The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

H Javanmard-Emamghissi, H Boyd-Carson, M Hollyman, B Doleman, A Adiamah, J N Lund, R Clifford, L Dickerson, S Richards, L Pearce, J Cornish, S Hare, S Lockwood, S J Moug, G M Tierney, COVID: HAREM (Had Appendicitis, Resolved/Recurred Emergency Morbidity/Mortality) Collaborators Group, H Javanmard-Emamghissi, H Boyd-Carson, M Hollyman, B Doleman, A Adiamah, J N Lund, R Clifford, L Dickerson, S Richards, L Pearce, J Cornish, S Hare, S Lockwood, S J Moug, G M Tierney, Nikhil Kulkarni, Isabel Pereira, Sarah Barlow, Sarannga Vanniasegaram, Natalie S Blencowe, Benjamin E Zucker, Abigail Tyer, Marianne Hollyman, Angeliki Kosti, Thomas Badenoch, Sarah Wheatstone, Mariam Jaffer, Hannah Gerretsen, Rahul Menon, Muhammad S Sajid, Lauren Kennedy, Ahmed Malik, Abeer Nada, Kausik Ray, Mansoor Khan, Massimo Varcada, Farid Froghi, Amjad Khalil, Demetra Kyprianou, Nila Tewari, Diwakar Ryali Sarma, Mariam Baig, Sumit Sood, Evonne Yu Wen Ng, Vincent Ng, Thomas Shortland, Gabriel Marangoni, Saboor Khan, Jawad Ahmad, Steven Brown, Arslan Pannu, Elizabeth Gemmill, Hannah Boyd-Carson, Philip Herrod, Satnam Singh Shari, Mohammed Jibreel Suliman Mohammed, Vijay Narbad, Nabih Hanbali, Anisa Kushairi, M A Matthew, Candice Downey, Amro Alamassi, Tim Wheatley, Katy Emslie, Bruno Alcocer, Simon Lau, Richard Morgan, Tanzeela Gala, Sherif Ibrahim, Mina Stephanos, Reda Mithany, Mostafa Abdelkarim, Gautham Venkatesan, Ahmad Aqsalan, John Taylor, Matthew Fok, Arjun Kattakayam, Kunal Rajput, Katherine Bevan, Hyun-Kyung Kim, Laylan Salih, Regina Sabaratnam, Mihaela Creanga, Adil Shafi, Jennifer Law, Mohammed Elniel, Matthew Walmsley, Shruti Ayyar, Julie Cornish, Nicola Reeves, Nicholas Mowbray, Issac Mayo, Ezzat Chohda, William Mccaughran, Emma Beck, Sowmya Garikipati, Bryony E Lovett, Firas Alkistawi, Chris Hadjitoffi, Aaliya Uddin, Panna K Patel, Siddhartha Handa, Jessica Parker, Dawn Littlehales, Ajay P Belgaumkar, Bankole Oyewole, Prabhat Narayan, Zain Elahi, Andrew Gaukroger, Declan Francis Joseph Dunne, George Emilian Nita, Ryan David Baron, Dana Sochorova, Peter Szatmary, Sukhpreet Ak Gahunia, Amy Jayne Thomas, Kulbir Singh Mann, Malcolm Mcfall, Nicholas Farkas, Hussam Siddig, John Camilleri-Brennan, Duncan Rutherford, Michael Wilson, Eleanor Massie, Kieran Mcgivern, Jennifer Mcguckin, Connor Mckee, Spyros Marinos-Kouris, Emanuele Gammeri, Nikhil Patel, Giulia Cillo, Alexander James Baldwin, Tania Magro, Kandaswamy Krishna, James Olivier, Ngozi Anyaugo, Ken Philip, Lyndsay Pearce, Azzam Al-Amin, Michael Thomas, Ian Anderson, Robert Clark, Gillian Tierney, Hannah Javanmard-Emamghissi, Carla Hope, Arjun Gowda, Dana Photiou, Francesca Malcolm, Prita Daliya, Zoe Chia, Najam Husain, Pradeep Thomas, Tomas Urbonas, Daniel Centea, Susan