The Impact of COVID-19 pandemic Lockdown on the utilization of acute surgical care, retrospective, multicenter analysis

Background: The emergency general surgery encompasses the care of critically ill patients, with a potentially high mortality if delayed. As some medical disciplines have reported a strong decrease of emergencies during the COVID-19 pandemic, remains the effect of the Lockdown on the general surgery emergencies unclear. Methods: This study is a retrospective, multicentre analysis of the general surgery emergency operations performed during the 2020 Lockdown and in the same period of 2019 in three centers covering the surgical care of the area Salzburg-North, Austria. Results: In total 165 emergency surgeries were performed in the study period of 2020 compared to 287 in Year 2019. This is a signicant decrease of 122 (42.5%) emergency surgeries during the COVID-19 Lockdown (p=0.005). The average length of hospital stay in the 2019 was in median 4 days and was reduced to 3 days during the Lockdown. Appendectomy remained the most performed emergency surgery for the both periods but the operations count reduced to less than a half with 72 cases in 2019 and 33 cases in 2020 (p=0.118). Considering the ration of appendectomy vs all emergency surgeries, it represented 25 % in 2019 and 20% in 2020. The emergency colon surgery observed the strongest decrease of 75% from 17 cases in 2019 to 4 in 2020. In addition, the emergency abdominal wall hernia, cholecystectomies for acute cholecystitis, small surgeries and proctological emergencies recorded drops of 70%, 39%, 33% and 47% respectively. A strongest reduction in frequency of 6 of 13 main categories of emergency surgeries was reported from Center 1, which was the only COVID designed Center (“Hot” hospital) in the examined region. Conclusions:

As the rst cases of a new viral pneumonia, today known as COVID-19 caused by corona virus SARS-CoV2, were reported from Wuhan/China in December 2019, nobody knew that in March 2020 the COVID-19 would become pandemic [5]. The high mortality of the disease, which initially reached 7.2% in Italy [6], forced the authorities, by missing causal therapy or vaccination, to a strict exposition prophylaxis ("Lockdown") to slow down the spread. The rst COVID-19 positive case in the state Salzburg, Austria was documented on 29th February 2020. Because of the growing caseload of COVID-19 positive patients, the government decided about the rst steps to restrict public life on 16th March 2020. These measures were gradually tightened until 14th April 2020 when parts of the restrictions withdrawn. In order to avoid the spread in the public hospitals and to save health care capacities, all elective interventions (incl. operations) were postponed and the population was encouraged to avoid the hospitals except emergency cases. Simultaneously with the increasing numbers of infected patients and growing fear of possible overwhelming number of COVID-19 patients, another effect of the Lockdown was reported from abroad. In the USA, the nine High-Volume catheterization laboratories reported a decrease activation for STelevation myocardial infarction (STEMI) of 38% [7]. The similar trend could be observed by neurologists from China and USA, who reported a dramatic decline of acute strokes of 30-50% [8,9].
At this moment, there is no knowledge about the effect of the Lockdown on the presentation of the general surgery emergencies, which could be crucial to prevent patients from severe adverse effects. The aim of this work is to investigate whether there have been any changes in the surgical emergency operations in the north of the state Salzburg, Austria (supply region 51) during the national Lockdown.

Methods:
We have conducted a retrospective analysis of all general surgery emergency surgeries performed in the entire emergency Region 51 in the period from 1 March to the 15th of April 2020 (= 6 weeks). The Region 51 is a de ned north part of the state Salzburg, Austria with 364.797 inhabitants, which is 66% of the population of the whole state Salzburg. There are three general surgery centers providing emergency surgical care in this region: All three centers submitted their data during the study period. Demographic data (age, sex), the length of hospital stay (LOS), the type of acute surgery, the indication for surgery and the mortality rates were analyzed. For comparison, the equal parameters from the three centers in the same time period 1 March to the 15th of April of the year 2019 were used. The surgeries were divided into 13 main categories, de ned upon the most frequent clinical diagnosis, according to which the statistic comparation followed. (appendectomy, cholecystectomy, bowel ischemia, small bowel perforation, acute abdominal wall hernia, bowel obstruction, small acute surgeries = small one day surgeries, colon emergencies, proctological emergencies, revision operations after any index operation, emergency thorax surgery, abdominal trauma surgeries, stomach bleeding or perforation surgeries) Table 1. Only Center 1 was dedicated as a regional COVID Center ("Hot" hospital) so it covered the care of COVID and Non-COVID patients. This took place in a dedicated COVID Clinic located on the Campus of the University Hospital in Salzburg [10]. Center 2 and 3 remained COVID free during the Lockdown. All patients included in the study were considered COVID-19 negative.
Statistical Analysis: Statistical analysis was performed using SPSS-Statistical-Analysis Software (SPSS Inc., Chicago, IL, USA). All data were tested for normal distribution by Kolmogorow-Smirnow-Test. Comparison data was done using paired-t-test respectively Wilcoxon signed rank test on a per subject basis. Population homogeneity was conducted using independent t-Test or Mann-Whitney-U-Test. If normally distributed, measurements were additionally presented as means and standard deviation (SD). p < 0.05 was regarded as statistically signi cant.

