amidst the pandemic. Methodology Consecutive adult patients (≥18 years) diagnosed with acute appendicitis were included in two cohorts for this retrospective analysis, comparing cases treated during the COVID-19 pandemic period (April to September 2020) with those treated one year prior. All patients underwent standardized assessments upon emergency department admission, including imaging studies and COVID-19 testing. Demographics, laboratory results, surgical details, and outcomes were compared between the pre- and post-pandemic groups, focusing on their overall management. Results The research involved a total of 172 individuals. During the pandemic (April to September 2020), 91 of these participants underwent surgery, which is more than the 81 individuals who had surgery during the same period the previous year (April to September 2019). Preoperative C-reactive protein levels were significantly higher in the pandemic group (P = 0.0455). The time from admission to surgery was shorter in the pandemic group (7.5 ± 4.6 vs. 5.8 ± 4.9; P = 0.0155). The overall operative and laparoscopic operative times were longer in the pandemic group (65 vs. 71 minutes, P = 0.391, and 55 vs. 62 minutes, P = 0.1424, respectively). However, these differences were not statistically significant. The number of patients presenting with complicated appendicitis was significantly higher in the pandemic group than in the nonpandemic group (44.4% vs. 61.4%; P = 0.034). The length of stay was shorter in the pandemic group (P = 0.53). Conclusions Our study suggests that surgery for acute appendicitis remains safe and feasible during the COVID-19 pandemic, with comparable outcomes. However, we noted an increase in the number of patients presenting with complicated appendicitis, possibly influenced by national pandemic guidelines in the United Kingdom. Despite this trend, our findings affirm the continued effectiveness of surgical management for acute appendicitis during the pandemic, highlighting the adaptability of healthcare systems in addressing emergent medical needs under challenging circumstances.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

BACKGROUND

Previous studies on nonoperative management (NOM) of acute appendicitis (AA) indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between nonoperative and operative management groups, regardless of COVID-19 status.

METHODS

We queried the National COVID Cohort Collaborative from 2020 to 2023 to identify adults with AA who underwent operative or NOM. COVID-19 status was denoted as follows: COVID-negative, COVID-active, or COVID-recovered. Intention to treat was used for NOM. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities.

RESULTS

A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and recovered less often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of NOM between COVID groups. Adjusted analysis indicated, compared with operative, NOM carried higher odds of mortality and readmission for COVID-negative and COVID-active patients.

CONCLUSION

This study demonstrates higher odds of mortality among NOM of appendicitis and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that NOM of appendicitis is associated with worse outcomes for COVID-active and COVID-negative patients. In addition, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patient from appendectomy for AA. Surgeon clinical judgment of a patient's physiology and surgical risk should, of course, inform the decision to proceed to the operating room.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

An Accountable Care Organization Maintains Access for Appendicitis During the COVID-19 Pandemic

INTRODUCTION

It has been reported that pediatric patients experienced a delay in treatment for acute appendicitis during the pandemic, resulting in increased rates of complicated appendicitis. We investigated the association of the COVID-19 pandemic and the incidence and severity of acute appendicitis among pediatric Medicaid patients using a population-based approach.

METHODS

The claims database of Partners For Kids, a pediatric Medicaid accountable care organization (ACO) in Ohio, was queried for cases of acute appendicitis from April to August 2017-2020. The monthly rate of acute appendicitis/100,000 covered lives was calculated each year and compared over time. Rates of complicated appendicitis were also compared. Diagnosis code validation for classification as complicated or uncomplicated appendicitis was performed for patients treated at our hospital.

RESULTS

During the study period, 465 unique cases of acute appendicitis were identified. Forty percent (186/465) were coded as complicated. No significant difference in the incidence of acute appendicitis cases was observed across the 4 y, either in an overall comparison or in pairwise comparisons (P > 0.15 for all). The proportion of acute appendicitis cases that were coded as complicated did vary significantly over the 4-year study period (P = 0.005); this was due to this proportion being significantly higher in 2018 than in either 2019 (P = 0.005 versus 2018) or 2020 (P = 0.03 versus 2018).

CONCLUSIONS

The COVID-19 pandemic was not associated with reduced access to treatment for acute appendicitis among patients in a pediatric Medicaid ACO. This suggests that an ACO may promote continued healthcare access for their covered population during an unexpected crisis.

Comparison of Pediatric Acute Appendicitis Before and During the COVID-19 Pandemic in New York City

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management. Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods: Patients aged 2-18 years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018-February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020-February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity. Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02). Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis.

