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Impact of the COVID-19 pandemic and restrictive measures on acute appendicitis: Do not let your guard down
Jeronimo Jose Herrera1, Ramiro Arrechea1, Matías Mihura2, Mariano Bregante3, José Pablo Medina4, Daniel Enrique Pirchi2
1 Department of General Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
2 Department of General Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires; Department of Esophagogastric Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
3 Department of General Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires; Department of Hepato-Pancreato-Biliary Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
4 Department of General Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires; Department of Abdominal Wall Surgery, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| Date of Submission | 15-Aug-2021 |
| Date of Acceptance | 25-Oct-2021 |
| Date of Web Publication | 06-Jan-2022 |
Correspondence Address:
Jeronimo Jose Herrera,
Hospital Británico de Buenos Aires, Perdriel 74, 1280, Ciudad Autónoma de Buenos Aires
Argentina
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmas.jmas_267_21 PMID: 35046185
Background: The COVID-19 pandemic has altered the usual dynamics of consultation and presentation for acute appendicitis (AA). The aim of this study was to evaluate the impact of the pandemic and restrictive measures on the cases of AA.
Subjects and Methods: A retrospective study of patients diagnosed with AA between December 2019 and July 2020 was conducted. Patients were classified into two groups; one that underwent treatment in the 16 weeks before the implementation of lockdown in Argentina (Group 1) and another that underwent treatment in the 16 weeks after (Group 2). Demographic, clinical and surgical variables were evaluated.
Results: Overall, 91 patients underwent surgery, 61 and 30 patients in each group, showing a 51% drop in the incidence. The second group delayed seeking medical care longer (mean 46 h vs. 27 h, P < 0.05), had a higher rate of perforated appendicitis (30% vs. 11%, P < 0.05) and a higher rate of complicated appendicitis (56.6% vs. 18%, P < 0.01). These results were associated with a longer operative time (43.7 ± 15.5 min vs. 36.1 ± 11.1 min, P < 0.05) and a longer mean length of hospital stay (1.9 days vs. 1.4 days, P < 0.01); however, no increase in the quantity and severity of post-operative complications was observed.
Conclusion: COVID-19 pandemic and restrictive social measures led to fewer consultations for abdominal pain, resulting in a lower number of AA diagnosed. In addition, a longer delay in seeking medical care was observed, leading to more advanced disease, longer operative time and length of hospital stay.
Keywords: Acute appendicitis, appendectomy, COVID-19, incidence, lockdown, outcomes
How to cite this URL:
Herrera JJ, Arrechea R, Mihura M, Bregante M, Medina JP, Pirchi DE. Impact of the COVID-19 pandemic and restrictive measures on acute appendicitis: Do not let your guard down. J Min Access Surg [Epub ahead of print] [cited 2022 Jan 23]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=335072 |
| ¤ Introduction | |  |
Acute appendicitis (AA) is the most frequent cause of urgent abdominal surgery at General Surgery Departments worldwide. Incidence varies from 82 to 111 cases for each 100,000 inhabitants in the United States and more than 150 cases for each 100,000 inhabitants in European countries.[1]
The management of AA consists of early diagnosis and rapid intervention to avoid serious complications as the risk of gangrene and perforation of the caecal appendix is higher after the first 36 h from symptom onset.[2]
Currently, laparoscopic appendectomy (LA) is the gold standard for the treatment of AA, due to its benefits of minimally invasive surgery and the possibility it provides to explore the abdominal cavity to rule out other causes of acute abdomen and the presence of free fluid in two or more quadrants.
Over the past years, the option of conservative medical treatment with antibiotic therapy and a watch-an-wait attitude has been suggested in select patients with uncomplicated AA in the initial stage of the disease; however, this treatment has not shown to be effective in more advanced diseases.[3]
In the majority of complicated cases, the most common finding is inflamed appendicitis, while in the remaining cases there is a variable distribution of incidence between gangrenous and perforated appendicitis. As can be expected, there is a positive correlation between delay from symptom onset to surgery and histopathological findings. Complicated AA is more often seen in patients with a longer delay to treatment who, as a result, are more likely to develop postoperative complications.[4]
Since the discovery of the SARS-CoV-2 virus and the respiratory syndrome, it causes (COVID-19), the number of infections has exponentially increased worldwide. The disease was declared a pandemic by the World Health Organisation on March 11, 2020.[5],[6] Because of the worldwide alarm, Mandatory Preventive Social Isolation (Aislamiento Social Preventivo y Obligatorio in Spanish) or lockdown was implemented in Argentina on 20 March, 2020. This measure led to a marked decrease in medical consultations at health-care centres throughout the country. Consultations for abdominal pain were no exception. Associated with this trend, there seems to have been an increasing incidence of complicated AA.
