Abstract
Background:
The corona virus disease of 2019 (COVID-19) imposed new public health constraints that deterred people from coming to the hospital. The outcome of patients who developed appendicitis during mandated COVID-19 quarantine has yet to be examined. The main objective was to establish whether there was an increased rate of perforated appendicitis seen during COVID-19 quarantine. Secondary objectives included observing the type of procedure performed, length of stay, and associated complications.
Materials and Methods:
This retrospective analysis was designed to look at the rates of appendicitis and perforated appendicitis observed during mandatory “safer at home order” from March to May 2020. The same time period a year earlier was used for comparative analysis. The study utilized data gathered from a single health care system, which consisted of a large regional referral center with three emergency rooms (ERs). Patients were included in the study if they presented to any ER in our health care system with a chief complaint of acute appendicitis. Perforated appendicitis was determined either radiographically or intraoperatively. Interventions included surgery, percutaneous drainage, or medical management.
Results:
There were 107 patients who were included. During quarantine, a total of 48 patients presented with acute appendicitis, with 16 perforations, compared with the previous year where 59 patients presented with acute appendicitis, with 10 perforations (33% versus 17% P = .04). Most patients underwent laparoscopic appendectomy (91%, n = 98), six patients (6%) were managed with intravenous antibiotics and 3 patients (3%) with percutaneous drainage. Patients who perforated had a longer duration of symptoms (2 versus 1, P = .03), white blood cell count (13,190 versus 15,960 cells/mm3, P = .09), and longer operative time (72 versus 89 minutes, P = .01). Patients who perforated had an increased length of stay and rate of complication.
Conclusion:
There was an overall increased rate of perforated appendicitis seen during quarantine compared with the previous year. Patients with perforated appendicitis had an increased length of stay, longer operative time, and increased rate of complications. Thus, although people were staying home due to public health safety orders, it negatively impacted those who developed appendicitis who may have presented to the hospital otherwise sooner.
Introduction
The corona virus disease of 2019 (COVID-19) outbreak created an unparalleled modern public health crisis not only in the United States but also around the world. Although COVID-19 was originally detected in Wuhan, China, urban globalization and international travel allowed the quick dissemination of the virus, and by June 2020, nearly every country in the world had reported cases. 1 In an effort to contain the rapid spread of COVID-19, several countries inaugurated mandatory quarantine orders and social distancing restrictions. In the greater Miami, Florida area, where our institution is located, compulsory “safer at home” orders were put in place midnight March 24, 20202 and ended the morning of May 20, 2020. 3 During this time, all public and private gatherings were prohibited, except to engage in essential activities.
Although people were mandated to stay home, there was also a concomitant public fear of hospitals, perceived as epicenters for COVID-19 exposure. Not only were fewer people going out and about their normal lives, but also fewer people were going to the hospital. 4 This led to a drop in emergency room (ER) volumes by as much as 50%.5,6 Although fewer people presented to the ER during the pandemic, we conjectured that when they did present, their illness was further progressed. In addition, it has been previously observed that prehospital delay increases the incidence of perforated appendicitis. 7 We, therefore, hypothesize that there was an increase in the incidence of perforated appendicitis in patients seen during the COVID-19 quarantine.
Materials and Methods
Patient population and data collection
Patients included in the study must have presented to our institution between March 24, 2019 and May 19, 2019 and between March 24, 2020 and May 19, 2020. These dates were selected, because they represent the period of time the shelter in place order was in effect and then for comparison analysis, the same time period a year earlier.
Patients were included if they presented to the hospital or any ERs associated with our institution, and then were diagnosed with acute appendicitis. Patients were excluded if they had been previously diagnosed with appendicitis before the shelter in place order and subsequently presented with recurrent appendicitis or for interval appendectomy. Patients were also excluded if they were already hospitalized for another cause and received the diagnosis of acute appendicitis while already inpatients. In addition, patients were excluded if they were younger than the age of 18.
Charts were identified via our electronic medical record system by using International Classification of Disease, Tenth Revision (codes K35, K35.2, K35.20, K35.21, K35.3, K35.31, K35.32, K35.33, K35.8, K35.80, K35.89, K35.890, K35.891). The data were collected by reviewing hospital notes, lab values, and imaging. Patients were diagnosed with appendiceal perforation either radiographically or at the time of surgery (intraoperatively). Radiographic evidence of acute appendicitis was defined by appendiceal dilatation (>6 mm diameter), wall thickening (>3 mm), or peri-appendiceal inflammation. Patients with complicated appendicitis were delineated from those with non-complicated appendicitis based on the identification of phlegmonous or perforated appendix, or with a peri-appendicular abscess. If diagnosed intraoperatively, perforated appendicitis was visualized by the surgeon and recorded in the operative note.
On admission to the ER, demographic data collected such as age, sex, height, and weight, and number of days that patients had experienced symptoms before hospital arrival were self-reported by the patients. Objective data, including length of stay, white blood cell count on admission, ICU admission, type of intervention, complications during the hospital stay, estimated blood loss, antibiotics, and anesthesia time, were recorded in the chart by hospital staff. Operative time was recorded by the anesthesia team and included the time of induction through the time of extubation.
The authors obtained an institutional review board (IRB) approval before beginning data collection. Data were collected by only those approved on the IRB.
Statistical analysis
To evaluate differences during the two time periods, patient demographic, clinical and treatment characteristics are reported. All data were interrogated by using exploratory data analysis techniques. Continuous data are described as mean and standard deviation or median and interquartile range, and categorical data are reported as counts and percentages. 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.
