Paediatric Appendicitis: Has SARS-COV-2 Influenced the Clinical Profile and Management during the Pandemic Period?

Introduction: The Coronavirus Disease-2019 (COVID-19) had profound repercussions on routine medical practices all over the globe. There are fewer studies on the impact of the pandemic on childhood surgical conditions like Acute Appendicitis (AA), which is the most common paediatric surgical emergency. Aim: To analyse whether COVID-19 has influenced the clinical profile and management of paediatric appendicitis during the pandemic period. Materials and Methods: A retrospective study was carried out in the Department of Paediatric Surgery, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India, comparing AA cases during the pandemic period (group A=from February 2020 to January 2022) with AA cases during the prepandemic period (group B=from February 2018 to January 2020). Analysis of data regarding patient demographics (age, sex), duration of symptoms and hospital stay, type of appendicitis, total and differential leucocyte count, ultrasonographic findings, treatment modality and complications was done. Subgroup analysis of children in group A was done by comparing AA cases with active/recent COVID-19 infection (Subgroup A1) with the rest of AA in the group (Subgroup A2). Pearson's Chi-square test was used for the analysis of categorical variables and independent t-test was used for numerical data. p-value<0.05 was considered significant. Results: There were 826 AA cases, with 375 children in group A and 451 in group B. A significant reduction in the number of AA cases was noted during the first year of the pandemic (n=167 vs n=242, p-value=0.009) and a significantly higher number of cases were managed conservatively during the pandemic period (n=48 vs n=10, p-value <0.0001). Children with active/recent COVID-19 infection presented late (p-value=0.03), had a significantly higher incidence of complicated appendicitis (p-value=0.02), decreased total leucocyte count (p-value=0.01), decreased polymorph count (p-value=0.02) and higher incidence of the conservative modality of treatment (p-value<0.005). Conclusion: Overall, there were no significant differences in the clinical profile of AA during the pandemic period. But, children with AA who had active/recent COVID-19 infection had a longer duration of symptoms and a higher incidence of complicated appendicitis. The pandemic influenced the management protocols with an increase in the number of AA cases being managed conservatively when compared to the prepandemic period. [ FROM AUTHOR] Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Procalcitonin as a Prognostic Marker of Complicated Appendicitis

Introduction: Acute appendicitis is the most common cause of acute abdominal pain as well as one of the most frequently performed procedures in general surgery. Different prognostic laboratory markers have been studied to identify patients with complicated appendicitis and it is unknown whether the level of procalcitonin in adults could be used as a predictive marker. From a cut-off point, Does procalcitonin have predictive value for complicated appendicitis? Methods: Prospective, observational study. Patients from the Civil Hospital of Guadalajara with a diagnosis of Appendicitis, presurgical laboratory studies and Procalcitonin, and undergo appendectomy in this institution. A calculated sample was obtained based on the surgeries performed annually. Result(s): 80 appendicectomies were performed in the 12-month period (2021;COVID pandemic) obtaining: 37 patients with uncomplicated appendicitis (Phase I and II) 43 patients with complicated appendicitis (Phase III and IV) The procalcitonin levels of both groups were analyzed to demonstrate differences between them, Mann-Whitney U test gives us as a result a p value <0.05. For the cut-off point at the most suitable procalcitonin level for this sample we decided to use the Yauden index method in the analysis of the ROC curve: it is observed that the cut-off point with a sensitivity of 72.1% and a specificity of 81.1% for the sample is 0.305. Conclusion(s): Procalcitonin has been shown to be a useful marker for discriminating the severity of appendicitis and that the best cutoff point for this sample is 0.3 ng/dl.

Patients with appendicitis during COVID-19 pandemic: a retrospective cohort study.

