Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Cohort Study

Background: During the coronavirus disease 2019 (COVID-19) pandemic, the management of acute appendicitis shifted towards non-operative management in the United Kingdom (UK). The open approach was recommended over the laparoscopic approach due to the risk of aerosol generation and subsequent contamination. The aim of this study was to compare the overall management and surgical outcomes of the patients treated for acute appendicitis before and during the COVID-19 pandemic. Materials and Methods: We performed a retrospective cohort study at a single district general hospital in the UK. We compared the management and outcome of the patients diagnosed with acute appendicitis before the pandemic, from March to August 2019, and during the pandemic, from March to August 2020. We looked at the patient demographics, methods of diagnosis, management, and surgical outcomes for these patients. The primary outcome of the study was the 30-day readmission rate. Secondary outcomes included length of stay and post-operative complications. Results: Over the period of six months, a total of 179 patients were diagnosed with acute appendicitis in 2019 (Pre-COVID-19 pandemic, from March 1, 2019, to August 31, 2019) versus 152 in 2020 (during the COVID-19 pandemic, from March 1, 2020, to August 31, 2020). For the 2019 cohort, the mean age of the patients was 33 (range 6-86 years), 52% (n=93) were female, and the mean BMI was 26 (range 14-58). For the 2020 cohort, the mean age was 37 (range 4-93 years), 48% (n=73) of the patients were female, and the mean BMI was 27 (range 16-53). At the first presentation, in 2019, 97.2% of the patients (174 out of 179) received surgical treatment compared to 70.4% (107 out of 152) in 2020. Three per cent of the patients (n=5) were managed conservatively in 2019 (two out these failed conservative management) as compared to 29.6% (n=45) in 2020 (21 of these failed conservative management). Pre-pandemic, only 32.4% (n= 57, ultrasound (US) scan: 11, computer tomography (CT) scan): 45, both US and CT: 1) of the patients received imaging to confirm the diagnosis as compared to 53.3% during pandemic (n=81, US scan: 12, CT scan: 63, both US and CT: 6). Overall, the CT to US ratio increased. We found that during 2019, 91.5% (n=161/176) of the patients who received surgical treatment went through laparoscopic surgery as compared to only 74.2% (n=95/128) in 2020 (p<0.0001). Postoperative complications occurred in 5.1% (n=9/176) of the surgical patients in 2019 as compared to 12.5% (n=16/128) in 2020 (p<0.033). The mean length of hospital stay in 2019 was 2.9 days (range 1- 11) versus 4.5 days in 2020 (range 1-57) (p<0.0001). The 30-day readmission rate was 4.5% (8/179) versus 19.1% (29/152) (p<0.0001). The 90-day mortality rate was zero for both cohorts. Conclusion: Our study shows that the management of acute appendicitis changed due to the COVID-19 pandemic. More patients went through imaging, especially CT scans for diagnosis and received non-operative management with antibiotics only. The open surgical approach became more common during the pandemic. This was associated with longer lengths of hospital stay, more readmissions, and an increase in postoperative complications.