The patterns and changes of general surgical presentations during the first wave COVID-19 pandemic at a metropolitan Sydney hospital

doi:10.21203/rs.3.rs-1654786/v1

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Research Article

The patterns and changes of general surgical presentations during the first wave COVID-19 pandemic at a metropolitan Sydney hospital

https://doi.org/10.21203/rs.3.rs-1654786/v1

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Background:

The impact of SARS-COV-2 virus (COVID-19) has been well documented in international settings with a reduction in overall emergency presentations both influenced by social distancing and lockdowns. This study focuses on several common acute general surgical pathologies exploring differences in presentations and clinical outcomes for appendicitis, cholecystitis, and incarcerated hernias during the first wave.

Methods:

A retrospective review of medical records of all patients was analysed in two groups: the non-COVID-19 group (combined 2017–2019) and the COVID-19 group (2020).

Results:

There were 3,316 acute emergency surgical presentations with an 8.2% decrease in total presentations in 2020. There were 477 appendicectomies, 224 cholecystectomies, and 121 repair of incarcerated hernias. All general surgical procedures demonstrated significant differences between non-COVID and COVID cohorts, including length of stay (LoS) (2.7 vs 2.1, p = 0.009) and onset of symptoms (1.6 vs 2.2, p = 0.018) for those aged less than 25 years. Patients with appendicitis aged less than 25 years had a significantly longer onset of symptoms before hospital presentation and shorter LoS in the COVID group (1.7 vs 2.5, p = 0.002; 2.9 vs 2.3, p = 0.016). Likewise, patients with cholecystitis had a significantly longer onset of symptoms in the COVID-19 cohort compared to their counterparts (2.0 vs 3.0 days, p = 0.025). There were no significant differences in biochemical, clinical or post-operative outcomes.

Conclusion:

The first wave of the COVID-19 pandemic significantly reduced acute general surgical presentations. For those less than 25 years in the COVID-19 cohort, overall LoS was shorter despite indicating significantly delayed presentations.

COVID-19

physical distancing

appendicitis

cholecystitis

length of stay

COVID-19, a contagious disease, known as the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was declared a pandemic by the World Health Organisation on 11th March 2020. The Australian government introduced “social distancing” five days later and significant changes in the public health system were progressively implemented. International communities recognised a reduction in emergency presentations between March and April 2020 ranging from 13.0–46.3%, compared to the previous year^,. On 25th March 2020 following the National Cabinet announcement and acting on the advice of the Australian Health Protection Principal Committee, New South Wales (NSW) public hospitals suspended all non-urgent elective surgery.

With scientific communities working to better understand the nature of the disease and to develop prevention protocols, the provision of acute surgery services inevitably had to continue to function including for potential life-threatening pathologies such as cancer with hospitals reorganising their infrastructure within a socially distance manner. During the first wave of the pandemic, countries internationally reported patients were severely affected by the disease and disturbingly results directly influenced surgical outcomes^,^,. In comparison our local health districts have sparsely analysed the effect those initial public health measures had with respect to delayed presentations to ED or advert short- and long-term clinical outcomes. This project aims to specifically study the impact those restrictive measures had during the first wave of COVID-19 pandemic on several common general surgical presentations at a Sydney metropolitan hospital.

A retrospective review was conducted for all emergency general surgical presentations at Bankstown-Lidcombe hospital, NSW, Australia between February to August, and from 2017 to 2020. Ethics approval was granted from the local Human Research and Ethics Committee [2021/PID00924]. The inclusion criteria were any patients admitted to the general surgical unit who with an acute surgical pathology. The primary objective was to determine any differences in presentations for all acute general surgical admissions. The secondary objective was to further determine any changes in clinical outcomes in a refined subgroup of the most common pathologies, including appendicitis, cholecystitis, and incarcerated hernias.

The data collected included:

- Demographic information: sex, age, age groups (< 25, 25–40, 40–55, 55–70, 70+), body mass index (kg/m²), onset of symptoms to hospital presentations (days)

- Sepsis: two or more of quick Sequential Organ Failure Assessment (qSOFA) criteria consisting of respiratory rate ≥ 22 breaths/minute, Glasgow coma scale < 15, and systolic blood pressure ≤ 100 mmHg.

