The impact of the COVID-19 pandemic on the severity of emergency bowel surgery

Background: The COVID-19 pandemic was declared on 11 March 2020. This had an unprecedented impact on both primary and specialty care that went beyond patients directly infected with the SARS-CoV-2 virus. Visits to emergency departments declined precipitously during the pandemic due to hospital avoidance, and when patients did present to the emergency department, it was with more advanced diseases. The objective of this quality improvement project was to compare the severity of emergency abdominal surgery before and during the pandemic. Methods: We conducted a retrospective chart review of all emergency general surgeries performed at Vernon Jubilee Hospital in the fiscal year prepandemic (2019-2020) and in the first 2 years of the pandemic period (2020-2022). Appendectomies, cholecystectomies, and hernia operations that did not involve the bowel were excluded, as were emergencies following elective surgery. Patient demographics and outcomes were recorded, including two previously validated scores that measure surgical disease severity: the HospitAl length of stay, Readmission, and Mortality rates (HARM) score, scored from 0 to 11, and the World Society of Emergency Surgery ( WSES) score, scored from 0 to 18. We also tested whether having a family doctor, being admitted to hospital while COVID-19 admissions were higher than five per month, and presenting more than 72 hours after the onset of symptoms affected outcomes and analyzed results for the 3-month periods following "restrictive" and "permissive" elective surgery shutdowns. Results: There were 85 cases prepandemic and 147 cases during the pandemic: 78 in the first year and 69 in the second year. Age, sex, Charlson Comorbidity Index scores, and whether the patient had a family doctor were similar prepandemic and during the pandemic. During the pandemic, patients were more likely to have a presentation more than 72 hours after the onset of symptoms (61.2% vs 30.6%, P < .001), a colon resection (48.3% vs 32.9%, P = .023), ischemic bowel (9.5% vs 1.2%, P = .013), overall complications (49.0% vs 15.3%, P < .001), Clavien-Dindo 3 to 5 complications (15.0% vs 5.9%, P = .016), a longer operating time (135 minutes vs 107 minutes, P = .001), a higher HARM score (2.4 vs 1.6, P = .015), and a higher WSES score (5.8 vs 3.2, P < .001) compared with prepandemic. Complications, the HARM score, and the WSES score were not affected by the lack of a family doctor or by more than five COVID patients admitted concurrently to hospital per month, but presentation after 72 hours was associated with higher HARM and WSES scores. There was a trend toward higher overall complications (51.4% vs 44.4%, P = .59), Clavien-Dindo 3 to 5 complications (27.0% vs 22.2%, P = .66), a higher HARM score (2.6 vs 1.9, P = .18), and a significantly higher WSES score (6.9 vs 4.8, P = .025) following restrictive versus permissive elective surgery shutdowns. Conclusions: Patients who required emergency abdominal surgery fared worse in multiple dimensions during the pandemic compared with prepandemic. We could not demonstrate an association between concurrent COVID-19 admissions or lack of a family doctor with worse outcomes; however, there was a strong association between the pandemic period and delayed presentation and an association between delayed presentation and increased disease severity. Moreover, periods in which outpatient surgery and endoscopy were shut down may have contributed to delays in diagnosis and increased disease severity during the pandemic.