The study we conducted at a rural part of the low middle-income country Nepal, came up with various findings especially associated with COVID 19 era comparing the findings with non COVID times. We could find few studies related to appendicitis during this pandemic and most of them arrived into a conclusion of treating lesser number of patients amidst the present scenario.[6, 7] In contrary, we could see a greater number of patients surfacing to the emergencies and getting operated in comparison to the same time frame before this contagious disaster. The valid reason for this disparity could be due to closure of private hospitals around the area from where the patient turns up and the pooling occurred at our institute as this serves as one of the tertiary centers in the region. The duration of pain abdomen before presentation to the hospital significantly increased in between two groups, latter showing 55.4 ± 25.9 hours (P = 0.04). The scenario of delayed presentation to health care centers has been since ages in developing countries due to unaffordability issues, difficult geographical topography and lack of adequate transportation during normal days which itself was compromised. These obligations were further accentuated by the blooming contagion that led to harrowing consequences, which can be anticipated during these times of strict immobility, being confined to homes, maintaining social distancing, taking home based treatments in the fear and anxiety of contracting virus from health care personnel and hospitals. This further aggravates the diseased status of the patient arching to complexity which can be exemplified by the increased rates of perforation and complicated cases in our setting. Appendicular perforation is one of the dreaded complications of late presentation to the hospital which increases morbidity and mortality in comparison to non-complicated appendicitis. Studies have shown the perforation rates ranging from 16% to 40%. Our study showed almost similar rates of perforation though there was slight increase in perforation rates in group B by six percent comparing to group A patients (14.2% vs 20%) while total complicated cases increased by around 5% (33.3% vs 38%). Snapiri et al. showed total complicated rates of 22% during COVID times which was similar to study by Tankel et al. however our data shows almost doubled rate of complicated cases. Overall prevalence of fecalith was 14.2% in our study in which 33.3% of perforations in group A and 60% of perforations in group B were fecalith induced. The prevalence rate was similar to study from West Indies by Ramdass et al. where fecaliths were present in 13.6% of the appendectomy specimens.
The mean operative time duration increased significantly between two groups, the latter one showing mean duration slightly more in comparison. This could be due to extra precautions taken by the operating surgeons, virtually limiting chances of prick injuries, trying the best to limit complications to occur and operating while wearing Personal Protective Equipment (PPE) with a foggy visibility along with complicated appendicitis encountered mandated extra cautiousness to take into account. Tankel et al. in his publication accounted the mean duration of surgery for 47.2 ± 28.9 minutes which almost corroborates our timing of 51.0 ± 9.4 minutes. Around two to six percent of cases with AA present with appendiceal mass which mainly includes inflammatory phlegmon or abscess. Overall rate of appendicular lump was 7.6% in our study. Only three cases were managed conservatively in group B which included appendicular lump in two cases. Duration of hospital stay tend to decrease in group B patients in our study with statistical significance in comparison to group A which could be due to patients willing to get discharged early once operated if feasible, minimizing the risk of protraction of the virus from other patients who have been hospitalized. Also, this practice allowed the rapid turnover of the patients allowing void of the beds that may be required in times of crises if surge of the COVID cases were to be seen in the forthcoming days.
Our study depicted that the surgical approach that was mandated at our institute for long before the pandemic ensued, is still being followed and the treatment strategy for the cases of AA was solely based upon the clinical judgement of the surgeon whether to operate or not, maximizing the use of protective gears with minimum use of man powers in operating room. The principle of treating the primary cause rather than the symptoms of the disease was not violated keeping in mind the burden of the present contagion scenario which seems quiet less in developing countries like Nepal in comparison to the other parts of the world. Similarly, there might be some obligations for proceeding with conservative approaches with antibiotics alone in the setting of a low-income country where radiological investigations like CECT might not be feasible or available in order to diagnose non complicated appendicitis and rule out complicated cases. What our experience suggests is the cost factor if tabulated while performing CT abdomen along with fetching antibiotics almost completes the surgery. The financial aspects also need to be considered while working on low resource settings like ours where the needy ones are striving for surgical health and financial burden needs to be mitigated providing the definite care in a low budget scenario.
There are several limitations of the study. This is a single center analysis of the patients with a smaller sample size which might not cover all the demographic and clinical aspects of the cohorts. As the current pandemic is yet unknown till when it shall perish, corona virus has been seen to involve almost many of the bodily systems. The novice nature of this contagion which seems to involve gastrointestinal system might even affect the clinical course of appendicitis which is yet to be elucidated, in which case the number of samples might increase along the parameters. None of the patients had testing for coronavirus as the tests were limited, costly and reserved for symptomatic or suspected cases. Still, we are experiencing positive cases without symptoms while tracing contacts, there would have been cohorts with positivity of the virus without symptoms if tests were implemented which would have changed the treatment modality for suspected uncomplicated cases.