The Covid-19 epidemic is the first pandemic in the modern era, currently affecting most countries worldwide. Its spread and quick diffusion around the globe is unprecedented, involving many European countries like Italy, Spain , and France. Following the paradigm of the United Kingdom, many countries adopted a more lax strategy to fight the virus' spread, but soon after implemented social distancing policies . On the other hand, Greece adopted such measures quickly, from the beginning of March 2020, and employed a rather aggressive strategy involving timely closure of educational institutions, recreational facilities, and businesses in an effort to minimize the spread of the virus and ease the load imposed on its healthcare system. The rapid adoption of emergency measures in Greece in all aspects of life (healthcare, education, economy) prevented hospitals from being overwhelmed. In the SED, every aspect of the patient pathways was changed to minimize the disease's spread. Outpatient clinics have dramatically decreased and, in some cases, ceased completely, in order to control the cross-infection. Elective non-cancer surgery has been canceled, first to allocate staff, particularly anesthesiologists, to help with the Covid-19 patients, and secondly to free up operating rooms with valuable ventilators in case of need. However, emergency surgery is an essential service that cannot and was not interrupted during the lockdowns and continues to run in full capacity, and it is the objective of this study.
Looking at the amount of patients reviewed by General Surgery in the Emergency Department during the different periods of the pandemic in comparison to the same periods of 2019, the number of patients decreased by 35,9% (from 2839 in 2019 to 1819 in 2020). The time periods A and D correspond to the application of “lockdown” measures in Greece. There was a statistically significant reduction of motor vehicle accidents (13.5% vs 14.8%, p = 0.04) and torso injuries (2.4% vs 5.2%, p = 0.01) compared with the matched patient cohort during the same time periods of 2019. A significant rise in the rate of traumatic brain injuries (11.4% vs 6%, p < 0.001), abdominal pain (14% vs 12.4%, p = 0.04) and hospital admissions (7.6% vs 3.7%, p = 0.002) was evident. During time-period D (second “lockdown”), a significant reduction in the cases of perianal abscess (2.2% vs. 4.7%, p = 0.04) or hernia-related complaints (1.1% vs. 5.1%, p = 0.001) was observed. A significant increase in the rate of false injuries was also demonstrable (28.6% vs. 22.4%, p = 0.02).
Analysis of patients presenting during time-period B (lift of “lockdown” measures) did not reveal any statistically significant differences in reason for visiting the SED compared to their 2019 counterparts. The same holds for time-period C (partial “lockdown” measures), except for hernia cases, which exhibited significant reduction (1.6% vs. 5%, p = 0.002). When patients presenting during the first “lockdown” period were compared with those presenting during the second “lockdown” period, a significant reduction of perianal abscess cases was noticed in the latter group (5.9% vs. 2.2%, p = 0.009).
Throughout the lockdown, evidently, the patients avoided visiting the hospital in fear of getting infected with the Covis-19 virus and not wanting to overload an already stretched service. With the directives to the citizens being of not leaving their home in order to protect the national public health system and save lives by social distancing, may have been misleading to the general population to think that they may not leave their homes at any cost and put greater pressure to an already overwhelmed health system. Many may likely have feared becoming infected by the Coronavirus and encountered life-threatening situations such as myocardial infarctions or accidents at home. Other symptoms, such as abdominal or perianal pain, must have been managed at home. General Practitioners must have played a significant role in treating patients with acute conditions, such as acute cholecystitis, with conservative antibiotic treatment and phone follow-ups. De Simone et al.  reported that non-operative treatment could be applied in acute appendicitis, acute cholecystitis, adhesive bowel obstructions, and incarcerated hernias in the period of the pandemic. East et al.  reported that a manual reduction of incarcerated hernias under analgesia or sedation is a useful first treatment in situations where surgical management is not immediately available, including the Covid-19 pandemic. Simultaneously, a reasonable decrease in road traffic accidents was encountered due to the population's traffic limitations.
We were expecting the patients to present with a delayed and more severe presentation of symptoms during the Covid-19 period. However, no significant differences were encountered in the admission rates for peritonitis, the ICU admission rate, mortality rate, or length of hospital stay in any of the study periods. A plausible explanation of this fact is that there might be an increasing unknown number of patients suffering from acute abdominal conditions staying at home. Additional research is necessary, as data from the outpatient clinic were not available at the time of the pandemic.
Deciding to perform emergency surgery in the current environment is a significant one and requires planning and involving senior surgeons. All patients should be considered as infected until proven otherwise. In our hospital, as a preoperative screening protocol, each patient is undergoing an RT-PCR Covid-19 test. This is following the SCOUT study  that found at least 1 in every 100 asymptomatic patients undergoing any surgery (elective or emergency) being infected with the SARS-CoV-2 virus and suggests that patients undergoing surgery should be screened with RT-PCR. Despite early recommendations against minimally invasive surgery [14, 15], there is little evidence about laparoscopy's aerosolization potential and thus virus dissemination. The most recent policy is to minimize the free release of insufflated gas [16, 17].This is the policy that we have adhered to since the beginning of the pandemic, maintaining the usual overall rate of laparoscopic surgeries in patients admitted from the SED while adhering to proposed international surgical practice guidelines and directives .
The main limitation of this study is its single-center retrospective design. The results may not apply to all the hospitals. Many patients may have been admitted to less risky peripheral hospitals. Moreover, the after-effects of the reduction of SED patients cannot be accurately measured and the overall impact it will bears on Greek national health system remains as yet unknown.