The Coronavirus Disease 19 (COVID-19) pandemic greatly affected the Quebec healthcare system from spring 2020 onward; the consultation delays that were generated may have delayed the management of urgent intra-abdominal pathologies. Our objective was to evaluate the impact of the pandemic on the length of stay and complications within 30 days of treatment of patients consulting for acute appendicitis (AA) at the Centres intégrés universitaires de santé et de services sociaux (CIUSSS) de l'Estrie-Centre hospitalier universitaire de Sherbrooke (Estrie-CHUS), Quebec, Canada. Methods: The authors conducted a single-center retrospective cohort study on the charts of all patients diagnosed with AA at the CIUSSS de l'Estrie-CHUS between March 13 and June 22, 2019 (control group) and between March 13 and June 22, 2020 (pandemic group). This corresponds to the first wave of COVID-19 in Quebec. Patients included were those with a radiologically confirmed diagnosis of AA. There was no exclusion criteria. Outcomes assessed were length of hospital stay and 30-day complications. Results: The authors analyzed the charts of 209 patients with AA (117 patients in the control group and 92 patients in the pandemic group). No statistically significant difference was observed for the length of stay or the complications between the groups. The only significant difference was the presence of hemodynamic instability on admission (22.2 vs. 41.3%, P=0.004) as well as a trend that did not reach statistical significance regarding the proportions of reoperation before 30 days (0.9 vs. 5.4%, P=0.060). Conclusion: In conclusion, the pandemic did not affect the length of stay of AA managed at the CIUSSS de l'Estrie-CHUS. It is not possible to conclude whether the first wave of the pandemic influenced complications related to AA.

Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis.

INTRODUCTION: The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic. METHODS: Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared. RESULTS: During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001). CONCLUSIONS: Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.

Impact of the COVID-19 pandemic on the outcomes of laparoscopic appendectomy for acute appendicitis.

Purpose: This retrospective study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the time interval from symptom onset to surgery and on the operative outcomes of laparoscopic appendectomy for patients with acute appendicitis. Methods: Between October 2018 and July 2021, laparoscopic appendectomy was performed in 502 patients with acute appendicitis admitted to Hallym University Chuncheon Sacred Heart Hospital in Chuncheon, Korea. We compared demographic data, serum levels of inflammatory markers, time to event of appendicitis, and operative outcomes between the pre-COVID-19 and post-COVID-19 pandemic groups. Results: Laparoscopic appendectomy was performed in 271 patients in the pre-COVID-19 group and in 231 patients in the post-COVID-19 group. There were no differences in baseline characteristics, serum inflammatory marker levels, or the proportions of complicated appendicitis between the groups (25.1%, pre-COVID-19 vs. 31.6%, post-COVID-19; P = 0.106). The time intervals between symptom onset and hospital arrival (24.42 hours vs. 23.59 hours, P = 0.743) and between hospital arrival and the start of surgery (10.12 hours vs. 9.04 hours, P = 0.246) did not increase post-COVID-19. The overall 30-day postoperative complication rate did not differ significantly between the groups (9.6% vs. 10.8%, P = 0.650), and the severity of 30-day postoperative complications was also similar in both groups (P = 0.447). Conclusion: This study demonstrates that hospitalization and surgeries were not delayed in patients with acute appendicitis and that the operative outcomes of laparoscopic appendectomy did not worsen despite the COVID-19 pandemic.

The use of monopolar diathermy in laparoscopic appendectomy, Is it really safe?

Background: There have been numerous techniques used in laparoscopic appendectomy (LA) to divide the mesoappendix, including LigaSure, Harmonic scalpel, clips, endoloop ligatures, Endo GIA staplers, and bipolar coagulation. However, few studies have investigated monopolar diathermy for mesoappendix division. Therefore, this study aimed to assess both its safety and efficacy in LA. Method(s): In this prospective non-randomized study, patients (n = 87) who underwent LA for acute appendicitis were included. The bipolar electrocautery was used for mesoappendix division in the first 33 patients (BC group), while the monopolar electrocautery was used in the next 54 patients (MC group). Result(s): The median operative time was significantly shorter in the MC group (42 min. vs 47 min. in BE group, p = 0.01). One patient converted to open surgery in the MC group due to uncontrollable bleeding. There were no significant differences between both groups regarding postoperative complications and hospital stay (p = 0.91, p = 0.13, respectively). Conclusion(s): Monopolar electrocautery is safe and effective for mesoappendix division in LP in comparison to bipolar electrocautery. However, larger and multicentric studies are required to validate our results.Copyright © 2023 The Authors

Biofeedback Treatment Can Improve Clinical Condition and Quality of Life in Patients with Pelvic Floor Dyssynergy with Irritable Bowel Syndrome: A Prospective Cohort Study

Background: Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD). Method(s): This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18-70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient's response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report). Result(s): Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 +/- 11.4. The average resting pressure decreased in response to treatment;however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001). Conclusion(s): Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.Copyright © 2023 The Author(s).