The primary endpoint was to identify rates of complicated appendicitis during the stay-at-home order. The secondary endpoint was to compare outcomes of patients with acute appendicitis. Statistical analyses were carried out by using SAS Software version 9.4 (SAS Institute, Inc., Cary, NC). All statistical tests were two-sided, and P value <.05 was considered statistically significant.
Results
A total of 107 patients with acute appendicitis were identified: 48 patients were treated during the stay-at-home order and 59 patients the previous year (Table 1). The mean age at diagnosis was 42 ± 18 years. Most patients were women (54%) with an average body mass index (BMI) of 30 ± 5 kg/m2. The median duration of symptoms was 1 day (IQR: 1–3), and median white blood cell count was 14,000 cells/mm3 (IQR: 11–17). The majority of patients underwent laparoscopic appendectomy (91%, n = 98) with a median operative time of 75 minutes (IQR: 64–91). One patient had a laparoscopic hemicolectomy. Six patients (6%) were managed with intravenous antibiotics and 3 patients (3%) with CT-guided percutaneous drainage. Twenty-six patients (24%) were found to have complicated appendicitis, with 2 patients requiring ICU care postoperatively.
Patient and Treatment Data
Cases of acute appendicitis treated during the stay-at-home order were more likely to be complicated relative to the previous year (33% versus 17%, P = .04) There were no differences in sex, age, BMI, duration of symptoms, white blood cell count, or surgical management among the two periods of the study. Patients with complicated appendicitis presented with a longer duration of symptoms (2 versus 1, P = .03) as well as elevated white blood cell count (13,190 versus 15,960 cells/mm3, P = .09), and they had longer operative time (72 versus 89 minutes, P = .01) compared with non-complicated appendicitis.
The median length of stay in the hospital was 2 days (IQR: 1–2 days), and the peri-operative rate of complications before discharge was 7%. Most of these patients belonged to the perforated group (75%). Three patients developed bacteremia, 3 had postoperative ileus, 1 had intra-abdominal abscess, 1 surgical site infection, 1 urinary tract infection, and 1 patient had postoperative hypoxemia but recovered. There were no differences in morbidity or length of stay among complicated appendicitis and the two periods of the study.
Discussion
The pathophysiology of appendicitis is not fully understood, though it is believed that the natural history begins as inflammation, and progresses to localized ischemia, then perforation, and finally abscess. It is hypothesized that appendicitis likely begins by some sort of obstruction occurring at the appendiceal orifice, that is, lymphoid hyperplasia, infection, fecalith, or tumor. This obstruction leads to an increase in intraluminal pressure and subsequent small vessel occlusion and lymphatic stasis. The appendix continues to distend, worsening the lymphatic and vascular compromise until the wall becomes ischemic and necrotic and ultimately perforates. 8
Accordingly, the longer patients wait to go to the hospital, the higher the likelihood of perforation. This is consistent with previous papers that discuss how prehospital delay is associated with higher rates of perforation. 7 There were more patients who presented with perforated appendicitis during COVID-19 quarantine compared with the same time period the previous year, likely due to observing the quarantine restrictions and fear of contracting COVID-19 at the hospital. This notion is consistent with reports of up to 48% patients deferring medical care during quarantine seen in other health care systems as well,9,10 which could allow us to generalize our observations.
Understanding trends of disease processes such as appendicitis during the COVID-19 is imperative for preparing for the next public health crisis. Patients should not be discouraged to stay home when their health is compromised. The public health benefit from staying home in an attempt to reduce pandemic spread in exchange for one's personal health may actually increase health care costs and increase morbidity, as treating an advanced illness becomes more difficult and costly. When patients present with advanced appendicitis that has perforated during a pandemic, we have shown that their length of stay is increased, and therefore more hospital resources are utilized.
At our institution, we believe that the decrease in absolute volume on patients with appendix presenting between 2019 and 2020 was not only inherent to the quarantine order, but also due to the lack of tourism in South Florida during the pandemic. 11 Miami-Dade county was particularly hard hit, with more than 22,000 confirmed cases and 800 deaths reported by June 2020. 12 Spring is often a popular time for tourism, but throughout the pandemic, hotels, beaches, stores, and tourist attractions remained closed. 13
There are several shortcomings of the article that the authors could identify. The retrospective nature of the data may introduce selection bias for cases with acute appendicitis. The limited sample size from a single institution challenges the ability to generate robust estimates on the rate of perforation. The ability to identify a complete 30-day postoperative complication rate was limited by lack of follow-up due to quarantine, and the fact that the data were collected and analyzed less than 30 days since the safer at home order was lifted. Thus, only in hospital, complications were included. Further, neither patients' personal perception of COVID-19 nor their willingness to seek medical evaluation was assessed. Nevertheless, the strength of this current series resides in the fact that this is one of the first surgical series to evaluate outcomes of an acute surgical pathology during a global pandemic.
Conclusion
We identified an increase in perforated appendicitis seen during the COVID-19 quarantine. However, appendicitis is just one disease process that can worsen when treatment is delayed. There are several other surgical pathologies (cholecystitis, oncologic operations, etc.) that were deferred during quarantine at our institution either due to delayed patient presentation, patient hesitation, or because of statewide mandates that banned all nonurgent surgeries during the pandemic. 14 Long-term patient outcomes have yet to be studied for these cases as well. More research is needed to understand the delicate balance between staying home to observe quarantine orders at the expense of risking worsening disease progression.
Footnotes
Funding Information
No funding was received for this study.