The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

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Abstract

Background

Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK).

Methods

Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up.

Results

The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26–49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1–4] days vs. 3 [2–4], p < 0.001). At 30 days, complications were significantly higher in the operative group ( p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive.

Conclusion

COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

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Most cited references 22

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Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Dmitri Nepogodiev, James C. D. Glasbey, Elizabeth Li … (2020)

Summary Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

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The epidemiology of appendicitis and appendectomy in the United States.

DAVID G ADDISS, NATHAN SHAFFER, BARBARA S. FOWLER … (1990)

To describe the epidemiology of appendicitis and appendectomy in the United States, the authors analyzed National Hospital Discharge Survey data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in the United States during this period, accounting for an estimated 1 million hospital days per year. The highest incidence of primary positive appendectomy (appendicitis) was found in persons aged 10-19 years (23.3 per 10,000 population per year); males had higher rates of appendicitis than females for all age groups (overall rate ratio, 1.4:1). Racial, geographic, and seasonal differences were also noted. Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months. The highest rate of incidental appendectomy was found in women aged 35-44 years (43.8 per 10,000 population per year), 12.1 times higher than the rate for men of the same age. Between 1970 and 1984, the incidence of appendicitis decreased by 14.6%; reasons for this decline are unknown. A life table model suggests that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Overall, an estimated 36 incidental procedures are performed to prevent one case of appendicitis; for the elderly, the preventive value of an incidental procedure is considerably lower.

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COVID ‐19 pandemic: perspectives on an unfolding crisis

A. Spinelli, G Pellino (2020)

A time of crisis

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Author and article information

Contributors

H. Javanmard-Emamghissi:

ORCID: http://orcid.org/0000-0002-4270-5020

Hannah.javanmard@gmail.com

Journal

Journal ID (nlm-ta): Tech Coloproctol

Journal ID (iso-abbrev): Tech Coloproctol

Title: Techniques in Coloproctology

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1123-6337

ISSN (Electronic): 1128-045X

Publication date (Electronic): 15 July 2020

Publication date PMC-release: 15 July 2020

Pages: 1-11

Affiliations

[1 ]GRID grid.413619.8, ISNI 0000 0004 0400 0219, Royal Derby Hospital, University of Nottingham at Derby, ; Derby, UK

[2 ]GRID grid.413619.8, ISNI 0000 0004 0400 0219, Royal Derby Hospital, ; Derby, UK

[3 ]GRID grid.416340.4, ISNI 0000 0004 0400 7816, Musgrove Park Hospital, ; Taunton, UK

[4 ]GRID grid.240404.6, ISNI 0000 0001 0440 1889, NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, ; Nottingham, UK

[5 ]The Countess of Chester, Chester, UK

[6 ]GRID grid.416091.b, ISNI 0000 0004 0417 0728, Royal United Hospital, ; Avon, Bath, UK

[7 ]Salford Royal NHS Trust, Salford, UK

[8 ]GRID grid.419436.d, ISNI 0000 0004 0648 9361, Cardiff Royal Infirmary, ; Cardiff, UK

[9 ]GRID grid.439210.d, ISNI 0000 0004 0398 683X, Medway Maritime Hospital, ; Kent, UK

[10 ]GRID grid.418447.a, ISNI 0000 0004 0391 9047, Bradford Royal Infirmary, ; Bradford, UK

[11 ]GRID grid.416082.9, ISNI 0000 0004 0624 7792, Royal Alexandra Hospital, ; Paisley, UK

Author information

H. Javanmard-Emamghissi http://orcid.org/0000-0002-4270-5020

Article

Publisher ID: 2297

DOI: 10.1007/s10151-020-02297-4

PMC ID: 7362319

PubMed ID: 32671661

SO-VID: 55adf91a-062d-43d3-a806-8e7718040ffc

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 9 June 2020

Date accepted : 5 July 2020

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The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

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Most cited references 22

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

The epidemiology of appendicitis and appendectomy in the United States.

COVID ‐19 pandemic: perspectives on an unfolding crisis

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