Where Did All the Appendicitis Go? Impact of the COVID-19 Pandemic on Volume, Management, and Outcomes of Acute Appendicitis in a Nationwide, Multicenter Analysis

Abstract

Objective: The study objective was to evaluate effects of the COVID-19 pandemic on rates of emergency department (ED) acute appendicitis presentation, management strategies, and patient outcomes. Summary Background Data: Acute appendicitis is the most commonly performed emergency surgery in the United States and is unlikely to improve without medical or surgical intervention. Dramatic reductions in ED visits prompted concern that individuals with serious conditions, such as acute appendicitis, were deferring treatment for fear of contracting COVID-19. Methods: Patients from 146 hospitals with diagnosed appendicitis and arrival between March 2016 and May 2020 were selected. Electronic medical records data were retrospectively reviewed to retrieve patient data. Daily admissions were averaged from March 2016 through May 2019 and compared with March 2020. April-specific admissions were compared across the 5-year pre-COVID-19 period to April 2020 to identify differences in volume, demographics, disease severity, and outcomes. Results: Appendicitis patient admissions in 2020 decreased throughout March into April, with April experiencing the fewest admissions. April 2020 experienced a substantial decrease in patients who presented with appendicitis, dropping 25.4%, from an average of 2030 patients (2016–2019) to 1516 in 2020. An even greater decrease of 33.8% was observed in pediatric patients (age <18). Overall, 77% of the 146 hospitals experienced a reduction in appendicitis admissions. There were no differences between years in percent of patients treated nonoperatively (P = 0.493) incidence of shock (P = 0.95), mortality (P = 0.24), or need for postoperative procedures (P = 0.81). Conclusions: Acute appendicitis presentations decreased significantly during the COVID-19 pandemic, while overall management and patient outcomes did not differ from previous years. Further research is needed focusing on putative explanations for decreased hospital presentations unrelated to COVID-19 infection and possible implications for surgical management of uncomplicated acute appendicitis. Keywords: acute appendicitis, COVID-19, decreasing volumes, multicenter study

Incidence of Complicated Appendicitis during the COVID-19 Pandemic versus the Pre-Pandemic Period: A Systematic Review and Meta-Analysis of 2782 Pediatric Appendectomies

“…This twenty-seven-item scale has minimum and maximum scores of 0 and 32, respectively. On the basis of these scores, the risk of bias in each study was declared as high (score 0-15), moderate (score = [16][17][18][19][20][21][22][23], or low (score > 23). Subsequently, the inter-observer agreement on these scores was adjudged using the Kappa statistics [28].…”

“…Despite the confinement measures, acute appendicitis does not quarantine [ 18 ]. The pandemic has impacted volume, diagnostic and management strategies, and patient outcomes of acute appendicitis [ 19 , 20 ]. A nationwide study in the United States found a significant decrease in acute appendicitis presentation, while two studies from Germany observed a decrease in the number of appendectomies during the lockdown [ 19 , 21 , 22 ].…”

“…The pandemic has impacted volume, diagnostic and management strategies, and patient outcomes of acute appendicitis [ 19 , 20 ]. A nationwide study in the United States found a significant decrease in acute appendicitis presentation, while two studies from Germany observed a decrease in the number of appendectomies during the lockdown [ 19 , 21 , 22 ]. Additionally, it was suggested that non-operative management (NOM) could be a safe alternative to surgery during the pandemic [ 23 , 24 , 25 ].…”

“…A study from Budapest suggests that a higher number of perforated appendices is in line with international trends, and shares no correlation with the COVID-19 pandemic [ 24 ]. In contrast, various studies have also demonstrated no significant differences in the rates of complicated appendicitis among children presenting during the pandemic versus the pre-pandemic period [ 19 , 20 ]. Due to these conflicting findings, there is no consensus statement regarding the incidence of complicated appendicitis among the children presenting during the pandemic.…”

COVID-19 and Complicated Appendicitis: What is the Relationship?

“…Firstly, in the face of the pandemic, people were reluctant to leave their homes to seek medical care due to fears of contracting the virus within the hospital environment [11][12][13] and movement restrictions placed by different governments in a bid to contain the spread of the virus [8]. These led to delayed presentations and hence an increased risk of complications arising in the setting of acute appendicitis.…”