METHODS

This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE.

RESULTS

In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates.

CONCLUSION

The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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.

Racial and ethnic variation in emergent surgical care and outcomes during the COVID-19 pandemic: post hoc analysis of an EAST MCT

Objectives

The COVID-19 pandemic highlighted concerns regarding the equity of medical care. We evaluated associations between race/ethnicity, timing of hospital presentation and outcomes of acute appendicitis (AP) and acute cholecystitis (AC) during the initial pandemic peak.

Methods

Analysis was performed on a prospective, observational, multicenter study of adults with AP or AC. Patients were categorized as pre-pandemic (pre-CoV: October 2019–January 2020) or during the first pandemic peak (CoV: April 2020 through 4 months following the end of local pandemic restrictions). Patient demographics, American Association for the Surgery of Trauma (AAST) imaging/pathology grade, duration of symptoms before triage, time from triage to intervention and hospital length of stay were collected.

Results

A total of 2165 patients (1496 pre-CoV, 669 CoV) were included from 19 centers. Asian and Hispanic patients with AC had a longer duration of symptoms prior to presentation during CoV than pre-CoV (100.6 hours vs 37.5 hours, p<0.01 and 85.7 hours vs 52.5 hours, p<0.05, respectively) and presented later during CoV than Black or White patients (34.3 and 37.9 hours, p<0.01). During CoV, Asian patients presented with higher AAST pathology grade for AP compared with pre-CoV (1.90 vs 1.26, p<0.01). Asian and Hispanic patients presented with higher AAST pathology grade for AC during CoV versus pre-CoV (2.57 vs 1.45, p<0.01, and 1.57 vs 1.20, p<0.05, respectively). Patients with AC and an AAST pathology grade of ≥3 were at higher odds of postoperative complications (OR 4.4, 95% CI 1.0 to 18.4) and AP (OR 2.8, 95% CI 1.3 to 6.0). Asian and Hispanic patients with AC had a higher risk of postoperative complications compared to White patients (Asian: OR 3.9, 95% CI 1.2 to 12.7; Hispanic: OR 3.3, 95% CI 1.2 to 8.9).

Conclusion

Asian and Hispanic patients had a longer duration of symptoms before hospital presentation during the initial COVID-19 peak, had higher odds of postoperative complications and more advanced pathologic disease.

Level of evidence

III, Prognostic/epidemiological.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

BACKGROUND

Acute appendicitis (AAp) is the most frequent cause of acute abdominal pain, and appendectomy is the most frequent emergency procedure that is performed worldwide. The coronavirus disease 2019 (COVID-19) pandemic has caused delays in managing diseases requiring emergency approaches such as AAp and trauma.

AIM

To compare the demographic, clinical, and histopathological outcomes of patients with AAp who underwent appendectomy during pre-COVID-19 and COVID-19 periods.

METHODS

The demographic, clinical, biochemical, and histopathological parameters were evaluated and compared in patients who underwent appendectomy with the presumed diagnosis of AAp in the pre-COVID-19 (October 2018-March 2020) and COVID-19 (March 2020-July 2021) periods.

RESULTS

Admissions to our tertiary care hospital for AAp increased 44.8% in the COVID-19 period. Pre-COVID-19 (n = 154) and COVID-19 (n = 223) periods were compared for various parameters, and we found that there were statistically significant differences in terms of variables such as procedures performed on the weekdays or weekends [odds ratio (OR): 1.76; P = 0.018], presence of AAp findings on ultrasonography (OR: 15.4; P < 0.001), confirmation of AAp in the histopathologic analysis (OR: 2.6; P = 0.003), determination of perforation in the appendectomy specimen (OR: 2.2; P = 0.004), the diameter of the appendix (P < 0.001), and hospital stay (P = 0.003). There was no statistically significant difference in terms of interval between the initiation of symptoms and admission to the hospital between the pre-COVID-19 (median: 24 h; interquartile range: 34) and COVID-19 (median: 36 h; interquartile range: 60) periods (P = 0.348). The interval between the initiation of symptoms until the hospital admission was significantly longer in patients with perforated AAp regardless of the COVID-19 or pre-COVID-19 status (P < 0.001).

CONCLUSION

The present study showed that in the COVID-19 period, the ultrasonographic determination rate of AAp, perforation rate of AAp, and duration of hospital stay increased. On the other hand, negative appendectomy rate decreased. There was no statistically significant delay in hospital admissions that would delay the diagnosis of AAp in the COVID-19 period.