- Biochemical parameters: White cell count (WCC), C-reactive protein (CRP), haemoglobin, platelets, creatinine, urea, albumin, liver function tests, and lactate

- Imaging: ultrasound (US) and computed tomography (CT) scan and associated CT findings.

- Management: American Society of Anaesthesiologist (ASA) physical status, operative management.

- Outcomes: operative time (Anaesthetic and surgical, hours), length of stay (LoS, days), intensive care unit (ICU) admission and ICU LoS, post-operative complications (surgical and medical), and in-hospital mortality.

Patients were divided into two groups: non-COVID-19 (2017–2019) and COVID-19 (2020). Statistical analyses were performed using IBM SPSS Statistics version 27.0. Continuous variables assessed the relationship between linear data and correlation based on a level of significance set at p value of 0.05. Continuous variables were expressed as mean, median, range, and standard deviation (SD). The differences between proportions between the COVID-19 and non- COVID-19 groups derived from categorical data were analysed using Pearson chi and student t test for continuous variables. Further analysis by age groups and sex followed.

There was a total of 42,225 emergency presentations to hospital with 3,316 emergency surgical admissions. There was an overall decrease in the total number of emergency general surgical presentations by 8.2% (846.3 vs 777, p = 0.171, Fig. 1). The total cohort had an average age of 40.0 (± 22.3) years with a negative skewed distribution [0–25 years (31.9%), 26–40 years (25.9%), 40–55 years (17.2%), 55–70 years (12.2%), 70 + years (12.9%)]. There was an approximately equal distribution of men and women (51.3% vs 48.7%). The three most common ethnicities included Caucasian (45.1%), middle eastern (35.9%), and Asian (16.2%). The average BMI was 27.6 (± 6.9) kg/m².

For all general surgical procedures and clinical outcomes for the COVID-19 group, sex did not show any significant difference for onset of symptoms (2.1 days male vs 2.8 days female, p = 0.190), operative time (1.6 hours male vs 1.7 hours female, p = 0.597), post-operative complications (11.2% male vs 5.1% female, p = 0.113), return to theatre (1.0% males vs 1.0% females, p = 0.994), LoS (2.4 male vs 2.6 female, p = 0.462), mortality (1.0% male vs 0.0% female, p = 0.314). However, there were significant differences in the total LoS (2.7 vs 2.1, p = 0.009) for all patients, similarly for 40–55 years (2.7 vs 1.9, p = 0.029), and those aged 70 years and older (6.2 vs 3.2, p = 0.018). There was also a significant difference of 0.6 days from onset of symptoms to presentation to ED (1.6 vs 2.2, p = 0.018) for those aged less than 25 years.

Appendicectomy

There were 477 appendectomies recorded with the average age and sex ratio similar between both cohorts. There was no overall difference from onset of symptoms to presentation at hospital (2.0 vs 2.4 days, p = 0.214, Table 1), but patients aged less than 25 years old had a significantly longer onset of symptoms before hospital presentation (1.7 vs 2.5, p = 0.002) and shorter LoS (2.9 vs 2.3, p = 0.016) in the COVID-19 group. Biochemical parameters at presentation did not show any statistical differences except for albumin (43.3 vs 41.2, p < 0.001). The use of US showed a significant reduction of 9.4% in the COVID-19 cohort compared to their counterparts (97 vs 19, p = 0.038). There was no significant difference in CT findings, sepsis, or rate of perforated appendicitis. The operative time was approximately 1.5 hours for both groups with those aged 55–70 years old in the COVID-19 cohort having a significantly longer operative time (1.8 vs 2.3 hours, p = 0.048). The non-COVID-19 cohort showed a significantly higher rate of unplanned return to theatre of 4.3% (5.2% vs 0.9%, p = 0.046). The total COVID-19 cohort demonstrated a significantly shorter LoS by 0.4 days compared to their counterparts (2.9 v 2.5 days, p = 0.027); furthermore, those aged 40–55 years old had a 1.2 day shorter LoS (3.3 vs 2.1 days, p = 0.008).