Moug, Christopher Brown, Mari-Claire Mcguigan, Carly Bisset, Abigail Ingham, Norman Galbraith, Rachael Clifford, Luke Dickerson, Sonia Lockwood, Judith Johnston, Ashish K Shrestha, Anang Pangen, Charannya Balakumar, Sara Iqbal, Samip Prakash, Jaideep Rait, Anreea Hanu, Richard Guy, Talal Majeed, Robert Young, Sarah Shamim, Mina Mesri, Roshani Patel, Sophia Lewis, Adesuwa Theresa Eigbadon, Dixa Thakrar, Evangeline Karamitsou, Yetunde Oyeyipo, Uqba Nadeem, Sibusiso Ndlovu, Angela Fnshawe, Nikola Henderson, Christopher Payne, Darren Porter, Adam Brooks, Rachel Xue Ning Lee, Jamaal Jackson, Alastair James Morton, Olamide Ebunoluwa Oyende, Dawit Worku, Amanda Koh, Trisha Kanani, James Blackwell, Melissa Shaw, Christopher Lewis-Lloyd, Lauren Blackburn, Alfred Adiamah, Shafaque Shaikh, Mudassar Ghazanfar, Mootaz Elhusseini, Amir Abdelhamid, Jonathan Eley, Ahmed Nassar, Eriberto Farinella, Zeeshan Mahmood, Tania Policastro, Richard J McGregor, Dimtrios Damaskos, Maria Drogouti, Zofia Tuharska, John Matthew Bennett, Ramez Antakia, Robert O'neill, Richard Hardwick, Nicola Fearnhead, Athanasios Xanthis, Fanourios Georgiades, Victoria Hudson, James Ashcroft, Arminder Singh, Laura Osborne, Ondrej Ryska, Beatrix Weber, Frederick Searight, Calum McCoss, Mark Bignell, Rikhilroy Patel, Giles Bond-Smith, Christopher Lewis, Gethin Williams, Harriet Whewell, Laurie Smith, Rucira Ooi, Anna Powell-Chandler, Alethea M Tang, S K Richards, D B Thompson, Jonathan Van Dellen, Victor Alberto, Shahram Shirazi, Hossein Arang, Nabila Rahman, Eimear Monaghan, Kristine Dodds, Olaitan Babalola, Pascal Airhunmwunde, Imran Alam, Kelvin Wang, Fedder Artemis, Imeshi Wijetunga, Thomas Kidd, Keshav Nambiar, Cho Ee Ng, Toni Collier, Basil Ibrahim, Khizar Khan, Kumuthan Sriskandarajah, Theo Pelly, Joseph Vance-Daniel, Pawan Dhruva Rao, Kellie Bateman, Ana Gavrila, Muhammad Imran Aslam, Verda Amin, Richard Wilkins, Shahbaz Zafar, Charalampos Konstantinou, Sian Mcdonald, Annalie Baker, Amy Fardie, Arnold Hill, Josh De Marchi, Sorcha O'Grady, Gemma Faulkner, Hema Sekhar, Marta Martinez-Iglesias, Cameron Alexander, Eloise Lawrence, Graham Williams, Swati Bhasin, Rajesh Yagati Satchidanand, Chamindri Weerasinghe, Ian Dorrington, Aloka Liyanage, Ayesha Mian, Mihai Paduraru, Seshu Bylapudi, Krystian Pawelec, Milin Rao, Cleo Kenington, Sarah Hudson-Phillips, Zac Vinnicombe, H Javanmard-Emamghissi, H Boyd-Carson, M Hollyman, B Doleman, A Adiamah, J N Lund, R Clifford, L Dickerson, S Richards, L Pearce, J Cornish, S Hare, S Lockwood, S J Moug, G M Tierney, COVID: HAREM (Had Appendicitis, Resolved/Recurred Emergency Morbidity/Mortality) Collaborators Group, H Javanmard-Emamghissi, H Boyd-Carson, M Hollyman, B Doleman, A Adiamah, J N Lund, R Clifford, L Dickerson, S Richards, L Pearce, J Cornish, S Hare, S