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Table of Content - Volume 19 Issue 3- September 2021
An audit on emergency open appendicectomy on non-covid patients during lock down period of covid 19 pandemic: Experience at our center
Gopinath H Venkatarao1*, Arun Kumar Ragulupadu Vadde2
1Associate Professor, 2Professor. Department of General Surgery, Subbaiah Institute of Medical Sciences Shimoga Nidige Hobli, Holebenavalli Post, Karnataka– 577222, INDIA.
Abstract Background: This study aims to to scrutinize the impact of coronavirus disease 2019 (COVID-19) on demography and patient characteristics in emergency open appendectomy and to study, is there any delay in seeking surgical care and its impact on operative and post op outcomes Background: The novel coronavirus (COVID-19) strain has resulted in restrictions potentially impacting patients presenting with acute appendicitis and their disease burden. Methods: a retrospective observational study assessing of all patients admitted with acute appendicitis and who have undergone open emergency appendectomy at SUIMS shimoga , between march 2020 to June 31 2020 corresponding to lockdown period in India. Results: Of the 29 patients that underwent surgical intervention, 24 patients (82.75%) were diagnosed with complicated acute appendicitis. In patients presenting during the COVID-19 pandemic, more complications were seen in 19 patients presenting with symptoms for more than 24 hours compared to patients who present earlier (82.6%). Mean operative time is 105 minutes with not much statistical difference between uncomplicated (86) and complicated appendicitis groups (108)(P=0.2). Mean hospital stay is 9.07 days with not much statistical difference (P=0.7) between uncomplicated (10) and complicated appendicitis groups(8.8). Conclusion: The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common surgical emergency like acute appendicitis. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself. There is significant increase in complicated appendicitis. Thus during this adversity of the current pandemic, acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.
INTRODUCTION The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-cov-2) which has created significant impact in the emergency surgical health delivery including acute appendicitis. Most of the countries are trying to outweigh the deleterious effect of the contagion with strategies of social distancing and lock down to mitigate the serious outcome of the virus.1 India reported first covid case in Jan 27, 2020 and Karnataka reported first case in March 8th 2020. India reported first covid death on 12th march from Karnataka. GOI announced lockdown from March 24 and extended up to June 8 2020 for 75 days). Acute appendicitis (AA) is one of the most common surgical emergencies worldwide with the life time risk of 7–8%. Gold standard treatment for Acute Appendicitis has been surgery. The novel coronavirus (COVID-19) strain has resulted in restrictions potentially impacting patients presenting with acute appendicitis and their disease burden. During the pandemic, the spectrum of the surgical emergencies are not supposed to decrease, however one can ascertain that the complexity of the lesion might be more severe owing to late presentation, pursuing home based treatment due to inaccessibility of transportation, fear of contracting the virus in the hospitals and denied treatment. Few studies related to appendicitis during this pandemic and most of them arrived to a conclusion of seeing a lesser number of patients coming to emergencies amidst the present scenario.2,3,and 4 This may not be true in settings of low-income country, especially in tertiary centers which opened despite of the fear of COVID 19.
Aims and objectives
MATERIALS AND METHODS 1. we performed a retrospective review of all patients admitted with acute appendicitis and who have undergone open emergency appendectomy, between specified time periods related to the first wave of COVID-19 in our institution Subbaiah institute of Medical Sciences (SUIMS)) admission data of all emergency open appendectomies for un complicated and complicated appendicitis, (defined as perforation of the appendix, gangrenous appendicitis, and/or abscess/phlegmon , confirmed with surgeon operative notes and /or hpe) at ,SUIMS shimoga , between march 2020 to June 31 2020 corresponding to lockdown period were collected. The socio demographic variables like age, gender and co morbidity data were noted. The ethical consent was obtained from the institutional ethical Committee and the hospital case sheets were used for the data collection. Exclusion criteria-
Variables collected include patient age, gender, comorbidities, American Society of Anesthesiologists (ASA) score, COVID-19 status, pre-operative symptoms duration, and labs. Other variables collected Include time from presentation until surgery, intraoperative time, and postoperative diagnosis, hospital length of stay, HPE postoperative complications and patient follow up data from OPD after discharge from the hospital up to 30 days. Uncomplicated appendicitis was defined as an inflamed appendix or periappendicitis without signs of necrosis or perforation as described by surgeon and pathologist. Complicated appendicitis was defined as inflammation of the appendix with presence of gangrene, evident necrosis or perforation, as described by the pathologist, and/or presence of perforation or abscess formation, as described by the surgeon. In operated patients, the in-hospital delay or time to surgery was defined as the time between presentation at the ED and the start of the operation.5 The primary outcome was the occurrence of post- operative SSI formation within one month of surgery. Surgical wound infection was determined as per a modification of CDC definitions of surgical wound infections.6 This was determined clinically by postoperative visits and imaging with USG. All charts were screened for any imaging done within one month of surgery for related or unrelated reasons, any readmissions, all interval follow-up visits relative to the date of surgery, and any post- operative procedures such as aspirations /incision and drainage of collections and Secondary suturing.
Statistics and statistical analysis Statistical analysis was performed using JASP Team (2020). JASP (Version 0.14.1) [Computer software].{https://jasp-stats.org/}. For continuous variables, the distributions during the two time periods were compared by using Student's t-test. For categorical data, differences in percentages across subgroups were assessed by using chi-squared test or Fisher's exact probability test as appropriate. P-values <.05 were considered significant.