Appendicular peritonitis as a variant of Crohn's disease manifestation in children recovered from a novel coronavirus infection COVID-19.

Immune changes arising against the background of COVID-19 can lead to the manifestation of autoimmune diseases and provoke the development of Crohn's disease. In the presented work, we describe two clinical cases of manifestation of Crohn's disease in children after suffering a novel coronavirus infection COVID-19. Moreover, the variant of manifestation in both cases was spilled purulent appendicular peritonitis. In the first case, the child underwent a traditional appendectomy and abdominal sanitation. However, the choice of traditional appendectomy in this version of the pathological process led to severe consequences for the patient (a complicated postoperative period and multiple surgical interventions), including for the formed intraperitoneal abscesses and intestinal fistula, which is most characteristic of Crohn's disease. Therefore, the patient was diagnosed with Crohn's disease only after numerous operations. Regarding the second case, the situation was completely different, despite the obvious manifestations of ARVI (sore throat, fever), which led to the belated diagnosis of appendicitis in this child. Laparoscopic appendectomy and simultaneous adequate abdominal sanitation made it possible to avoid repeated surgical interventions in this case. In both cases, patients at the diagnosis were sent to federal clinics to select specific therapy. In our opinion, it is worth paying close attention to pediatric patients with a novel coronavirus infection and abdominal pain syndrome since this may be onset of inflammatory bowel disease.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Acute appendicitis

Acute appendicitis is inflammation of the vermiform appendix. It is the commonest general surgical emergency in children and young adults, yet its diagnosis can still confound even the most skilled surgeon due to its highly variable presentation of appendicitis, with fewer than 50% of patients exhibiting classical features. Taking a detailed history and performing a careful examination remains the cornerstone of diagnosis. Urinalysis and blood tests, particularly C-reactive protein, are useful adjuncts and are performed routinely. Radiological imaging, commonly ultrasound and computed tomography scans, also have a role when the diagnosis is unclear and/or other common conditions need to be excluded, such as gynaecological pathology in young females. Nevertheless 20% of appendices removed in UK are histologically normal. Appendicitis scoring systems may further assist in stratifying risk and increasing the accuracy of diagnosis. Recently, there has been growing interest in non-surgical management of appendicitis, particularly during the COVID-19 pandemic. Antibiotics alone have been used to successfully treat uncomplicated appendicitis (without perforation, abscess or gangrene) in the short-term, however nearly 40% of these cases eventually require appendicectomy. Surgery, usually laparoscopic appendicectomy, remains the treatment of choice for acute appendicitis and non-operative management is reserved for specific cases.Copyright © 2023

Operative Management of Acute Appendicitis Was Safe During the COVID-19 Pandemic Shutdown.

INTRODUCTION: In the spring of 2020, New York City was one of the first epicenters of the COVID outbreak. In this study, we evaluate the incidence and treatment of appendicitis in two New York City community hospitals during the COVID pandemic. METHODS: This retrospective study focused on the incidence and outcome of acute appendicitis in the adult population (>18 y old) during peak-COVID periods (March 16, 2020,-June 15, 2020) compared to pre-COVID and post-COVID periods. We compared the number of patients who underwent operative versus nonoperative management, patient demographics, length of stay (LOS), complications, and readmission rates within these time periods. Data are presented as mean ± standard deviation (analysis of variance). RESULTS: From January 1, 2020 to December 31, 2020, 393 patients presented with acute appendicitis and 321 (81.7%) were treated operatively, compared to 441 total and 366 treated operatively (83%) in 2019 (P = 0.88). During the COVID outbreak, fewer patients presented with appendicitis (mean 6.9 ± 1 pre-COVID case/week, 4.4 ± 2.4 peak-COVID cases/week and 7.6 ± 0.65 post-COVID cases/week, P = 0.018) with no significant difference in the pre-COVID and post-COVID period. There was no difference in LOS between the pre-, peak-, and post-COVID periods with a median of 1 for all the three, (interquartile range (IQR): 0.8-2, 0.6-2, 0.6-2, respectively, P = 0.43). Additionally, there was no difference in 30-day readmission rates (4.2%, 0%, 3.9%, P = 0.99) and postoperative complications (4.2%, 0%, 2.9%, P = 0.98). CONCLUSIONS: During peak-COVID, there was a significant reduction in the number of patients who presented with acute appendicitis without a post rebound increase in presentation. Those who presented during peak-COVID were able to undergo operative management safely, without affecting LOS or postoperative complications.