Table 1 - Comparative analysis between the COVID-19 cohort and the control cohort for appendicitis

	Control Cohort (2017-2019)	COVID-19 Cohort (2020)	P value
Demographic Information
Age [years], mean (SD)	29.2 (17.2)	30.2 (17.3)	0.607
Sex Male Female	199 (54.5%) 166 (45.5%)	63 (56.3%) 49 (43.8%)	0.748
Body mass index (BMI) [kg/m²], mean (SD)	26.0 (6.6)	24.6 (5.5)	0.096
Months Feb March April May June July August	43 (11.8%) 61 (16.7%) 48 (13.2%) 51 (14.0%) 43 (11.8%) 69 (18.9%) 50 (13.7%)	12 (10.7%) 18 (16.1%) 18 (16.1%) 13 (11.6%) 17 (15.2%) 16 (14.3%) 18 (16.1%)	0.791
Onset of symptoms (days) Aged less than 25 years	2.0 (3.3) 1.7 (1.2)	2.4 (2.9) 2.5 (2.5)	0.214 0.002*
Biochemical Parameters [normal range], mean
White cell count (x10⁹/L) [4.0 – 10.0] C reactive protein (mg/L) [<4.9] Haemoglobin (g/L) [130 -170] Creatinine (µmol/L) [60 – 110] Urea (mmol/L) [4.0 – 9.0] Albumin (g/L) [33 – 48] Lactate (mmol/L) [<1.9]	12.9 39.0 141.6 70.6 4.6 43.3 1.5	13.2 30.3 141.6 70.9 4.6 41.2 1.7	0.590 0.205 0.987 0.872 0.799 <0.001* 0.174
Sepsis	6 (1.6%)	1 (0.9%)	0.563
Imaging
US	97 (26.6%)	19 (17.0%)	0.038*
CT scan	153 (41.9%)	40 (20.7%)	0.242
Ct findings: Abscess Phlegmon Free gas	364 (99.7%) 0 (0.0%) 2 (0.5%)	112 (100.0%) 0 (0.0%) 0 (0.0%)	0.579 - 0.432
Operative management
ASA status ASA 1 ASA 2 ASA 3 ASA 4	223 (61.1%) 119 (32.6%) 23 (6.3%) 0 (0.0%)	73 (65.2%) 32 (28.6%) 6 (20.7%) 1 (0.9%)	0.256
Operative time [hours], mean (SD) Aged 55 – 70 years	1.5 (0.5) 1.8 (0.6)	1.6 (0.6) 2.3 (1.0)	0.082 0.048*
Perforation	44 (12.1%)	9 (8.0%)	0.236
Post-operative Outcomes
Post-operative complications	14 (3.8%)	3 (2.7%)	0.563
Return to theatre	19 (5.2%)	1 (0.9%)	0.046*
ICU Admission Mean length of stay (SD)	5 (1.4%) 0.1 (0.5)	2 (1.8%) 0.1 (0.6)	0.749 0.560
Total length of stay in hospital [days] mean (SD) Aged less than 25 years 40 – 55 years	2.9 (2.1) 2.9 (1.7) 3.3 (2.3)	2.5 (1.5) 2.3 (1.3) 2.1 (0.9)	0.027* 0.016* 0.008*
In-hospital mortality	0 (0.0%)	0 (0.0%)	-

Cholecystectomy

There were 224 cholecystectomies included with the average age, proportion of sex, and biochemical parameters similar between both cohorts (Table 2). There was a significant difference of one day delay, from onset of symptoms to hospital presentation, for the COVID-19 cohort compared to their counterparts (2.0 vs 3.0 days, p = 0.025). Furthermore, those aged less than 25 years in the COVID-19 group had a significant difference of 5.8 days in presentation compared to their non-COVID-19 counterparts (1.1 vs 6.9 days, p = 0.006). The use of US showed a significant reduction of 19.8% in the COVID-19 cohort compared to their counterparts (102 vs 31 p = 0.006). CT findings of a thickened gallbladder wall was significantly higher in the non-COVID cohort compared to their counterparts (54.8% vs 9.1%, p < 0.001). There was no difference in sepsis, perforation, or gangrenous gallbladder rates. The operative time was 2.8 hours for both groups with a significant difference of 0.6 hours for those aged less than 25 years (2.6 vs 2.0 hours, p = 0.046). There were no significant differences in post-operative complications (3.8% vs 2.7%, p = 0.563). Those aged between 25–40 and 40–55 years had a significantly shorter LoS in the COVID-19 cohort compared to their counterparts (4.1 vs 2.5, p = 0.003; 5.1 vs 3.4, p = 0.048).

