Introduction

Acute abdomen accounts for 7-10% of all Emergency Department visits, being acute appendicitis (AA) the most common cause of pain in the lower abdomen¹. There is a direct relationship between delays in accessing healthcare and the outcomes of AA, with more adverse results².

The Coronavirus pandemic was declared on March 11, 2020 by the World Health Organization, with 118 000 cases in 114 countries and 4 291 deaths³. As of July 13, 2020, 97 509 cases and 1 818 deaths were reported in Argentina⁴.

In addition to the implications associated with COVID-19 patient care, the changes in the health system organization directly affected patients with other conditions. Challenges have arisen from preoperative, intraoperative and postoperative care of patients requiring surgical management. Such issues include the management of the Emergency Department visits, deciding on conservative or surgical treatment, oncology patients requiring surgery, the postponement and delay of elective surgeries in symptomatic patients, and the preservation and care of health workers⁵.

In our hospital, since the social, preventive and mandatory lockdown implemented on March 20 this year, there has been a marked reduction in the number of Emergency Department visits due to abdominal disorders.

This study aims to analyze the results of a cohort of patients undergoing surgery for acute appendicitis during the COVID-19 pandemic in a teaching hospital in Buenos Aires, and to compare outcomes with the same period in 2019, assessing the differences in incidence, severity, and evolution of cases.

Material and methods

A retrospective analysis of prospectively collected data was conducted on patients undergoing surgical management of AA in a University Hospital in Buenos Aires between March 20 and July 13, 2019, and March 20 and July 13, 2020. Patients were randomized to two groups depending on whether the intervention was during the pandemic (2020) or not (2019).

Data taken into account were:

▪▪Preoperative data: Sex and age, comorbidities, history of abdominal surgeries.

▪▪Intraoperative data: Conventional or laparoscopic approach, appendicitis according to Carr’s classification⁶, presence or absence of appendicular plastron, presence or absence of peritonitis, need for abdominal drainage, and operative time.

▪▪Postoperative data: Hospitalization days, staging and complications according to the Clavien-Dindo classification⁷, incidence of postoperative abdominal collections, need for reoperation, readmittance, and home antibiotic therapy.

Both patient cohorts were compared in terms of the surgery and its outcomes. Diagnosis was made based on the clinical picture, laboratory tests, and imaging (ultrasound/CT scan). As for the management of patients during the pandemic, a Committee of Experts developed protocols for the different sectors. Those protocols were adapted as per the National Ministry of Health regulations and the situation in our setting, so that, at first, screening for suspected cases of COVID-19 consisted of a clinical examination; later on, preoperative nasopharyngeal swab was used. Postoperative swabbing was always determined by the clinical picture.

STATA software was used for statistical analysis (v11.1, StataCorp, College Station, Texas, USA). Categorical variables were described as percentages and are also presented as proportions in the tables, while numerical variables were described as mean and standard deviation. The Chi Square Test was used to compare categorical variables, and the Student-T Test was used to compare numerical variables; the cases in which the Fisher Test was used are included in the tables because it was a reduced sample. All variables with p < 0.05 were considered statistically significant.

Results

A total of 127 patients were included, 81 operated between March 20 and July 13, 2019, and 46 operated during the same period in 2020. Table 1 summarizes the preoperative characteristics of both groups. Mean age of presentation was 31,8 +/-17,31 years in the 2019 group and 37,5 +/-19,69 years in the 2020 group, being the frequency slightly higher in the male and female patients respectively. Comorbidities included previous abdominal surgeries, smoking, chronic obstructive pulmonary disease, diabetes mellitus, dyslipidemia, chronic kidney disease, and high blood pressure, finding no relevant differences. In the 2019 group, the average delay in consultation was 1.69 days (SD 1.98) and 2.40 (SD 2.44; p = 0.110) in the 2020 group.