Experiences of Acute Surgical Care During the Coronavirus Disease 2019 Pandemic Among Patients and Their Next of Kin

INTRODUCTION

Since March 2020, the coronavirus disease 2019 pandemic has affected healthcare systems worldwide. It is largely unknown how acutely ill surgical patients and their next of kin have perceived the hospital care during the ongoing pandemic. Therefore, we aimed to explore their experiences.

MATERIAL AND METHODS

We performed 12 interviews with patients who had undergone acute abdominal surgery in a public acute care hospital in Sweden during March to June 2020. In addition, we interviewed 10 of the patients' next of kin. We analyzed the interviews using content analysis.

RESULTS

Our analysis resulted in two themes: "Worries about seeking acute care" and "The surgical care worked adequately, even though the system was overloaded." The participants experienced that the hospital maintained its functionality during the ongoing pandemic. Both the patients and their next of kin experienced insufficient information by the hospital, especially during the initial acute phase and at discharge, which led to a perceived loss of control. The implemented ban on visitors was found to have had both positive and negative effects for the patients, whereas the next of kin's experiences focused on the difficulties with not being able to visit.

CONCLUSIONS

Our findings indicate that the challenges of communication with patients and their next of kin are exacerbated during a crisis such as a pandemic. In addition, a ban on visitors might have both positive and negative aspects. Therefore, we propose individualized routines for visits to acute surgical patients when possible.

Academic Medical Centers Experienced Higher Rates of Post-Operative Health-Care-Associated Infections during the COVID-19 Pandemic: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Trial

Background: We sought to examine health-care-associated infections (HAIs) among patients undergoing an appendectomy at academic medical centers (AMCs) and non-AMCs during the coronavirus disease 2019 (COVID-19) peri-pandemic. We hypothesized that AMCs would have higher rates of post-operative HAIs during the first wave of the pandemic. Patients and Methods: We performed a post hoc analysis of a prospective, observational, multi-center study of patients aged >18 years who underwent an appendectomy for acute appendicitis before (pre-CoV), during (CoV), and after pandemic restrictions were lifted (post-CoV). Patients were grouped according to hospital type (AMC vs. non-AMC). Our primary outcome was the incidence of post-operative HAIs. Results: There were 1,003 patients; 69.5% (n = 697) were treated at AMCs and 30.5% (n = 306) at non-AMCs. Patients at AMCs had greater rates of concomitant COVID-19 infections (5.5% vs. 0.7%; p < 0.0001) and worse operative appendicitis severity (p = 0.01). Greater rates of HAIs were seen at AMCs compared with non-AMCs (4.9% vs. 2%; p = 0.03). Surgical site infections were the most common HAI and occurred more often at AMCs (4.3% vs. 1.6%; p = 0.04). Only during CoV were there more HAIs at AMCs (5.1% vs. 0.3%; p = 0.02). Undergoing surgery at an AMC during CoV was a risk factor for HAIs (adjusted odds ratio [aOR], 8.55; 95% confidence interval [CI], 1.03-71.03; p = 0.04). Conclusions: During the COVID-19 pandemic, appendectomies performed at AMCs were an independent risk factor for post-operative HAIs. Our findings stress the importance of adherence to standard infection prevention efforts during future healthcare crises.

Clinical Experience of Emergency Appendectomy under the COVID-19 Pandemic in a Single Institution in South Korea

Background and Objectives: The COVID-19 pandemic has brought serious changes in healthcare systems worldwide, some of which have affected patients who need emergency surgery. Acute appendicitis is the most common surgical disease requiring emergency surgery. This study was performed to determine how the COVID-19 pandemic has changed the treatment of patients with acute appendicitis in South Korea. Materials and Methods: We retrospectively reviewed a medical database that included patients who underwent surgery for acute appendicitis in our hospital from January 2019 to May 2021. We classified the patients into two groups according to whether they were treated before or after the COVID pandemic and 10 March 2020 was used as the cutoff date, which is when the World Health Organization declared the COVID pandemic. Results: A total of 444 patients were included in the “Pre-COVID-19” group and 393 patients were included in the “COVID-19” group. In the “COVID-19” group, the proportion of patients with severe morbidity was significantly lower. The time that the patients spent in the emergency room before surgery was significantly longer in the ”COVID-19” group (519.11 ± 486.57 min vs. 705.27 ± 512.59 min; p-value < 0.001). There was no difference observed in the severity of appendicitis or in the extent of surgery between the two groups. Conclusions: During the COVID-19 pandemic, a statistically significant time delay (186.16 min) was needed to confirm COVID-19 infection status. However, there was no clinical difference in the severity of appendicitis or in the extent of surgery. To ensure the safety of patients and medical staff, a COVID-19 PCR test should be performed.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background

Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems.