Table 2

Comparative analysis between the COVID-19 cohort and the control cohort for cholecystitis
	Control Cohort (2017–2019)	COVID-19 Cohort (2020)	P value
Demographic Information
Age [years], mean (SD)	50.2 (19.9)	51.2 (20.1)	0.593
Sex Male Female	67 (42.9%) 89 (57.1%)	22 (32.4%) 46 (67.6%)	0.136
Body mass index (BMI) [kg/m²], mean (SD)	30.4 (6.8)	29.6 (7.3)	0.490
Months Feb March April May June July August	13 (8.3%) 23 (14.7%) 33 (21.2%) 19 (12.2%) 24 (15.4%) 24 (15.4%) 20 (12.8%)	6 (8.8%) 9 (13.2%) 10 (14.7%) 14 (20.6%) 7 (10.3%) 15 (22.1%) 7 (10.3%)	0.453
Onset of symptoms (days) Aged less than 25 years	2.0 (2.8) 1.1 (0.5)	3.0 (3.8) 6.9 (7.0)	0.025* 0.006*
Biochemical Parameters [normal range], mean
White cell count (x10⁹/L) [4.0–10.0] C reactive protein (mg/L) [< 4.9] Haemoglobin (g/L) [130–170] Creatinine (µmol/L) [60–110] Urea (mmol/L) [4.0–9.0] Albumin (g/L) [33–48] Lactate (mmol/L) [< 1.9] GGT ALP ALT AST Bilirubin	12.1 43.9 137.6 80.5 5.5 40.2 1.7 184.6 113.9 137.6 114.8 18.8	11.2 39.2 159.1 76.3 5.2 38.4 1.9 174.1 117.3 153.0 125.8 21.2	0.286 0.681 0.098 0.499 0.457 0.061 0.216 0.798 0.796 0.678 0.770 0.476
Sepsis	9 (5.8%)	6 (8.8%)	0.400
Imaging
US	102 (65.4%)	31 (45.6%)	0.006*
CT scan	78 (50.0%)	36 (52.9%)	0.686
Ct findings: Thickened gallbladder wall > 3mm Free fluid	40 (54.8%) 9 (12.3%)	3 (9.1%) 5 (15.2%)	< 0.001* 0.691
Operative management
ASA status ASA 1 ASA 2 ASA 3 ASA 4	32 (20.6%) 74 (47.7%) 43 (27.7%) 6 (3.3%)	10 (14.7%) 39 (57.4%) 17 (25.0%) 2 (2.9%)	0.675
Operative time [hours], mean (SD) Aged less than 25 years	2.8 (0.9) 2.6 (0.8)	2.8 (1.1) 2.0 (0.6)	0.999 0.046*
Perforation	4 (2.6%)	3 (4.4%)	0.465
Gangrene	22 (14.1%)	9 (13.2%)	0.863
Post-operative Outcomes
Post-operative complications	14 (3.8%)	3 (2.7%)	0.563
Return to theatre	3 (1.9%)	1 (1.5%)	0.814
ICU Admission Mean length of stay (SD)	14 (9.0%) 0.5 (2.3)	11 (16.2%) 0.7 (1.9)	0.115 0.486
Total length of stay in hospital [days], mean (SD) Aged 25 to 40 years Aged 40 to 55 years	7.2 (11.4) 4.1 (3.0) 5.1 (4.2)	5.0 (5.7) 2.5 (1.0) 3.4 (1.7)	0.127 0.003* 0.048*
In-hospital mortality	2 (1.3%)	0 (0.0%)	0.348

