Managing appendicitis during the COVID-19 pandemic in the UK.

Editor

A number of surgical bodies and organizations have issued guidance for surgery during the current COVID-19 pandemic. UK and Ireland Intercollegiate Board guidance attempts to address the role of conservative management and concerns over laparoscopic surgery, specifically in regard to aerosol-generating potential and associated theoretical infection risk.

The uncertainty surgeons face around whether non-operative management should be increased for acute surgical conditions, including appendicitis, has been highlighted. We believe conservative management should not be undertaken in patients who would normally undergo appendicectomy. Indeed, early operative management may be favoured over conservative management due to the potential shorter length of stay (LOS) in hospital. Early appendicectomy would also avoid complications of failed conservative management.

We would not advocate serial blood tests or CT, as diagnosis and ongoing assessment should remain clinical. Blood tests, including C-reactive protein and white cell count, may be normal in the presence of appendicitis. Performing these investigations, in particular CT, presents a logistical challenge and increases the risk of cross-exposure of staff and patients at a time when we should be aiming to minimize this.

Many of the patients in whom diagnostic uncertainty exists will be females of reproductive age and pelvic irradiation is contraindicated under ‘normal circumstances’. Additional investigations should be avoided at a time when resources are under pressure.

It is worth remembering that open appendicectomy has an excellent outcome. We previously presented our findings comparing open and laparoscopic appendicectomy. There were significantly shorter operation times (34·2 versus 59·2 min) and reduced LOS (median: 1 versus 2 days) in open compared to laparoscopic appendicectomy. Each of these is beneficial during this COVID-19 pandemic.

Managing surgical patients during this pandemic poses a challenge and we agree laparoscopic procedures should be avoided. Excellent outcomes could be achieved by early open appendicectomy in patients with clinical appendicitis.