Objective

To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic.

Methods

Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel.

Result

There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients.

Conclusions

COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00836-2.

Complicated Severe Appendicitis in a 58-Year-Old Female After COVID-19 Infection: A Coincidence or an Association?

Acute appendicitis (AA) remains the most common cause of acute abdomen worldwide. Although overall mortality in developed countries is low, complication due to perforation, abscess formation, stump appendicitis and intra-abdominal sepsis is associated with increased morbidity. Throughout the COVID-19 pandemic, an increasing proportion of complicated appendicitis has been reported. In this case, we present a 58-year-old female with a remote history of COVID-19 infection and severe appendicitis, complicated by sepsis. Viral infection has previously been proposed as a cause of appendicitis. Our report aims to describe our patient’s course and comment on a potential association with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, as well as future diagnostic and management considerations.

Impact of COVID-19 on appendicitis presentations in children in Australia and New Zealand

BACKGROUND

In contrast to many countries, the prevalence of COVID-19 in Australia and New Zealand has been low. We hypothesised, however, that a potential secondary effect of the COVID-19 pandemic would be delayed presentation of paediatric appendicitis, with resultant higher rates of complicated appendicitis. This study was an initiative of the Australian and New Zealand Surgery in Children Registrars' Association for Trials collaborative, a trainee-led research group based in Australia and New Zealand.

METHODS

A binational multicentre, retrospective review was undertaken of paediatric patients with appendicitis early in the COVID-19 pandemic (20 March-30 April 2020), compared with previous years (2018, 2019). Primary outcomes were the duration of symptoms prior to presentation and the severity of disease.

RESULTS

A total of 400 patients from six centres were included. Duration of symptoms prior to presentation, sepsis at presentation, complicated disease and presence of complications did not differ significantly between time periods. Duration of intravenous antibiotic treatment and overall antibiotic treatment were both significantly shorter during 2020 (2.4 days versus 3.5 in 2018 and 3.0 in 2019 [P = 0.0038] and 3.7 days versus 5.2 in 2018 and 4.6 in 2019 [P = 0.04], respectively). Management approach did not differ, with the majority of patients managed operatively.

CONCLUSIONS

We did not demonstrate any difference in duration of symptoms prior to presentation or other markers of disease severity early in the pandemic. Duration of antibiotic treatment was shorter during this period compared with previous years. Management of children with appendicitis, both simple and complicated, did not appear to change as a result of COVID-19.

Long term results on the severity of acute appendicitis during COVID-19 pandemic

Background

Acute appendicitis cases increased in severity following COVID-19–related restrictions in March, 2020. We investigated if similar changes occurred during Wave 2.

Methods

Acute appendicitis patients during Wave 1 were grouped 8 weeks before (Group A) and after (Group B) stay-at-home restrictions were initiated on March 15, 2020. Cases in Wave 2 were grouped 8 weeks before (Group C) and after (Group D) November 6, 2020. Groups were compared to equivalent time frames in 2018/2019.

Results

Group A versus B revealed 42.6% decrease (confidence interval: − 59.4 to − 25.7) in uncomplicated appendicitis and 21.1% increase (confidence interval: 4.8–37.3) in perforated appendicitis. Similar patterns were noted comparing Group C versus D without statistical significance. The changes seen in Wave 1 were significantly different than in 2018/2019. This trend continued in Wave 2.

Conclusion

Similar to Wave 1, acute appendicitis cases increased in severity during wave 2 of COVID-19, but with less prominence.

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.

Multicenter cohort study on the presentation and treatment of acute appendicitis during the COVID-19 pandemic

PURPOSE

Current studies have demonstrated conflicting results regarding surgical care for acute appendicitis during the COVID-19 pandemic. This study aimed to assess trends in diagnosis as well as treatment of acute appendicitis in the Netherlands during the first and second COVID-19 infection wave.

METHODS

All consecutive patients that had an appendectomy for acute appendicitis in nine hospitals from January 2019 to December 2020 were included. The primary outcome was the number of appendectomies for acute appendicitis. Secondary outcomes included time between onset of symptoms and hospital admission, proportion of complex appendicitis, postoperative length of stay and postoperative infectious complications. Outcomes were compared between the pre-COVID group and COVID group.