Incarcerated hernias

There were 121 incarcerated hernias recorded with the average age, proportion of sex, and biochemical parameters similar between both cohorts (Table 3). The three main types of incarcerated hernias included inguinal, ventral/umbilical and intra-abdominal. There was no difference in onset of symptoms to presentation at hospital (1.9 vs 2.2 days, p = 0.656). The use of CT imaging was employed more often in the COVID-19 group than their counterparts (79.8% vs 94.1%, p = 0.156). Features of bowel obstruction on CT were demonstrated in 38.5% of the control cohort, but 47.1% of the COVID-19 group (p = 0.502). Bowel involvement within the hernia sac was evident in 54.5% of the total cohort and mesh was used in 61.1% with no significant differences between groups. The most common surgical approach for the COVID-19 group was laparoscopic (58.8%) versus open for the control cohort (51.9%). No patients had unplanned returned to theatre in the COVID-19 group (0.0% vs 7.7%, p = 0.237). There was no significant difference in operative time between the two groups (2.3 vs 2.4, p = 0.902). Furthermore, those aged 55 to 70 years experienced significantly shorter operative times by 0.9 hours (2.5 vs 1.6, p = 0.020) and shorter LoS by 5.4 days (6.7 vs 1.3, p = 0.019).

Table 3

Comparative analysis between the COVID-19 cohort and the control cohort for incarcerated hernia
	Control Cohort (2017–2019)	COVID-19 Cohort (2020)	P value
Demographic Information
Age [years], mean (SD)	61.9 (19.1)	59.5 (14.9)	0.629
Sex Male Female	58 (55.8%) 46 (44.2%)	13 (76.5%) 4 (23.5%)	0.108
Body mass index (BMI) [kg/m²], mean (SD)	29.1 (6.5)	27.7 (7.4)	0.450
Months Feb March April May June July August	6 (5.8%) 18 (17.3%) 17 (16.3%) 18 (17.3%) 17 (16.3%) 18 (17.3%) 10 (9.6%)	2 (11.8%) 7 (41.2%) 0 (0.0%) 2 (11.8%) 2 (11.8%) 2 (11.8%) 2 (11.8%)	0.210
Onset of symptoms	1.9 (2.1)	2.2 (1.6)	0.656
Biochemical Parameters [normal range], mean
White cell count (x10⁹/L) [4.0–10.0] C reactive protein (mg/L) [< 4.9] Haemoglobin (g/L) [130–170] Creatinine (µmol/L) [60–110] Urea (mmol/L) [4.0–9.0] Albumin (g/L) [33–48] Lactate (mmol/L) [< 1.9]	10.6 19.3 139.5 94.8 7.2 40.3 1.5	9.8 22.3 143.1 101.1 7.4 38.6 1.4	0.531 0.784 0.487 0.701 0.893 0.210 0.643
Type of hernia Inguinal Ventral / umbilical Intra-abdominal	37 (35.6%) 57 (54.8%) 10 (9.6%)	8 (47.1%) 9 (52.9%) 0 (0.0%)	0.339
Sepsis	0 (0.0%)	0 (0.0%)	-
Imaging
US	3 (2.9%)	2 (11.8%)	0.088
CT scan	83 (79.8%)	16 (94.1%)	0.156
CT features of bowel obstruction	40 (38.5%)	8 (47.1%)	0.502
Operative management
ASA status ASA 1 ASA 2 ASA 3 ASA 4	10 (9.6%) 43 (41.3%) 44 (42.3%) 7 (6.7%)	4 (23.5%) 5 (29.4%) 5 (29.4%) 3 (17.6%)	0.128
Operative time [hours], mean (SD) Aged 55 to 70 years	2.3 (1.2) 2.5 (1.5)	2.4 (1.1) 1.6 (0.3)	0.902 0.020*
Bowel involvement in hernia	55 (52.9%)	11 (64.7%)	0.364
Mesh used	66 (63.5%)	8 (47.1%)	0.198
Surgical approach Open Laparoscopic Laparoscopic converted to open Hybrid	54 (51.9%) 46 (44.2%) 1 (1.0%) 3 (2.9%)	7 (41.2%) 10 (58.8%) 0 (0.0%) 0 (0.0%)	0.646
Post-operative Outcomes
Post-operative complications	25 (24.0%)	4 (23.5%)	0.964
Return to theatre	8 (7.7%)	0 (0.0%)	0.237
ICU Admission Mean length of stay (SD)	21 (20.2%) 0.8	3 (17.6%) 0.6	0.807 0.229
Total length of stay in hospital [days], mean (SD) Aged 55 to 70 years	6.9 (9.2) 6.7 (11.2)	4.8 (4.5) 1.3 (0.6)	0.348 0.019*
In-hospital mortality	3 (2.9%)	1 (5.9%)	0.522

Our findings demonstrated a reduction in the total volume of general acute surgical presentations consistent with the international literature^,^,. Our experience was congruent with the overall decline in emergency department visits between March and May 2020 in Western Sydney Local Health District and Australia, with a drop of 25% and 38%, respectively^,. South Australian trauma service also experienced a significant reduction of 45% notably in those aged 40–54 years old.

