Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study

Abstract

Purpose: The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown.

Methods: We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications.

Results: A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760).

Conclusion: Introduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.

Keywords: Appendicitis; COVID-19; Laparoscopy; RIF pain.

Fig. 1

Change in imaging before and after change in Intercollegiate guidelines. Graph demonstrating distribution of patients who did (black) and did not (grey) undergo abdominal USS and abdominal CT for the investigation of suspected appendicitis in cohort A and cohort B. *Value showing statistical significance using Fisher’s exact test. CT computed tomography; USS ultrasound scan

Fig. 2

Management of patients diagnosed with appendicitis before and after change in Intercollegiate guidelines. a Graphs demonstrating number of patients undergoing surgical (black) and non-operative (grey) management in cohorts A and B. b Of patients undergoing surgical management for appendicitis, those managed with a laparoscopic (black) and open (grey) approach in cohorts A and B. *Value showing statistical significance using Fisher’s exact test. Mx management

Fig. 3

Differences in inflammatory markers on admission in patients diagnosed with appendicitis after change in Intercollegiate guidelines. Differences in WCC, neutrophil count and CRP on admission following new guideline implementation in patients who went on to have surgical (black) and non-operative (grey) management. Error bars demonstrate 95% confidence intervals. *Value showing statistical significance. CRP C-reactive protein; WCC white cell count

Fig. 4

Length of stay in patients presenting after change in Intercollegiate guidelines. Length of stay in patients managed surgically or non-operatively for appendicitis presenting after implementation of new guidance. Vertical lines demonstrate median LOS. Vertical line demonstrates median. *Value showing statistical significance using two-tailed unpaired t test. Mx management

Fig. 5

SARS-CoV-2 PCR testing in patients presenting before and after change in Intercollegiate guidelines. Graph demonstrating distribution of patients who did (black) and did not (grey) undergo SARS-CoV-2 PCR testing in cohort A and B. *Values showing statistical significance using Fisher’s exact test. PCR polymerase chain reaction; SARS-CoV-2 severe acute respiratory syndrome coronavirus 2