Several studies worldwide have shown that the effects of the pandemic and restriction measures taken by governments have led to variable results in the incidence, presentation and complications of patients with AA.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] Countries' cultural, social and economic particularities may play a role in the mentioned variations.
The main aim of this study was to evaluate the effect of the COVID-19 pandemic on the incidence, presentation and outcome of AA in a Latin American developing country with its particular cultural-socio-economic environment and pandemic management.
| ¤ Subjects And Methods | | |
The study was conducted at a private 400-bed health-care institution receiving around 1,000,000 patient visits per year. Between 200 and 250 laparoscopic appendectomies are performed yearly. Patients are first seen at the emergency department (ED) where the necessary resources (laboratory, diagnostic imaging) are available for early diagnosis and treatment by specialists in abdominal surgery on active call.
Design
A retrospective analysis of routinely collected data from the database of the Department of General Surgery was conducted evaluating patients seen between 29th November, 2019, and 10thJuly, 2020.
Population
All patients who underwent surgery for AA were included. Type of treatment, surgical approach or the presence of phlegmon or plastron were not considered to be exclusion criteria. All patients younger than 16 years (paediatric population) were excluded from the study. The electronic records of the patients were reviewed when further information was necessary or when data were lacking in the database.
Variables
The following variables were analysed
Patient characteristics
Demographic and clinical data, such as sex, age, body mass index (BMI), history of arterial hypertension (AHT), diabetes (DBT), abdominal surgery and anaesthetic risk according to the American Society of Anaesthesiologists (ASA) score. Pre-operative data: White bloodcell count, delay in presentation to the ED since symptoms onset, and need for abdominal computed tomography (CT) scan. Intra-operative data: Macroscopic findings for inflamed, gangrenous and perforated appendicitis and complicated appendicitis (the latter defined as findings of gangrene, perforation and/or peritonitis in two or more quadrants), need for intra-abdominal drain placement, operative time and need for conversion from laparoscopic to open surgery. Post-operative data: Length of hospital stay, complications according to the Clavien–Dindo severity classification divided into Grades I and II (minor) and III and IV (major), and readmissions.
The patients were divided into two groups: The pre-ASPO group (G1) consisting of all cases that occurred before the Mandatory Preventive Social Isolation regime or lockdown was implemented and the 'ASPO' group (G2). Patients in G1 were seen during 16 weeks before 20 March, 2020, the day on which ASPO was implemented, and those in G2 during in the 16 weeks after.
To analyse the impact of the pandemic and mandatory confinement measures on patients with AA, we compared the two groups.
Surgical technique
Surgical management of the AA was via the laparoscopic approach in all patients, regardless of whether or not they had symptoms or a positive polymerase chain reaction (PCR) test for SARS-CoV-2. In the context of the increased demand on the health-care system, an algorithm was developed for conservative treatment in selected patients with a positive PCR test in the initial stage of the disease.
To reduce the risk of aerosolisation of viral particles, an aspiration system with a chlorine-containing trap was placed on one of the 5-mm trocars. The exchange of instruments between trocars and procedure time were reduced to the minimum. All medical personnel involved used level-3 personal protection equipment.[17]
Ethics approval
Ethical approval was waived by the local Ethics Committee of the British Hospital of Buenos Aires in view of the retrospective nature of the study, and all the procedures being performed were part of the routine care.
Due to the retrospective nature of the study, the Ethics Committee waived the requirement for written informed consent; however, all patients signed the surgical consent form.
Statistical analysis
Categorical variables are presented as percentages. Continuous variables with a normal distribution are expressed as number and percentage (n; %) or median and standard deviation, while variables with a non-normal distribution are shown as median and percentile (25%–75%) or as mean and standard deviation, according to their distribution. To compare differences, Fisher's exact, Mann–Whitney or χ2 tests were used, according to the type of variable. All statistical analyses were performed using Graph Pad Prism-8.02TM software.
| ¤ Results | | |
During the study period, a total of 91 patients were admitted to the hospital and treated at the Department of General Surgery; 61 (67%) in the pre-ASPO and 30 (33%) in the ASPO group.
Demographics and clinical characteristics for the study population are shown in [Table 1]. When comparing the two groups, no significant statistical difference was found in sex, age, BMI and ASA score. Nevertheless, a medical or surgical history, AHT, diabetes and previous abdominal surgeries were more frequently found in G1.
