Incidence and severity of pediatric appendicitis during the COVID‑19 pandemic

Abstract

We read the article by del Giorgio et al. in the March 2023 issue of World Journal of Pediatrics with great interest [1]. The authors evaluated the incidence of pediatric appendicitis at their institutions during the first year of the pandemic compared to a four-year control period. They found an increased incidence of appendicitis but did not find differences between study groups for length of stay, age and sex distributions, and proportion of complicated appendicitis. The authors concluded that delay in care for pediatric acute conditions was not a key factor in outcomes during the pandemic. Given their data, we support this conclusion for their institutions. However, we caution the authors, as they draw conclusions about all of Canada, but both institutions involved in this study are located in Montreal. We conducted a similar study evaluating pediatric appendicitis at our institution in Toronto, Ontario, and found different results, as compared in Table 1 [2]. We similarly found significant increases in acute appendicitis incidence and no significant difference in length of stay; however, our results suggest worsened outcomes during the pandemic, demonstrated through an increased rate of complicated/perforated appendicitis (from 28.3% to 38.8%). The pre-pandemic group in del Giorgio et al.’s study had an increased perforation rate (37.7%) compared to ours, although within the typically reported rates (20%–45%) for appendicitis [3, 4]. We cannot explain these differences, but they may be of clinical significance. We evaluated additional metrics, including the duration of antibiotic treatment, surgery length and readmission rate, supporting our observed worsened outcomes during the pandemic. Table 1 Comparison of pediatric appendicitis studies by del Giorgio et al. [1] and Quaglietta et al. [2] Variables Del Giorgio et al. [1] Quaglietta et al. [2] Pre-pandemic control group Pandemic study group Pre-pandemic control group Pandemic study group Study period 49 mon (March 2016-March 2020) 12 mon (April 2020-March 2021) 17 mon (February 2018-June 2019) 17 mon (February 2020-June 2021) Inclusion criteria Acute appendicitis Acute appendicitis Acute appendicitis; < 18 y Acute appendicitis; < 18 y Exclusion criteria Not stated Not stated Interval appendectomy Incidental appendectomy Interval appendectomy Incidental appendectomy Number 2326 (570/y) 736 491 612 Definitions Proportion of perforated appendix and proportion of requiring abscess drainage Proportion of perforated appendix and proportion of requiring abscess drainage Perforation, abscess and/or bowel obstruction as determined by surgeon, radiologist and/or pathology reports Perforation, abscess and/or bowel obstruction as determined by surgeon, radiologist and/or pathology reports Results  Non-operative management, n (%) Not evaluated Not evaluated 36 (7.3) 44 (7.1)  Perforation/complication, n (%) 875 (37.7) 262 (35.6) 139 (28.3) 239 (38.8)  Abscess drainage, n (%) 353 (15.2) 101 (13.7) 12 (2.4) 19 (3.1)  Length of stay (d), median (IQR) Evaluated but data not available Evaluated but data not available 2.0 (4.0) 2.0 (3.0) Duration of antibiotic treatment (d), median (IQR) Not evaluated Not evaluated 2.0 (8.0) 2.0 (11.0)  Surgery length (min), median (IQR) Not evaluated Not evaluated 105 (30) 115 (10)  Readmission rate, n (%) Not evaluated Not evaluated 21 (4.3) 50 (8.1) IQR interquartile range Personal communications with other pediatric hospitals in Ontario revealed similar increases in volume, with one institution also observing increased complicated/perforated appendicitis rates. In Canada, healthcare is under provincial jurisdiction; thus, provinces experienced variable coronavirus disease 2019 (COVID-19) policies mandated by provincial governments (school lockdowns, restaurants, worship centers, healthcare policy for urgent versus non-urgent care, etc.), in addition to federally mandated policies (international travel, land-border closures, testing policies, quarantines, etc.), that may have impacted healthcare, including pediatric acute appendicitis. Given this information, we are unsure whether del Giorgio et al.’s findings can be generalized to all of Canada given that both institutions are located within Montreal. Overall, this is an important article to understand the impacts of the COVID-19 pandemic on broader healthcare. The authors should be cautious in generalizing to encompass the entire nation when only studying one region, especially knowing that Canada is a federalist state with different healthcare systems and provincial government-based COVID-19 pandemic policies.