Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany

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Abstract

Purpose

The COVID-19 pandemic has transformed medical care worldwide. General surgery has been affected in elective procedures, yet the implications for emergency surgery are unclear. The current study analyzes the effect of the COVID-19 lockdown in spring 2020 on appendicitis treatment in Germany.

Methods

Hospitals that provided emergency surgical care during the COVID-19 lockdown were invited to participate. All patients diagnosed with appendicitis during the lockdown period (10 weeks) and, as a comparison group, patients from the same period in 2019 were analyzed. Clinical and laboratory parameters, intraoperative and pathological findings, and postoperative outcomes were analyzed.

Results

A total of 1915 appendectomies from 41 surgical departments in Germany were included. Compared to 2019 the number of appendectomies decreased by 13.5% (1.027 to 888, p=0.003) during the first 2020 COVID-19 lockdown. The delay between the onset of symptoms and medical consultation was substantially longer in the COVID-19 risk group and for the elderly. The rate of complicated appendicitis increased (58.2 to 64.4%), while the absolute number of complicated appendicitis decreased from 597 to 569, ( p=0.012). The rate of negative appendectomies decreased significantly (6.7 to 4.6%; p=0.012). Overall postoperative morbidity and mortality, however, did not change.

Conclusion

The COVID-19 lockdown had significant effects on abdominal emergency surgery in Germany. These seem to result from a stricter selection and a longer waiting time between the onset of symptoms and medical consultation for risk patients. However, the standard of emergency surgical care in Germany was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02090-3.

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Most cited references 28

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A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Mary Charlson, Peter Pompei, Kathy Ales … (1987)

The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.

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Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Daniel Dindo, Nicolas Demartines, Pierre-Alain Clavien (2004)

Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.

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Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.

Aneel Bhangu, Kjetil Søreide, Salomone Di Saverio … (2015)

Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.

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Author and article information

Contributors

Arnulf G. Willms:

ORCID: http://orcid.org/0000-0001-9998-6735

ArnulfWillms@bundeswehr.org

Journal

Journal ID (nlm-ta): Langenbecks Arch Surg

Journal ID (iso-abbrev): Langenbecks Arch Surg

Title: Langenbeck's Archives of Surgery

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1435-2443

ISSN (Electronic): 1435-2451

Publication date (Electronic): 7 February 2021

Pages: 1-9

Affiliations

[1 ]GRID grid.493974.4, ISNI 0000 0000 8974 8488, Klinik für Allgemein- und Viszeralchirurgie, Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, ; Koblenz, Germany

[2 ]Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbeck, Hamburg, Germany

[3 ]GRID grid.492182.4, ISNI 0000 0004 0480 1286, Abteilung für Allgemein-, Viszeral-, Thorax- und Minimalinvasive Chirurgie, Rot-Kreuz-Klinikum München, ; München, Germany

[4 ]Klinik für Allgemein- Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Hamburg, Hamburg, Germany

[5 ]Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Berlin, Berlin, Germany

[6 ]Klinik für Allgemein-, Viszeral-und Transplantationschirurgie, Universitätsmedizin Mainz, Mainz, Germany

[7 ]GRID grid.411760.5, ISNI 0000 0001 1378 7891, Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, ; Würzburg, Germany

[8 ]GRID grid.492024.9, ISNI 0000 0004 0558 7111, Operatives Zentrum für Allgemeinchirurgie, Klinikum Fürth, ; Fürth, Germany

[9 ]GRID grid.461712.7, ISNI 0000 0004 0391 1512, Klinik für Viszeral-, Tumor-, Transplantations- und Gefäßchirurgie, Kliniken der Stadt Köln, Standorte Merheim und Holweide, ; Köln, Germany

[10 ]Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Ludwigshafen am Rhein, Ludwigshafen, Germany

[11 ]Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, InnKlinikum Altötting und Mühldorf, Altötting, Germany

[12 ]GRID grid.419839.e, Klinik für Allgemein- und Viszeralchirurgie, Thoraxchirurgie, Chirurgische Onkologie, Klinikum Saarbrücken, ; Saarbrücken, Germany

[13 ]GRID grid.411067.5, ISNI 0000 0000 8584 9230, Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen, ; Gießen, Germany

[14 ]GRID grid.411088.4, ISNI 0000 0004 0578 8220, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Frankfurt, ; Frankfurt, Germany

[15 ]Chirurgische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany

[16 ]GRID grid.10493.3f, ISNI 0000000121858338, Abteilung für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, ; Rostock, Germany

[17 ]GRID grid.7708.8, ISNI 0000 0000 9428 7911, Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, ; Freiburg, Germany

[18 ]GRID grid.500045.4, Abteilung für Allgemein- und Viszeralchirurgie, GFO Kliniken Bonn, ; Bonn, Germany

[19 ]GRID grid.411097.a, ISNI 0000 0000 8852 305X, Klinik und Poliklinik für Allgemein-, Viszeral-, Tumor- und Transplantationschirurgie, Uniklinik Köln, ; Köln, Germany

Author information

Arnulf G. Willms http://orcid.org/0000-0001-9998-6735

Article

Publisher ID: 2090

DOI: 10.1007/s00423-021-02090-3

PMC ID: 7867500

PubMed ID: 33550453

SO-VID: 409ffeb3-6ad2-423d-aff7-79e0d1b4d7c4

License:

This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany

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Abstract

Purpose

Methods

Results

Conclusion

Supplementary Information

Related collections

Novel Coronavirus Disease COVID-19

Most cited references 28

A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.

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