Changes in the Emergency General Surgery Operations in the Setting of COVID-19 and Impact of Strategy of Non-Operative Management on Outcomes in Acute Appendicitis

Abstract

Background: Coronavirus disease 2019 has posed significant challenges to the provision of elective and emergency general surgical care. Patterns of presentation have changed and management pathways have also been adapted, moving to more non-operative management (NOM) for some conditions. We investigated how COVID-19 changed the volume of emergency general surgery operating in our district general hospital (DGH). We aimed to evaluate the impact of NOM on outcomes in acute appendicitis.Methods: A retrospective case review of operating lists, patient handover lists, and patient notes was undertaken for patients presented between 1 st January 2020 and 3 rd June 2020. The study period was divided into two, with the period between 1 st January 2020 and 23 rd March 2020 representing the pre-COVID cohort.Results: Some 393 emergency general surgery operations were performed in the study period. There was a clear reduction in operating volume after 23 rd March 2020. During that same period, 325 patients were assessed with right iliac fossa (RIF) pain. Median age was 21 (range 5-87) and 201 patients were female (61.8%). The rate of NOM for suspected acute appendicitis was 8.8% in the pre-COVID group, which increased to 36.4% in the COVID group. The incidence of normal histology following appendicectomy did not change with this difference in management (16.1% compared to 17.9%, p = 0.78).Conclusions: This study summarizes the changes brought to the provision of emergency general surgery in the setting of a DGH by the COVID-19 pandemic. In particular, NOM was the preferred option for acute appendicitis but this did not alter the negative appendicectomy rate.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

“…Surgical societies put forth guidelines for management of AA, encouragin NOM for both uncomplicated and complicated appendicitis 30 . As previously discussed, this led to decreased operative management 1,23–25 . In comparison with pre-COVID studies suggesting suitable efficacy and safety of NOM of uncomplicated AA, 31 our study found significantly higher readmission, mortality, and LOS for both COVID-negative and COVID-active patients who underwent NOM.…”

“…30 As previously discussed, this led to decreased operative management. 1,[23][24][25] In comparison with pre-COVID studies suggesting suitable efficacy and safety of NOM of uncomplicated AA, 31 our study found significantly higher readmission, mortality, and LOS for both COVID-negative and COVID-active patients who underwent NOM. Among COVID-negative patients, both NOM and operative groups were relatively healthy at baseline, as demonstrated by low comorbidity index (CCI, <1).…”

“…The decreased incidence of operative management of AA during the pandemic has been well documented, 1,[23][24][25] although these studies consist mostly of COVID-negative patients or do not report COVID-19 test results, limiting interpretability. The incidence of appendectomy for COVID-negative patients in this study is in line with existing literature.…”