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      Investigation and management of suspected appendicitis during the COVID‐19 pandemic

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          Abstract

          Editor The COVID‐19 pandemic resulted in widespread change to the organization and delivery of emergency general surgery services in the United Kingdom 1 , 2 . The Royal College of Surgeons of England advised centres to avoid laparoscopy 3 , 4 and to consider the need for emergency surgery given the increased risks during the pandemic 5 . These guidelines were implemented in our institution on 26 March 2020. We prospectively collected data on the investigation and management of patients with suspected appendicitis between 26 March and 6 May 2020. We retrospectively collected data on patients undergoing appendicectomy (28 February ‐ 25 March 2020) to compare our operative approach and histology. We included patients aged >16 years of age admitted under the general surgery team. Patients receiving haemodialysis, chemotherapy or radiotherapy were excluded. Our primary outcome was to determine if SARS CoV‐2 diagnosis altered the management of appendicitis, secondary outcomes included; negative appendicectomy rate (NAR), length of stay (LOS) and readmission rate. Sixty seven patients were included in our analysis (26 March ‐ 6 May 2020). Twenty nine were diagnosed with appendicitis (Table  1 ), 25 (86 per cent) had diagnosis confirmed on imaging (ultrasound or CT), 21 (72 per cent) undergoing CT. Nine had an appendicectomy – all performed open. NAR was 0 per cent. The remaining 20 were managed conservatively with antibiotics. Of these, one required percutaneous drain insertion under image guidance by an interventional radiologist. Table 1 Key demographic and outcome data for cohorts before and after implementation of new RCSEng guidance March cohort (n = 29) April cohort (n = 22) P Age (years) 37 (19‐80)* 37 (17‐73)* 0·916 Gender Male 12 (55%) 14 (48%) 0·779 Female 10 (45%) 15 (52%) 0·779 Management Open surgery 3 9 0·193 Laparoscopic 19 0 <0·00001 † Conservative 0 20 <0·00001 † Imaging CT 11 (50%) 21 (72%) 0·145 USS 6 (27%) 4 (4%) 0·295 Complications 5 2 0·216 Readmission 2 2 1·00 Length of stay Operative Mx 3 days (1‐7)* 3 days (2‐4)* 0·388 Conservative Mx N/A 1 day (0‐7) * N/A NAR 2 (9%) 0 (0%) 0·181 * Values demonstrate medians and range. † Values showing statistical significance. CT = Computed Tomography; Mx = Management; NAR = Negative Appendicectomy Rate; USS = Ultrasound Scan. Only one patient in our cohort was suspected of having SARS CoV‐2 infection (based on chest radiographic appearances), with a subsequent negative PCR assay. They were treated conservatively for ultrasound proven appendicitis. There was a difference in LOS between patients undergoing conservative versus operative management for appendicitis (1 versus 3 days; P = 0·066 non‐significant). Twenty two patients underwent appendicectomy between 28 February and 25 March (Table  1 ). Eighteen (82 per cent) had positive imaging, 19 had a laparoscopic appendicectomy, three were done open. There was a higher rate of CT following the implementation of the new guidelines (72 versus 50 per cent; P = 0·145 non‐significant). Two patients had a negative appendicectomy. NAR was higher (9 versus 0 per cent; P = 0·181, non‐significant). LOS was comparable in the two operative groups (3 versus 3 days; P = 0·388). The COVID‐19 pandemic has placed an unprecedented demand on health services demonstrating a need for data on its effect on surgical care and outcomes 6 . With reports of increased morbidity and mortality for patients undergoing surgery following SARS CoV‐2 exposure 7 , national reform in the delivery of both elective and emergency surgery is unsurprising. We report a noticeable change in practice during the COVID‐19 pandemic, however the short timeframe for data collection with the need for early reporting has resulted in small case numbers. We managed the majority of appendicitis conservatively and when operating did not use laparoscopy. NAR has been reported as 20·6 per cent in large, international multicentre studies and as high as 50 per cent in individual centres 8 . Increased CT use during this period may help explain the low NAR (0 per cent) in our data, though it is difficult to determine the significance given our small sample size. Patients managed conservatively had a shorter LOS without development of more complications or readmission 3 .

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          Elective surgery cancellations due to the COVID ‐19 pandemic: global predictive modelling to inform surgical recovery plans

          Background The COVID‐19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID‐19. Methods A global expert‐response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian beta‐regression model was used to estimate 12‐week cancellation rates for 190 countries. Elective surgical case‐mix data, stratified by specialty and indication (cancer versus benign surgery), was determined. This case‐mix was applied to country‐level surgical volumes. The 12‐week cancellation rates were then applied to these figures to calculate total cancelled operations. Results The best estimate was that 28,404,603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID‐19 (2,367,050 operations per week). Most would be operations for benign disease (90.2%, 25,638,922/28,404,603). The overall 12‐week cancellation rate would be 72.3%. Globally, 81.7% (25,638,921/31,378,062) of benign surgery, 37.7% (2,324,069/6,162,311) of cancer surgery, and 25.4% (441,611/1,735,483) of elective Caesarean sections would be cancelled or postponed. If countries increase their normal surgical volume by 20% post‐pandemic, it would take a median 45 weeks to clear the backlog of operations resulting from COVID‐19 disruption. Conclusions A very large number of operations will be cancelled or postponed due to disruption caused by COVID‐19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to safely restore surgical activity. This article is protected by copyright. All rights reserved.
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            COVID ‐19 pandemic: perspectives on an unfolding crisis

            A time of crisis
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              Immediate and long‐term impact of the COVID ‐19 pandemic on delivery of surgical services

              Background The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery. Methods This was a scoping review of all available literature pertaining to COVID‐19 and surgery, using electronic databases, society websites, webinars and preprint repositories. Results Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross‐cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning. Conclusion Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.
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                Author and article information

                Journal
                Br J Surg
                Br J Surg
                10.1002/(ISSN)1365-2168
                BJS
                The British Journal of Surgery
                John Wiley & Sons, Ltd. (Chichester, UK )
                0007-1323
                1365-2168
                13 July 2020
                August 2020
                : 107
                : 9 ( doiID: 10.1002/bjs.v107.9 )
                : e337-e338
                Affiliations
                [ 1 ] Department of General Surgery Queens Hospital, BHR NHS Trust London UK
                [ 2 ] National Bowel Research Centre Blizard Institute, QMUL London UK
                Author notes
                [*]

                WE and NHB are joint first authors and contributed equally

                Article
                BJS11787
                10.1002/bjs.11787
                7404757
                32658307
                © 2020 BJS Society Ltd Published by John Wiley & Sons Ltd

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                Page count
                Figures: 0, Tables: 1, Pages: 2, Words: 799
                Product
                Categories
                General
                Correspondence
                Correspondence
                Custom metadata
                2.0
                August 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.6 mode:remove_FC converted:05.08.2020

                Surgery

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