RESULTS There were total 29 patients were studied. Demographic and Clinical characteristics and comorbidities such as diabetes and coronary artery disease of patients are presented in Table 1. Overall, the mean age of the entire population was 32.93 ± 16.11 years, and the gender was more frequently male (65.51 %). The mean WBC count on admission was 13,862/L. Of the 29 patients that underwent surgical intervention, 24 patients (82.75%) were diagnosed with complicated acute appendicitis. Analysis of Treatment and Complications. Table 2 24 patients presented at the hospital with symptoms present for > 24 h. (82.7%. In patients presenting during the COVID-19 pandemic, more complications were seen in 19 patients presenting with symptoms for more than 24 hours compared to patients who present earlier (82.6%). Mean operative is 105 minutes with not much statistical difference between uncomplicated (86) and complicated appendicitis groups (108)(P=0.2). Mean hospital stay is 9.07 days with not much statistical difference (P=0.7) between uncomplicated (10) and complicated appendicitis groups(8.8).
Table 1: Demographic and clinical characteristics of study population
Table 2: Analysis of Treatment and Complications
DISCUSSION The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. The aim of this study was to examine the impact of this COVID-19 lockdown on emergency open appendectomies in our institution Hospital set up. Our study reveals increased incidence of complicated acute appendicitis related to late presentations to hospital. There is not much statistical significance in mean operating time and hospital stay related to late presentation observed in the present study. However complications like wound infections are more in complicated appendicitis group again related to delayed admission to hospital. Many cohort studies have reported the increased hospital stay in the post-operative period and also the increased post-operative complication like rate of infection as counted by the number of SSI. Increased operative time could be due to extra precautions taken by the operating surgeons, virtually limiting chances of prick injuries while trying the best to limit complications to occur. Similarly, operating while wearing Personal Protective Equipment (PPE) with a foggy visibility along with complicated appendicitis encountered mandated extra cautiousness to take into account [1]. It is also opined that result of the delay in presentation and the laparoscopic management is not adopted due to the restriction imposed by the corona infection.1,4,7 Various studies have demonstrated an increase in the number of complicated acute appendicitis after the implementation of stay-at-home advisories due to COVID-19. The fear of contracting COVID-19 as well as the encouragement from authorities to avoid unnecessary presentations to the clinic and/or ER could explain the delayed presentation of patients to the hospital.8 It has been described that patients presenting to the hospital more than 24hrs after the onset of symptoms are at higher risk of suffering from perforated appendicitis.9,10 Tankel et al., in their cohort they did not identify an increased incidence of complicated appendicitis which is in discordance with our results.2 Other authors have reported increased incidence of complicated appendicitis as well increased late presentations of more than 24hours and increased mean operating time and also the proportion of complicated cases increased. The significant increase in the incidence of complicated appendicitis and the simultaneous decrease in the number of patients with uncomplicated appendicitis during the COVID-19 crisis could indicate that patients requiring urgent surgical intervention are not seeking timely and appropriate care.4,5-11 G. Orthopoulos, E. Santone, F. Izzo et al. explain that this increase cannot only be explained by the increased prehospital delay during the COVID-19 pandemic, nor can it merely be explained by progression of uncomplicated to complicated appendicitis over time. More likely, part of the patients with mild, uncomplicated appendicitis may have resolved spontaneously at home, which is in line with the theory that uncomplicated and complicated appendicitis are different diseases and not simply different grades of severity.7 H. Javanmard‐Emamghissi et al. and Javier Romario et al. confirm that with the delays in presentations, the severity with which they present to the hospitals were also increased tremendously in their study.12 Similar findings were observed in present study also. Delayed presentations to hospital along with complicated appendicitis like perforation seem to have prolonged hospital stay in various literatures.13,14 Prolonged hospital stay also was evident in the present study during the time of pandemic. This is a single center analysis of the patients with a smaller sample size which might not cover all the demographic and clinical aspects. As this study is only confined to covid lockdown period, prolonged operative time and prolonged stay could not be compared to pre pandemic similar data. The lesser time duration and lower number of cases are the limitations of the present study. The statistics may not be fully relied upon as this may be misleading, as the duration of the study is 75 days within lockdown and with the limited number of cases.
CONCLUSION The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common medical conditions. Caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself, which is a lesson to be adopted in present second wave of pandemic. The significant increase in the incidence of complicated appendicitis during the COVID-19 crisis from present study could indicate that patients requiring urgent surgical Intervention are not seeking timely and appropriate care. It is prudent to address patient fears and emphasize the need to seek appropriate care in a timely manner, with the already high health care cost associated with appendicitis related hospitalizations with second wave COVID-19 surge. Appendectomy should be the mainstay of treatment even during the adversity of COVID-19, as there is increased duration of presentation to hospital and complicated AA cases . The conservative approach in the fear of the pandemic might not be cost effective in areas of low income countries.1 Surgical care is a major element of a functioning health service and must be proactive in creating solutions to manage the increased numbers of patients waiting for access to services in this lockdown period of the country, most operating theatres have developed protocols regarding testing of patients/staff, reducing numbers of people at intubation/extubation and prolonged periods between cases. These factors have combined to reduce capacity within the operating theatre. Coupled with this, patients are concerned regarding presenting to hospital due to the risk of contracting COVID-19. It is still unclear how the risk of delayed presentations and delayed intervention will impact patients.15,16 Authors hope that these lessons from first lockdown are better implemented in the ongoing second pandemic wave with additional protection of vaccines and improved understanding of corona pandemic management in managing non covid elective and emergency surgical procedures.
REFERENCES
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