Predictors of recurrent appendicitis after nonoperative management: a prospective cohort study

Background: Appendectomy has been the standard of care for treatment of appendicitis for decades. Nonoperative management (NOM) of appendicitis is an alternative treatment strategy and had a resurgence of interest owing to the COVID-19 pandemic and the need for alternate care delivery models. One of the concerns for treatment of appendicitis with NOM is the recurrence rate. Despite this, there are few data examining the predictors of recurrence to tailor patient selection for NOM of appendicitis. The objective of this study was to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively. Methods: We conducted a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital between May 1, 2019, and Apr. 30, 2021. Patients with appendicitis who were treated nonoperatively were identified. Patient demographics, radiographic information, management, and clinical outcomes were recorded. Results: The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a univariate and multivariate time-toevent competing-risk analysis was performed with Cox regression. Of the 74 patients, 35 (47.3%) were women (median age 48 [interquartile range (IQR) 33-64] yr) with appendicitis treated successfully nonoperatively, 21 patients (29.2%) had recurrent appendicitis and 20 (27.8%) underwent an interval appendectomy. Median time to recurrence was 17 days (IQR 7-66). Presence of an appendicolith on imaging was associated with a higher cause-specific hazard of recurrent appendicitis. Age, sex and history of diabetes were not found to be associated with recurrence of appendicitis. The adjusted cause-specific hazard ratio of recurrent appendicitis for presence of appendicolith was 2.67 (95% confidence interval 1.09-6.56, p = 0.032). Conclusion: Our study found that presence of appendicolith was associated with a 2.67 increase in cause-specific hazard of developing recurrent appendicitis within 6 months. This information can help tailor patient selection for nonoperative management.

Appendicular peritonitis as a variant of Crohn's disease manifestation in children recovered from a novel coronavirus infection COVID-19.

Immune changes arising against the background of COVID-19 can lead to the manifestation of autoimmune diseases and provoke the development of Crohn's disease. In the presented work, we describe two clinical cases of manifestation of Crohn's disease in children after suffering a novel coronavirus infection COVID-19. Moreover, the variant of manifestation in both cases was spilled purulent appendicular peritonitis. In the first case, the child underwent a traditional appendectomy and abdominal sanitation. However, the choice of traditional appendectomy in this version of the pathological process led to severe consequences for the patient (a complicated postoperative period and multiple surgical interventions), including for the formed intraperitoneal abscesses and intestinal fistula, which is most characteristic of Crohn's disease. Therefore, the patient was diagnosed with Crohn's disease only after numerous operations. Regarding the second case, the situation was completely different, despite the obvious manifestations of ARVI (sore throat, fever), which led to the belated diagnosis of appendicitis in this child. Laparoscopic appendectomy and simultaneous adequate abdominal sanitation made it possible to avoid repeated surgical interventions in this case. In both cases, patients at the diagnosis were sent to federal clinics to select specific therapy. In our opinion, it is worth paying close attention to pediatric patients with a novel coronavirus infection and abdominal pain syndrome since this may be onset of inflammatory bowel disease.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Appendicular peritonitis as a variant of Crohn's disease manifestation in children recovered from a novel coronavirus infection COVID-19.

Immune changes arising against the background of COVID-19 can lead to the manifestation of autoimmune diseases and provoke the development of Crohn's disease. In the presented work, we describe two clinical cases of manifestation of Crohn's disease in children after suffering a novel coronavirus infection COVID-19. Moreover, the variant of manifestation in both cases was spilled purulent appendicular peritonitis. In the first case, the child underwent a traditional appendectomy and abdominal sanitation. However, the choice of traditional appendectomy in this version of the pathological process led to severe consequences for the patient (a complicated postoperative period and multiple surgical interventions), including for the formed intraperitoneal abscesses and intestinal fistula, which is most characteristic of Crohn's disease. Therefore, the patient was diagnosed with Crohn's disease only after numerous operations. Regarding the second case, the situation was completely different, despite the obvious manifestations of ARVI (sore throat, fever), which led to the belated diagnosis of appendicitis in this child. Laparoscopic appendectomy and simultaneous adequate abdominal sanitation made it possible to avoid repeated surgical interventions in this case. In both cases, patients at the diagnosis were sent to federal clinics to select specific therapy. In our opinion, it is worth paying close attention to pediatric patients with a novel coronavirus infection and abdominal pain syndrome since this may be onset of inflammatory bowel disease.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

COVID-19 opens the door for right iliac fossa pain treatment pathway

IntroductionThe COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR.MethodsA retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups.ResultsThe mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16–45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%.ConclusionsGreater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

[Impact of COVID-19 on morbidity, management, and course of acute appendicitisa retrospective cohort study].

