Acute appendicitis during the COVID-19 lockdown: never waste a crisis!

Dear Editor

In the past 9 months, the world has been dealing with the devastating global crisis caused by the SARS-CoV2 pandemic. To date, more than 33 million cases have been diagnosed worldwide and over 1 million people have died. This has caused new challenges for healthcare systems, including those associated with the management of surgical emergencies. Changes in the epidemiology, diagnosis and treatment of appendicitis during the pandemic also deserve attention ().

Fear of overburdening healthcare systems and becoming infected inside hospitals may have discouraged the patients from seeking care for non-COVID-19 illnesses, with the obvious consequence of a reduction in the rate of hospital admissions for patients with appendicitis.

As a result, while the number of COVID-19 cases increases, fewer patients present as an emergency with appendicitis, and those who do present with more advanced disease,,. Rather than a real decrease in the incidence of appendicitis, these findings are consistent with the hypothesis of prehospital selection, with high rates of successful resolution of uncomplicated appendicitis following patients’ self-medication with antibiotics at home.

The reported high proportion of perforated appendicitis during the pandemic can be explained neither by a more aggressive course of the disease nor by delay in seeking medical attention, but rather by selection due to undiagnosed resolving appendicitis. It is well known that a radical approach with a broader indication for surgical exploration is associated with a low proportion of perforations secondary to the detection of a larger number of patients with uncomplicated appendicitis, and not because fewer perforations occur. Conversely, the higher proportion of perforated appendicitis associated with a restrained attitude to surgical exploration, as is happening during the pandemic, is explained mainly by the detection of fewer patients with uncomplicated appendicitis and not by a real increase in the number of perforations.

The exceptional situation related to COVID-19 has led surgeons more often to consider antibiotic treatment alone for patients with appendicitis. Non-operative management with antibiotics has been evaluated widely in the literature during ‘peaceful times’, showing its initial efficacy in over 90 per cent of cases. Such a high efficacy rate for antibiotics-alone treatment strategies has proved to be important during the COVID-19 pandemic, when access to the operating room has been limited or sometimes not possible,.

Given the current status of the pandemic, which still requires a broader availability of ICU facilities and health workers to care for the overwhelming number of patients with COVID-19 infection and life-threatening conditions, a potentially increased rate of late recurrence of appendicitis following successful antibiotic treatment might occur.

The negative appendicectomy rate has decreased dramatically during the COVID-19 pandemic. A recent multicentre international study showed that, in patients aged 16–45 years, the negative appendicectomy rate was 20 per cent in the UK and 6.2 per cent in the other countries. Patients admitted with suspected appendicitis during the pandemic are more likely to undergo preoperative imaging, which possibly explains this fall.

Lastly, although there are no data to confirm the presence of SARS-CoV-2 in laparoscopic plumes of surgical smoke, several guidelines recommended erring ‘on the side of caution’, which has led some to discourage the use of laparoscopy and to advise open appendicectomy when surgery is unavoidable. The possible negative implications of open surgery for appendicitis include increasing surgical pain, wound infection and longer hospital stay, all factors that negatively affect the need to reduce the overcrowding of hospitals during the pandemic. Thus, as safe management of surgical plumes is possible,, and low-cost smoke filters are now available, surgeons should resume minimally invasive surgery considering the scientific evidence available, and offer patients the benefits of laparoscopic appendicectomy.

Disclosure. The authors declare no conflict of interest.

Table 1.

Overview of published research on acute appendicitis during the COVID-19 pandemic

Reference	n	Management (%)		Time to consultation (days)	Complicated appendicitis (%)	Approach (%)		Imaging (%)	NAR (%)	NOM failure (%)
		Surgery	NOM			Open	Laparoscopic
								US 17
English et al. 1
Before lockdown	29	76	0	n.r.	n.r.	14	86	CT 50	9	n.r.
								US 27
During lockdown	22	9	91	n.r.	n.r.	100	0	CT 72	0	n.r.
								US 4
Basamh et al. 2
During lockdown	42	0	100	n.r.	n.r.	n.a.		CT 100	n.a.	9.3 uncomplicated AA
										20 complicated AA
Ganesh et al. 3
Before lockdown	64	100	0	n.r.	n.r.	8	95	CT/MRI 61	n.r.	n.a.
During lockdown	32	56	44	n.r.	n.r.	89	11	CT/MRI 100	n.r.	3
Kelly et al. 4
During lockdown	18	39	61	n.r.	n.r.	n.r.		n.r.	n.r.	0
Dreifuss et al. 5
Before lockdown	65	n.r.		1.4	17	n.r.		n.r.	n.r.	n.r.
During lockdown	15	n.r.		2.4	47	n.r.		n.r.	n.r.	n.r.
Tankel et al. 6
Before lockdown	237	85.2	14.8	1.8	13.1	1.7	83.5	n.r.	n.r.	n.r.
During lockdown	141	92.2	7.8	1.	20.6	4.3	87.9	n.r.	n.r.	n.r.
Toale et al. 7
Before lockdown	122	87.7	12.3	2	10.3	17.8	82.2	CT 17.2	33.6	n.r.
								US 50.8
During lockdown	62	55	45	1.5	38	79	21	CT 55	0	n.r.
								US 42
Romero et al. 8
Before lockdown	141	n.a.	n.a.	n.r.	57.1*	n.a.		CT 29.8	n.a.	n.a.
During lockdown	55	n.a.	n.a.	n.r.	92*	n.a.		CT 46	n.a.	n.a.
Javanmard-Emamghissi et al. 9
During lockdown	500	46	54	n.r.	n.r.	56	44	CT 71	3	10

*Appendicitis with periappendicitis, appendicitis with rupture, complicated appendicitis. NOM, nonoperative management; NAR, negative appendicectomy rate; n.r., not reported; US, ultrasonography; n.a., not applicable; AA, acute appendicitis.