RESULTS

A total of 4401 patients were included. The mean weekly rate of appendectomies during the COVID period was 44.0, compared to 40.9 in the pre-COVID period. The proportion of patients with complex appendicitis and mean postoperative length of stay in days were similar in the pre-COVID and COVID group (respectively 35.5% vs 36.8%, p = 0.36 and 2.0 ± 2.2 vs 2.0 ± 2.6, p = 0.93). There were no differences in postoperative infectious complications. A computed tomography scan was used more frequently as a diagnostic tool after the onset of COVID-19 compared to pre-COVID (13.8% vs 9.8%, p < 0.001, respectively).

CONCLUSION

No differences were observed in number of appendectomies, proportion of complex appendicitis, postoperative length of stay or postoperative infectious complications before and during the COVID-19 pandemic. A CT scan was used more frequently during the COVID-19 pandemic.

A concise pathophysiological model of acute appendicitis against the background of the COVID-19 pandemic

One of the most common clinical pictures has become the focus of attention during the COVID-19 pandemic: acute appendicitis with the associated diagnostics and therapy. The aim of the work is to show inconsistencies with regard to epidemiology, pathophysiology and therapy against the background of the pandemic with special attention to the conditions for children and to explain the pathophysiological processes that are likely to underlie the disease based on scientifically plausible models.

Impact of COVID-19 on the incidence of CT-diagnosed appendicitis and its complications in the UK and Sweden

AIM

To compare the number of appendicitis cases and its complications, during the first months of the COVID-19 pandemic in Sweden and the UK and the corresponding time period in 2019.

METHOD

Reports of emergency abdominopelvic CT performed at 56 Swedish hospitals and 38 British hospitals between April and July 2020 and a corresponding control cohort from 2019 were reviewed. Two radiologists and two surgeons blinded to the date of cohorts analyzed all reports for diagnosis of appendicitis, perforation, and abscess. A random selection of cases was chosen for the measurement of inter-rater agreement.

RESULT

Both in Sweden (6111) and the UK (5591) fewer, abdominopelvic CT scans were done in 2020 compared to 2019 (6433 and 7223, respectively); p < 0.001. In the UK, the number of appendicitis was 36% lower in April-June 2020 compared to 2019 but not in Sweden. Among the appendicitis cases, there was a higher number of perforations and abscesses in 2020, in Sweden. In the UK, the number of perforations and abscesses were initially lower (April-June 2020) but increased in July 2020. There was a substantial inter-rater agreement for the diagnosis of perforations and abscess formations (K = 0.64 and 0.77).

CONCLUSION

In Sweden, the number of appendicitis was not different between 2019 and 2020; however, there was an increase of complications. In the UK, there was a significant decrease of cases in 2020. The prevalence of complications was lower initially but increased in July. These findings suggest variability in delay in diagnosis of appendicitis depending on the country and time frame studied.

Impact of the Coronavirus (COVID-19) Pandemic on the Care of Pediatric Acute Appendicitis

BACKGROUND

Appendicitis is the most common abdominal surgical emergency in children. With the rise of the Coronavirus-19 pandemic, quarantine measures have been enforced to limit the viral transmission of this disease. The purpose of this study was to identify differences in the clinical presentation and outcomes of pediatric acute appendicitis during the Coronavirus-19 pandemic.

METHODS

A single-institution retrospective assessment of all pediatric patients (<18 years old) with acute appendicitis from December 2019 to June 2020 was performed at a tertiary care children's hospital. Patients were divided into two groups: (1) the Pre-COVID group presented on or before March 15, 2020, and (2) the COVID group presented after March 15, 2020. Demographic, preoperative, and clinical outcomes data were analyzed.

RESULTS

45 patients were included with a median age of 13 years [IQR 9.9 - 16.2] and 35 males (78%). 28 patients were in the Pre-COVID group (62%) and 17 in the COVID group (38%). There were no differences in demographics or use of diagnostic imaging. The COVID group did have a significantly delayed presentation from symptom onset (36 vs 24 hours, P < .05), higher Pediatric Appendicitis Scores (8 vs 6, P = .003), and longer hospital stays (2.2 vs 1.3 days, P = .04). There were no significant differences for rates of re-admission, re-operation, surgical site infection, perforation, or abscess formation.

CONCLUSION

During the Coronavirus-19 pandemic, the incidence of pediatric acute appendicitis was approximately 40% lower. These children presented in a delayed fashion with longer hospital stays. No differences were noted for postoperative complications.