BACKGROUND: Acute appendicitis is one of the most common causes of abdominal pain requiring surgical intervention. This study aimed to assess the impact of the COVID-19 pandemic on the morbidity, therapeutic management, and course of acute appendicitis. METHODS: This study retrospectively analyzed patients hospitalized at a general surgery department between 1 January 2019 and 19 March 2020 and compared them to patients hospitalized between 20 March 2020 (global pandemic declaration date) and 6 June 2021. Therefore, our analysis encompassed the period 443 days preceding the pandemic and 443 days after the start thereof. Other factors evaluated herein included sex, length of hospital stay, time from symptom onset, type of surgery, laboratory test results, histopathological diagnosis, and polymerase chain reaction test results for SARS-CoV-2 infection. RESULTS: Statistical analysis was conducted using statistical software IBM SPSS version 27. Significant differences in length of hospital stay, time from symptom onset to hospital admission, number of leukocytes, and type of surgical procedure were observed between groups of patients treated before and after the pandemic. CONCLUSION: Acute appendicitis remained one of the most commonly encountered diseases requiring surgical intervention during the COVID-19 pandemic. Overall, significant differences were observed between patients treated before and after COVID-19 had been declared a pandemic.

The Influence of the COVID-19 Pandemic on the Prevalence, Characteristics, Management, and Outcomes of Acute Appendicitis at the Academic Tertiary Center, Jeddah.

BACKGROUND: Acute appendicitis is the leading cause of acute abdominal pain that requires immediate intervention. Nonetheless, during COVID-19, hospital visits decreased as a result of serious COVID-19 concerns at that time, resulting in a decreased number of diagnosed cases with acute appendicitis due to COVID-19 restriction issues. OBJECTIVES: To report the percentage numbers, characteristics, applied management, and outcomes of patients with acute appendicitis during the COVID-19 pandemic and compare them to pre-COVID-19 cases. METHODS: A retrospective cohort study included all patients with acute appendicitis in the determined periods "pre-COVID-19" and "during COVID-19" at King Abdul-Aziz Medical City, Academic Tertiary Center, Jeddah, Saudi Arabia. Mean and standard deviation were used, while categorical data were reported as frequencies and percentages. Variables were analyzed by the Chi-squared test, Fisher's exact test, and Mann-Whitney test as appropriate. RESULTS: A total of 298 patients were included. The period of the pre-COVID-19 pandemic had 161 (54%) patients, while 137 (46%) were identified during COVID-19. The number of laparoscopic appendectomies performed during COVID-19 was less than the pre-COVID-19 pandemic of 96 cases (70.1%) vs 133 cases (82.6%) (P=0.0106). Uncomplicated appendicitis was the most commonly reported type of appendicitis in both periods: 113 (82.5%) during COVID-19 vs 135 (83.9%) pre-COVID-19, (P=0.7526). Furthermore, the number of patients who presented to the ER between 24 and 48 hours after the onset of symptoms was similar before and during the pandemic: 111 (68.9%) vs 89 (65%). CONCLUSION: Overall, we conclude that during the COVID-19 period, there was a reduction in the number of patients presenting with acute appendicitis and a lower chance of undergoing laparoscopic appendectomy due to COVID-19 restrictions. There was also an increase in perforated appendicitis and a decrease in gangrenous appendicitis.