As for intraoperative parameters, the laparoscopic approach prevailed in both groups, based on the preference of the treating surgeon, being higher in the 2020 group (76.5% vs 91.3%; p = 0.08). A higher number of appendicular plastrons in the cohort affected by the pandemic (9.9% vs. 23.9%; p = 0.03) and of peritonitis (the difference between both groups was 14.4%; p = 0.09) were found, increasing the abdominal drainage (9.9% vs. 23.9%; p = 0.03). Despite the differences in severity between both groups, operative time was not significantly longer; these data are included in Table 2.

Table 3 shows the postoperative variables; readmission and long-term intravenous antibiotic therapy -requiring home care- showed statistically significant parameters.

According to the Clavien-Dindo staging system⁷, there was a higher incidence of severe complications in the 2020 group (80% were type IIIb), while the 2019 group was more likely to have minor complications (75% were type I).

During the pandemic, the average hospitalization days were 3.24 days (SD 7.31), being higher than the median in the 2019 group: 1.89 days (SD (2.04). The rate of complications doubled during the pandemic (4.9% vs. 10.9%; p = 0.21), and 2.5% required reintervention in the 2019 group vs. 8.7% (p = 0.03) in the 2020 group.

One 39-year old male patient with perforated AA and involvement of the appendiceal base required reintervention; this patient had required partial removal of the cecum and presented with an abscess during the postoperative period; surgical drainage was performed, approached by laparoscopy in both procedures. The 2020 group included 19-42 year-old men, two of them with no previous history; one had chronic kidney disease and multiple abdominal surgeries, and one was obese. The common features were peritonitis and gangrenous appendix. Three patients were first approached by laparoscopy and one of them by conventional approach due to immunosuppression, previous laparotomies and unconfirmed diagnosis of AA.

The reasons for reintervention were:

▪▪Patients 1 and 2: Abdominal collection.

▪▪Patient 3: Infected hematoma and evisceration.

▪▪Patient 4: Infected hematoma and then bowel perforation during severe COVID-19 infection, requiring ICU and MV.

No mortality was recorded in either period.

In the 2020 group, we added:

Patients with nasopharyngeal swab: Of the 46 patients undergoing surgery, 6 were tested before the procedure, 5 according to the protocol, and 1 due to clinical suspicion of COVID-19. All the tests were negative. In the postoperative period, 3 patients were swabbed due to clinical suspicion and only 1 was positive (Patient 4).

Discussion

Since the beginning of the social, preventive and mandatory lockdown declared in Argentina on March 20, consultations for abdominal pain have decreased at the Emergency Department of our hospital, finding more progressed cases intraoperatively and torpid postoperative course in the surgical pathology in general.

Given that appendectomy is the most frequent emergency intervention in General Surgery departments worldwide^8,9, with a lifetime cumulative risk for AA of 6.7% in women and 8.7% in men⁹, the purpose of this paper is to target those AA findings by comparing its incidence and severity during the COVID-19 pandemic with the same period in 2019.

A reduction in the total number of appendectomies in 2020 was found, compared to the same period in 2019; a greater number of phlegmons with statistically significant values, and an increase in appendicular plastrons and peritonitis were found in the 2019 and 2020 groups, respectively.

The delay in consultation was greater in 2020, and despite the absence of statistically significant values, we targeted notoriously progressed abdominal disorders and more torpid postoperative course, evidencing a delay in transfer for surgery. We were unable to clearly define the cause in the present article. The reasons for delayed visits to the Emergency Department may be associated to the fear of contagion and to the difficult access to healthcare centers. This is described in the literature: how people with conditions unrelated to a pandemic or epidemic decide not to consult -or go late- to the Emergency Department. Examples are the Influenza or Middle East Respiratory Syndrome (MERS) outbreaks^10-11 or the COVID-19 pandemic today^12,13.

Lazzerini describes the experience of 5 pediatric hospitals in Italy, and states that during the lockdown for coronavirus disease 2019 (COVID-19), official hospital statistics in the period March 1-27, 2020 show substantial reductions-ranging from 73% to 88%-in pediatric Emergency Department visits compared with the same time period in 2019 and 2018, and hypothesizes that it might reflect difficulty to access healthcare centers, or reticence to risk exposure to coronavirus, in addition to lower rates of acute infections and trauma as a result of the preventive measures adopted.