Lockwood, S J Moug, G M Tierney, Nikhil Kulkarni, Isabel Pereira, Sarah Barlow, Sarannga Vanniasegaram, Natalie S Blencowe, Benjamin E Zucker, Abigail Tyer, Marianne Hollyman, Angeliki Kosti, Thomas Badenoch, Sarah Wheatstone, Mariam Jaffer, Hannah Gerretsen, Rahul Menon, Muhammad S Sajid, Lauren Kennedy, Ahmed Malik, Abeer Nada, Kausik Ray, Mansoor Khan, Massimo Varcada, Farid Froghi, Amjad Khalil, Demetra Kyprianou, Nila Tewari, Diwakar Ryali Sarma, Mariam Baig, Sumit Sood, Evonne Yu Wen Ng, Vincent Ng, Thomas Shortland, Gabriel Marangoni, Saboor Khan, Jawad Ahmad, Steven Brown, Arslan Pannu, Elizabeth Gemmill, Hannah Boyd-Carson, Philip Herrod, Satnam Singh Shari, Mohammed Jibreel Suliman Mohammed, Vijay Narbad, Nabih Hanbali, Anisa Kushairi, M A Matthew, Candice Downey, Amro Alamassi, Tim Wheatley, Katy Emslie, Bruno Alcocer, Simon Lau, Richard Morgan, Tanzeela Gala, Sherif Ibrahim, Mina Stephanos, Reda Mithany, Mostafa Abdelkarim, Gautham Venkatesan, Ahmad Aqsalan, John Taylor, Matthew Fok, Arjun Kattakayam, Kunal Rajput, Katherine Bevan, Hyun-Kyung Kim, Laylan Salih, Regina Sabaratnam, Mihaela Creanga, Adil Shafi, Jennifer Law, Mohammed Elniel, Matthew Walmsley, Shruti Ayyar, Julie Cornish, Nicola Reeves, Nicholas Mowbray, Issac Mayo, Ezzat Chohda, William Mccaughran, Emma Beck, Sowmya Garikipati, Bryony E Lovett, Firas Alkistawi, Chris Hadjitoffi, Aaliya Uddin, Panna K Patel, Siddhartha Handa, Jessica Parker, Dawn Littlehales, Ajay P Belgaumkar, Bankole Oyewole, Prabhat Narayan, Zain Elahi, Andrew Gaukroger, Declan Francis Joseph Dunne, George Emilian Nita, Ryan David Baron, Dana Sochorova, Peter Szatmary, Sukhpreet Ak Gahunia, Amy Jayne Thomas, Kulbir Singh Mann, Malcolm Mcfall, Nicholas Farkas, Hussam Siddig, John Camilleri-Brennan, Duncan Rutherford, Michael Wilson, Eleanor Massie, Kieran Mcgivern, Jennifer Mcguckin, Connor Mckee, Spyros Marinos-Kouris, Emanuele Gammeri, Nikhil Patel, Giulia Cillo, Alexander James Baldwin, Tania Magro, Kandaswamy Krishna, James Olivier, Ngozi Anyaugo, Ken Philip, Lyndsay Pearce, Azzam Al-Amin, Michael Thomas, Ian Anderson, Robert Clark, Gillian Tierney, Hannah Javanmard-Emamghissi, Carla Hope, Arjun Gowda, Dana Photiou, Francesca Malcolm, Prita Daliya, Zoe Chia, Najam Husain, Pradeep Thomas, Tomas Urbonas, Daniel Centea, Susan Moug, Christopher Brown, Mari-Claire Mcguigan, Carly Bisset, Abigail Ingham, Norman Galbraith, Rachael Clifford, Luke Dickerson, Sonia Lockwood, Judith Johnston, Ashish K Shrestha, Anang Pangen, Charannya Balakumar, Sara Iqbal, Samip Prakash, Jaideep Rait, Anreea Hanu, Richard Guy, Talal Majeed, Robert Young, Sarah Shamim, Mina Mesri, Roshani Patel, Sophia Lewis, Adesuwa Theresa Eigbadon, Dixa Thakrar, Evangeline Karamitsou, Yetunde Oyeyipo, Uqba Nadeem, Sibusiso Ndlovu, Angela