It is well documented that delayed presentations of common general surgical pathologies such as appendicitis and cholecystitis may lead to higher rates of complications and LoS^,. The expectation was that the pandemic and lockdown may have contributed to delayed diagnoses, directly impacting clinical outcomes and LoS. Emergency surgery and procedures continued as elective procedure cancellations permitted resources and time for expectant management. However, this assumption was heavily galvanised by international experiences who reported delayed presentations and detrimental clinical outcomes. For instance, a Scottish study reported a significant increase in severe appendicitis resulting in greater proportion of emergency surgery and operative time. Additionally, a regional New Zealand study reported patients with appendicitis were 15.1 years younger their counterparts (21.5 vs 36.6, p < 0.01), had a longer onset of symptoms to presentation (2.82 vs 1.77 days) and shorter LoS, albiet not statistically significant.

During the first wave, Bankstown-Lidcombe hospital was a relatively spared centre like many other major Australian hospitals as resources were re-allocated towards major COVID-19 hospitals for expectant management of cases. In essence, our unit remained a relatively “clean” hospital which aided in assessing the true impact of the government restrictions rather than the disease itself. This study identified that there were no significant overall clinical differences in outcomes of common acute general surgical pathologies as most procedures were even more heavily driven by consultants and/or fellows. In the sub analysis of age groups there were significant differences that reflected the impact of the restrictions in presentations, particularly amongst the youth. We identified that those less than 25 years old had a significantly longer onset of symptoms before hospital presentation for appendicitis of 0.8 days (1.7 vs 2.5 days, p = 0.002) and 5.8 days for cholecystitis (1.1 vs 6.9 days, p = 0.006) compared to their counterparts. Surprisingly, for both pathologies, the LoS was overall significantly shorter in the COVID-19 group by 0.6 days (2.9 vs 2.3 days, p = 0.016) for appendicitis and one day for cholecystitis (2.0 vs 3.0 days, p = 0.025). In those aged less than 25 years and 40 to 55 years, similar significant reductions in LoS were also demonstrated (Table 1, Table 2). These two salient points on delayed presentation and LoS highlight the impact of societal restrictions and sturt surgical leadership, respectively. Our experience recognises that the younger age group seemed to have more delayed presentations overall, which may be due to the lockdown, social media access and fear of hospital exposure adversely affecting earlier presentation. We also believe that surgeons’ experience and prompt hospital discharge during the pandemic wave were key factors in delivering such satisfactory outcomes.

The investigations of choice were different and likely influenced by the potential respiratory transmission of COVID-19 with safe distancing protocols in place. The use of US had a significant reduction by 9.4% and 19.8% for appendicitis and cholecystic, respectively. Ultrasound use was impacted by safe distance protocols in place and physicians likely aware of the potential transmission thereby selecting alternative measures. Interestingly, CT findings of a thickened gallbladder wall was significantly higher in the non-COVID-19 cohort compared to their counterparts (54.8% vs 9.1%, p < 0.001). This study did not distinguish between acute and chronic cholecystitis features as a factor in the above findings, but Yeo’s radiological study has reported specific radiological findings based on gallbladder distension, pericholecystic haze, and liver enhancement. An American study reported a different experience with CT use demonstrating a significant decrease in CT abdomen and pelvis (33.6% vs. 31.1%), but increase in US abdomen (15.7% vs. 20.3%) during the pandemic period, except for an increase in CT chest. Whilst reductions in presentations account for this change, Houshyar attributes this as multifactorial relating to regional differences in disease prevalence, magnitude and scope of social distancing mandates, variable adoption of these measures by members of the public, and existing image ordering practices and resources.