Acute appendicitis during the COVID-19 pandemic: Experience in a high-level complex center in Boyacá, Colombia / Apendicitis aguda durante la pandemia de COVID-19: experiencia en un centro de alta complejidad en Boyacá, Colombia

Introducción. La pandemia de COVID-19 replanteó la forma de atención en los sistemas de salud, afectando todas aquellas patologías no relacionadas con infecciones respiratorias, como la apendicitis aguda. El miedo al contagio por SARS-CoV-2 y las medidas restrictivas a la movilidad pudieron aumentar el tiempo desde el inicio de los síntomas hasta la consulta al servicio de urgencias, derivando en complicaciones intra y posoperatorias. Métodos. Estudio observacional descriptivo de corte trasversal y retrospectivo, donde se incluyeron todos los pacientes diagnosticados con apendicitis aguda llevados a apendicectomía, que fueron divididos en dos grupos, considerados prepandemia, desde el 1° de septiembre de 2018 al 15 de marzo de 2020, y pandemia, desde el 16 de marzo de 2020 al 30 de septiembre de 2021. Resultados. Fueron identificados 1000 pacientes, distribuidos en 501 pacientes en el grupo prepandemia y 499 en el grupo pandemia. El promedio de tiempo de consulta desde el momento de inicio de síntomas hasta consulta fue de 43 horas en el grupo prepandemia y de casi 45 horas en el grupo pandemia. Discusión. A pesar de las restricciones por la enfermedad causada por el nuevo coronavirus y el miedo que puede existir por el contagio, en nuestro centro no se evidenció un cambio en el manejo y presentación de los pacientes diagnosticados con apendicitis aguda

Introduction. The COVID-19 pandemic varied the way health systems were attended, thus affecting pathologies not related to respiratory infections, such as acute appendicitis. Fear of SARS-CoV-2 infection and mobility restrictive measures may have implied a longer time from the onset of symptoms to consultation of the emergency department, leading to intraoperative and postoperative complications. Methods. Retrospective cross-sectional descriptive observational study, identifying all patients diagnosed with acute appendicitis and taken for appendectomy, divided into two groups, considered pre-pandemic, from September 1, 2018 to March 15, 2020, and pandemic, from March 16, 2020 to September 30, 2021. Results. One-thousand patients were identified, 501 patients were distributed in the pre-pandemic group and 499 in the pandemic group. The average consultation time from the time of onset of symptoms to consultation was 43 hours in the prepandemic group and almost 45 hours in the pandemic. Discussion. Despite the restrictions due to the disease caused by the new coronavirus and the fear that may existed due to contagion, in our center there was no evidence of a change in the management and presentation of patients diagnosed with acute appendicitis

A diagnostic conundrum: case of acute appendiceal abscess mimicking multisystem inflammatory syndrome in children in a toddler

Case Report: Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) can commonly present with gastrointestinal symptoms of abdominal pain, vomiting, or diarrhea. These symptoms along with high fever and elevated inflammatory markers can often mask underlying gastrointestinal inflammation and lead to a diagnostic dilemma. Case Presentation: We report a case of a 16-month-old with a history of exposure to SARS-Cov-2 virus, who presented with fever, cough, vomiting, and decreased activity. Her initial workup showed neutrophil-predominant leukocytosis with elevated CRP, ferritin, NTProBNP, and fibrinogen. Serology was positive for COVID-19 IgG antibodies, strongly favoring a diagnosis of MIS-C. Initial CT of the abdomen showed findings consistent with mild enteritis. Intravenous immunoglobulin was not administered as leukocytosis and all inflammatory markers except CRP improved during the course of her hospital stay with parenteral antibiotics, but she remained febrile with worsening abdominal symptoms. She then developed classic symptoms of peritonitis with tenderness and rigidity. Ultrasound of abdomen was inconclusive due to overlying bowel gas. Repeat CT of the abdomen showed multiple intra-abdominal abscesses with the largest rim enhancing lesion in the right lower quadrant. Her presentation was consistent with acute appendiceal abscess due to perforated appendix that improved with CT guided drainage and three weeks of intravenous antibiotics. She was then discharged and planned for an interval appendectomy after two weeks. [Figure presented] Conclusion(s): Symptoms of appendiceal abscess can mimic MIS-C. This case underscores the importance of considering appendicitis in the differential diagnosis in patients with MIS-C. Appendicitis can be missed in toddlers. Hence, clinical suspicion and repeat imaging is key for early diagnosis in this age group. CT Abdomen and Pelvis with intravenous and oral contrast showing findings of perforated, complicated acute appendicitis, with multiple abscesses. Copyright © 2023 Southern Society for Clinical Investigation.