Fnshawe, Nikola Henderson, Christopher Payne, Darren Porter, Adam Brooks, Rachel Xue Ning Lee, Jamaal Jackson, Alastair James Morton, Olamide Ebunoluwa Oyende, Dawit Worku, Amanda Koh, Trisha Kanani, James Blackwell, Melissa Shaw, Christopher Lewis-Lloyd, Lauren Blackburn, Alfred Adiamah, Shafaque Shaikh, Mudassar Ghazanfar, Mootaz Elhusseini, Amir Abdelhamid, Jonathan Eley, Ahmed Nassar, Eriberto Farinella, Zeeshan Mahmood, Tania Policastro, Richard J McGregor, Dimtrios Damaskos, Maria Drogouti, Zofia Tuharska, John Matthew Bennett, Ramez Antakia, Robert O'neill, Richard Hardwick, Nicola Fearnhead, Athanasios Xanthis, Fanourios Georgiades, Victoria Hudson, James Ashcroft, Arminder Singh, Laura Osborne, Ondrej Ryska, Beatrix Weber, Frederick Searight, Calum McCoss, Mark Bignell, Rikhilroy Patel, Giles Bond-Smith, Christopher Lewis, Gethin Williams, Harriet Whewell, Laurie Smith, Rucira Ooi, Anna Powell-Chandler, Alethea M Tang, S K Richards, D B Thompson, Jonathan Van Dellen, Victor Alberto, Shahram Shirazi, Hossein Arang, Nabila Rahman, Eimear Monaghan, Kristine Dodds, Olaitan Babalola, Pascal Airhunmwunde, Imran Alam, Kelvin Wang, Fedder Artemis, Imeshi Wijetunga, Thomas Kidd, Keshav Nambiar, Cho Ee Ng, Toni Collier, Basil Ibrahim, Khizar Khan, Kumuthan Sriskandarajah, Theo Pelly, Joseph Vance-Daniel, Pawan Dhruva Rao, Kellie Bateman, Ana Gavrila, Muhammad Imran Aslam, Verda Amin, Richard Wilkins, Shahbaz Zafar, Charalampos Konstantinou, Sian Mcdonald, Annalie Baker, Amy Fardie, Arnold Hill, Josh De Marchi, Sorcha O'Grady, Gemma Faulkner, Hema Sekhar, Marta Martinez-Iglesias, Cameron Alexander, Eloise Lawrence, Graham Williams, Swati Bhasin, Rajesh Yagati Satchidanand, Chamindri Weerasinghe, Ian Dorrington, Aloka Liyanage, Ayesha Mian, Mihai Paduraru, Seshu Bylapudi, Krystian Pawelec, Milin Rao, Cleo Kenington, Sarah Hudson-Phillips, Zac Vinnicombe

Abstract

Background: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK).

Methods: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up.

Results: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive.

Conclusion: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Keywords: Antibiotics; Appendicectomy; Appendicitis; COVID-19; Non-operative.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Study flow chart
Fig. 2
Fig. 2
Percentage of patients treated nonoperatively (blue), with laparoscopic appendicectomy (red), and open appendicectomy (green) on a week by week basis during the pandemic
Fig. 3
Fig. 3
Type of Personal Protective Equipment (PPE) used when performing appendicectomy by week of the study. FFP3 mask (blue), standard surgical mask (red), none (green), and other (orange)

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Source: PubMed

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