Despite the absence of reported cases of COVID-19, the general surgical unit did not identify any clinically significant differences in biochemical parameters, operative management, or major clinical outcomes between both groups. Bankstown-Lidcombe hospital remained a relatively ‘clean’ centre during the first wave and operative management was even more gilded by consultant decisions. Our previous work identified that those with necrotising fasciitis in the COVID-19 group had a significantly longer mean onset of symptoms till hospital presentation of 4.1 days, longer mean operative time, more likely to be admitted to ICU and not survive compared to their counterparts. A Melbourne base study who experienced different restrictions compared to Sydney reported those who had operations after-hours in the COVID-19 period were more likely to present with severe cholecystitis. An Israeli study who had similar experiences with lockdowns, but at the time overall better vaccination rates compared to Australia reported significant delays of presentation from onset of symptoms resulting in worse biochemical and clinical parameters compared to the control cohort. In contrast to our findings, their COVID-19 cohort underwent significantly higher rates of urgent surgery and greater LoS. The increase LoS was also attributed by worse clinical conditions, delayed PCR testing and fear of hospital exposure^,.

The uncertainty experienced by many other countries with COVID-19 undoubtedly influenced our management and assumptions about its clinical impact. Acting within resource limitations and preparation for the wave, the LoS was significantly shorter for appendicitis and cholecystitis in the COVID-19 cohort, which reflects the urgency to discharge patients from health care facilities sooner rather than later (2.9 v 2.5, p = 0.027). The Auckland experience similarly reported fewer operations, albeit non-significant, with a total median LoS difference of 0.5 days between the groups (1.8 vs 1.3, p = 0.031).

Australia experienced a lesser magnitude of the first wave compared to other countries with a total of 28,381 cases of COVID-19 by the end of 2020, including 909 deaths. With an established telehealth service pre-pandemic, the introduction of government subsidised telehealth services across Australia largely facilitated the management of non-COVID-19 health conditions. Our unit remained as a ‘clean centre’ during the first wave and our response in addressing common surgical pathologies were overall sound. Evidently, the access to these services and social restrictions contributed to the reduction in presentations and delayed presentations.

To the best of our knowledge, this report represents the first Sydney based study that thoroughly analysed presentations, biochemical and clinical parameters, and outcomes. Limitations of the study are attributed to the retrospective design with potential selection bias due to coding of the disease, which may not have captured all patients. One of the challenges with many studies is the reductive snapshot of comparing the current year with the previous year. Our review included previous years to provide a holistic picture of presentations with different findings. For the initial part of this study, this represents an important milestone for the South Western Sydney Local Health District during the first wave as the district subsequently experienced one of the strictest hardships during the Delta wave in 2021. We anticipate the pandemic to continue for many months, therefore surveillance and informed data decision processes are paramount to the provision of good service in achieving adequate patient care. Therefore, based on the same research principle, we plan to further explore the impact the delta and omicron wave had in our local health district.

The first wave of the COVID-19 pandemic significantly reduced acute general surgical presentations during the lockdown period. Patients aged less than 25 years old were most likely to present later for common surgical pathologies. Despite significantly delayed overall presentations for appendicitis and cholecystitis, sound clinical outcomes were satisfactorily met with overall shorter LoS.

ASA, American Society of Anaesthesiologist physical status

CRP, C-reactive protein

CT, computed tomography

ICU, intensive care unit

LoS, length of stay

NSW, New South Wales

qSOFA, Sequential Organ Failure Assessment

US, ultrasound

WCC, White cell count (WCC)

- Ethical Approval and Consent to participate

This project has been approved by the Human Research Ethics Committee with no restrictions. There is no source of financial or other support and no financial or professional relationships which may pose a competing interest. Ethics approval was granted from the local Human Research and Ethics Committee [2021/PID00924].

- Consent for publication

Ethics and consent approval was granted from the local Human Research and Ethics Committee [2021/PID00924].

- Availability of data and materials

The data is deemed confidential and under ethics cannot be disseminated openly due to confidentiality and privacy.

- Competing interests

All authors declare no competing interests.

- Funding

There was no funding for this study.

- Authors' contributions

All authors contributed to the conception and design of the manuscript, revised it critically for important intellectual content, approved the final version to be published and agreed to be accountable for all aspects of the work.

- Acknowledgements

We would like to extend our acknowledgement to the general surgical team members at Bankstown-Lidcombe hospital and the medical administration who assisted across the units in the collection of the data.

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No competing interests reported.

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The patterns and changes of general surgical presentations during the first wave COVID-19 pandemic at a metropolitan Sydney hospital

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Appendicectomy

Cholecystectomy

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