Mortality rate for AA is extremely low (< 0.1%), but it increases significantly in more progressed cases, such as gangrenous, perforated or abscessed appendicitis8. In the series analyzed, there are no important differences in the preoperative features of the patients. Mean age of presentation is the third decade of life, and male patients are slightly predominant in the total number included, in accordance with international parameters^15,16. An increased number of patients with peritonitis and a greater need for abdominal drainage were found, without significantly longer operative time.

Of the studies addressing patients diagnosed with AA during the COVID-19 pandemic, we analyzed one presented by Tankel. It is a multicenter, retrospective study including 378 patients. It describes a statistically significant reduction in the incidence of consultations for AA (decrease by 40.7%; p < 0. 02) between the two periods analyzed - pre-pandemic and pandemic, with no significant difference in AA severity, operative time, abdominal drainage requirement, or hospital stay (no significant p value); however, if we analyze the published values, we find 86% uncomplicated AA in the pre-pandemic period vs. 78.8% during the pandemic, and gangrenous AA, perforated AA, or periappendicular abscess in 13.1% and 20.6% of the patients, respectively¹².

Velayos presented a case report that includes 66 pediatric patients operated on for AA in the University Hospital of La Paz from January to April 2020, who were classified according to the time of the appendectomy - before the declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19), in Spain. Their findings were similar to ours, showing a higher proportion of complicated appendicitis in the post-COVID group compared to pre-COVID-19 (32 vs 7.3%; p = 0.015). Hospital stay was longer in the post-COVID-19 group (5.6 ± 5.9 vs. 3.2 ± 4.3 days; p = 0.041). No differences were found in the time of onset of symptoms or surgical time¹³.

It is also worth mentioning that while surgery was historically considered the gold standard of AA treatment^17,18, the conservative approach has been proposed as a valid option in this pandemic.

Javanmard-Emamghissi published a study including a cohort of 500 patients treated for AA in the UK during the COVID-19 pandemic¹⁹. Patients were divided into two groups, one managed conservatively (group 1) and the other under operative approach (group 2). Median length of hospital stay was significantly reduced in the conservatively managed group (2 days vs. 3; p = 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. It should be noted that failed conservative management with antibiotics occurred 10% (26/263), who went on to have surgery due to poor progression; of those 26, 2 patients required a right hemicolectomy: one for complicated AA and the other for malignancy, which is not described in group 2. Within the operative group, the majority had an open procedure (56%) versus laparoscopic (44%), showing with statistically significant values that hospital stay in those operated by laparoscopy was equal to that of the conservative group (2 days; p < 0.012).

Advocating for non-surgical treatment, two situations are described in this paper. On the one hand, the surgical team is exposed to high aerosol-generating procedures when managing COVID-19 patients; on the other hand, the high risk of mortality they have when operating on patients infected by coronavirus even in non-complex procedures²⁰. In that series, 4% of the patients were infected by Coronavirus with no differences in their progression.

In support of these concepts, we found a review published in 2016 by Sallinen²¹, describing that antibiotic therapy for uncomplicated AA presents 3% fewer major complications, 7% fewer minor complications, a marked reduction in hospital stay, and 92% fewer appendectomies in the first month, but at the same time shows a 23% recurrence rate within 1 year and longer hospital stay. The study emphasizes that although appendectomy is a routine surgical procedure with low mortality, 5-28% of patients develop a complication²².

As for mortality in patients operated with COVID-19, it is known that stress and systemic inflammation caused by surgery trigger cell-mediated immunity²³, resulting in exacerbated inflammatory response to the virus in the body, accelerating the development of symptoms and possibly increasing mortality^24,25.

In our Department, we choose not to follow a conservative approach to AA, considering laparoscopic appendectomy as the gold standard of treatment^26-28.

Based on our experience, we suggest that the reduction in Emergency Department visits -that was evident after the mandatory lockdown was determined- may have adversely affected the usual course of patients with AA.