To assess the change in incidence, the weekly number of patients with AA during the 16 weeks in each group was compared [Figure 1]. A difference in the distribution was observed, showing a 51% drop in the volume of patients with AA between G1 and G2. Over the 32 consecutive weeks, a marked drop in the number of cases was observed after the implementation of the ASPO lockdown. This low incidence persisted over the following weeks, showing an upward trend from week 8 of this period reaching the level of the pre-ASPO period from the 14th week onwards. | Figure 1: Weekly incidence for both groups over 32 consecutive weeks. A marked drop in the number of cases is observed after the implementation of the ASPO lockdown
Click here to view |
When analysing the pre-operative variables [Table 2], delay in presentation to the ED difference was statistically significant (P < 0.05). Differences in the degree of leucocytosis and the need for CT scan did not reach a level of statistical significance.
The intra-operative macroscopic findings [Table 2] show a significant change in their distribution in the second period compared to the first; a decrease in inflamed, an increase in perforated [Figure 2] and an increase in complicated appendicitis were observed. Operative time was significantly longer in the second compared to the first group. | Figure 2: Distribution of intra-operative macroscopic findings for both groups over 16 weeks, respectively
Click here to view |
Regarding post-operative variables, the mean length of the hospital had a significant difference between both groups. No significant differences were observed in terms of complication rate; however, in G1 a complication of type IIIb severity was observed [Table 2].
| ¤ Discussion | | |
In this study, we evaluated the impact of the pandemic and restriction measures on the incidence and presentation of AA. This phenomenon has been studied by other authors who found variable results.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] Coronavirus pandemic have impacted comparably in countries around the world but not in every aspect since there are independent features as culture, health care system management, severity and duration of social restriction measures, etc.The current study evaluated a population that lives in a different cultural-socio-economic environment and in a distinctive pandemic management context compared to those in the previously mentioned studies. A long-lasting severe restriction period parallel to the low number of COVID-19 cases and high population fear were Argentina pandemic initial handling characteristics.
The implementation of the lockdown associated with the risk of SARS-CoV-2 infection has led to a drop in incidence of AA and delay in seeking healthcare, resulting in more advanced disease. These findings may be explained by different factors and causes. There is a seasonal variation in the presentation of AA with a higher incidence in the summer months.[18],[19],[20] Nevertheless, this seasonal variation does not explain the sudden drop in the number of cases and the significant differences found in other variables.
This leads to the question if there was an actual decrease in the incidence or rather a modification due to external factors. To answer this, first, we could consider that the society-wide lockdown imposed by the government restricting free circulation has led to limitations in the possibility to seek medical care. If patients did so, they may have presented to healthcare centres closer to home to avoid travelling longer distances leading to a redistribution of medical consultations among hospitals, with visits increasing at some and decreasing at others. In addition, there has been a generalised anxiety and fear of contagion with COVID-19 when presenting to health-care centres, especially E. Ds. Altogether this may have led to an increase in self-medication with analgesics and/or antibiotics, resulting in the resolution of mild AA. Different authors have reported spontaneous resolution or good response to antibiotics in the early stages of the disease.[21] In G2 we found a lower rate of patients with a medical (AHT 6 vs. 1, P = 0.27; DBT 2 vs. 0, P = n/a) or surgical history (previous abdominal surgery 14 vs. 5, P = 0.48) which may confirm the hypothesis of patients not seeking medical care out of concern of contracting COVID-19, perhaps even more so among patients with comorbidities.
In our series, a statistically significant increase in the time between symptoms onset and patient's arrival at the ED was observed. As referenced before, it has been seen that this delay could result in more advanced diseases.[2] The presentation of more severe AA was observed to be directly correlated with longer operative time, longer hospital stay, and more frequent placement of an intra-abdominal drain (10% vs. 20%, P = 0.2). Nevertheless, this was not translated into a higher rate or increased severity of post-operative complications or the need for conversion to open surgery. In our series, no significant differences were found in terms of morbidity between the groups. In G1, a major IIIb complication occurred in a patient who initially presented with perforated AA with peritonitis in four quadrants and who developed an acute abdomen secondary to an intra-abdominal abscess requiring exploratory laparoscopy, peritoneal lavage and drainage of the abscess with a good outcome.
In this study, we did see a statistically significant increase in the mean operating time (43.7 ± 15.5 min vs. 36.1 ± 11.1 min, P ≤ 0.05). Nevertheless, it is unlikely to be attributable to active operating alone. Considerable changes to the operating environment, as reported in another study,[22] and unfamiliarity with these circumstances are also likely to contribute to an increase in the operative time.
One of the limitations of our study is that it is based on the observation and analysis of patients seen at a single centre. To confirm the above findings, data from other health-care centres should be collected and analysed and combined with official data from the national health-care system.
| ¤ Conclusion | | |
In the present study, we found a significant drop in the incidence of AA associated with a delay in seeking medical attention and the related outcomes referred, secondary to the restriction measures taken by the government added to the population fear of Coronavirus contagion. A balance between measures taken to control infectious diseases, such as COVID-19, and the continued management of emergency acute conditions is necessary.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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