The COVID-19 pandemic brought unprecedented challenges to the National Health Service and drove widespread changes in healthcare delivery. The UK had the benefit of witnessing the experiences in other countries before a surge in UK COVID-19 cases, allowing our surgical services some time to prepare (13,14). The UK Intercollegiate guidance (4) encouraged a move towards NOM of AA where appropriate. Two recent trials support this approach despite the optimum treatment of AA remaining controversial (7,15–17). During the pandemic other General Surgery departments across the UK were having similar quandaries as us in decision-making processes as a result of the Royal Colleges’ advice. (16) Our study adds to the literature by providing an insight into the workings behind a single-centre, aiding other similar sized centres in their decision-making for future viral spikes.
Following nationwide ‘lock-down’ in March 2020 fewer patients attended with AA (149 in 2019 vs 125 in 2020). NOM was used more frequently (9.4% in 2019 vs 24.8% in 2020) although the majority of patients still received OM. Patient selection for NOM appears to be in keeping with the advice provided by a recent AA update which advises NOM in patients with uncomplicated AA confirmed on imaging (15). The observed reduction in laparoscopic appendicectomy (92.6% of OM in 2019 vs 69.1% of OM in 2020; p <0.001) reflects our Trust’s iteration of the intercollegiate advice (4).
The current pandemic presents unquantified risks to patients. Some early collaborative trials showed there was an increased risk of morbidity and mortality in COVID-19 positive patients undergoing surgery (18). For surgeons this translates to new challenges in consent and shared decision-making. As the COVID-19 outbreak progressed our consent process changed to counsel patients on the risks associated with contracting the virus during the perioperative period. In 2019, 59 patients (39.5%) had a CT compared to 70 patients (56%) in 2020. This was to improve diagnostics and to guide appropriate management reducing unnecessary operating. Recent published guidance pushes towards imaging rather than diagnostic laparoscopy (19) and we had a lower negative appendicectomy rate in both cohorts (3.7% in 2019 and 3.2% in 2020) when compared with the literature (20,21). There is evidence that COVID-19 infection can clinically mimic AA in atypical cases (22) but none of the patients with a negative appendicectomy had COVID-19 confirmed on swab.
Patients presenting with AA during the COVID-19 pandemic had shorter hospital stays. This was the case for patients following an operation (median of 4 days in 2019 vs 3 days in 2020) despite evidence showing that open appendicectomies result in longer hospital admissions (5). These findings suggest that under normal circumstances we may be able to safely discharge patients earlier who are recovering from AA. This is supported by recent evidence demonstrating that OM of AA can be conducted as a day case in 25% of patients (23).
In this study, there are several limitations. It is a retrospective study and captures a small cohort of patients from a single-centre. However, it represents data from a large district general hospital and other studies have reported similar findings
(16,17) We cannot comment if patients re-attended out of area though this seems unlikely with Government advice to avoid non-essential travel (24).
In one sense the pandemic has presented an opportunity to put alternative approaches to the test. Easing of the preventive measures has demonstrated an evolving second peak of the virus and pressure on the health services may be worse than the first (25). This study has demonstrated few complications following NOM and subsequently our Trust is open to NOM in uncomplicated AA. Along with the strengthening body of evidence in support of this management strategy we are more equipped to counsel patients to make informed decisions about their care.