Results:
In the region Salzburg North, 165 emergency surgeries (ES) were performed in the study period of 2020 compared to 287 ES in 2019. This is a signi cant decrease of 122 (42.5%) emergency surgeries during the COVID-19 Lockdown (p = 0.005) ( Table 1 Table 1). The amount of cholecystectomies for acute cholecystitis dropped from 33 operations to general, the Centre 1 recorded the signi cant drops in 6 of the de ned main categories of the surgeries (Table 1) (Fig. 1).

Discussion:
The COVID-19 pandemic Lockdown caused a signi cant reduction of the general surgical emergency operations of 42.5% (p = 0.005) in the entire Region 51. This noteworthy reduction of emergencies was reported also from other medical specialties around the globe. Garcia et al. reported about diminished activations of US cardiac catheterization laboratory for STEMI in the COVID-19 era [7]. The Medscape Medical News also announce a 30% decreased rates of major stroke in Chicago [8]. Furthermore, the preliminary data to Stroke care from Shanghai reported a decrease of thrombectomies by 50% in the rst month after the Spring Festival (24th to 30th January 2020) [9]. Those specialties discussed the reduction of stress and the deceleration of public live as a potential reason for such a decline of cardiovascular emergencies [7][8][9].
As the role of negative stress in functional gastrointestinal disorders is well known, the effect of stress on development of abdominal emergencies has not been described so far [11].
The strong decrease of acute appendectomies and acute cholecystectomies of 54% and 39% respectively in the year 2020 in our cohort is striking. Many different deviations of stated therapies, to minimize the risk of COVID-19 cross infection are being reported. Patel et al. described shortly ago an increased consumption of a conservative antibiotic therapy for uncomplicated appendicitis, during the Lockdown in England [12]. This therapy is in the literature stated as a feasible and save option, but with an increased risk for appendicitis recurrence [13,14]. Patel also reported a deviation from the guidelines and an exclusively use of a conservative therapy as a rst line treatment for acute cholecystitis [12,15].
Based on this knowledge, all centers in Region 51 con rmed no change to the state of the art operative therapy of acute appendicitis and cholecystitis.
The o cial recommendation of the authorities to the public was to avoid hospitals until a "real" emergency occurs. Furthermore, the patients were encourage to discuss the general practitioners in the rst line. According to that, the general practitioners haven´t reported any increase of patients load or change of the therapeutic pathways, including the reporting of all patients suspected of abdominal emergency to a surgical specialist. If the reduction of the case load of emergencies or preferred antibiotic treatment or both are responsible for reduction of acute surgeries in our region stays unknown.
The strict politics of the authorities, with the clear aim of preparing the medical system for a huge number of COVID-19 positive patients, as seen in Italy, caused a dramatic reduction of all elective surgeries of 46% during the Lockdown. We have also observed a faster relocation of the Non-COVID patient's therapy to the outpatient setting, leading to a shorter median LOS of 3 days (reduction of 25%) in the examined period of 2020. The same trend was reported by Patel et al. in his cohort with a signi cant reduction of LOS from 3 to 2 days (p = 0.04) [12].
The general avoidance of medical care due to the social distancing or due to the concerns of patients of being infected with COVID-19 in the hospital, remain the most common reasons for the decrease of emergency surgeries in entire Region 51. To underline these facts, we have identi ed a noticeable decrease in the frequency of 6 of 13 main categories of emergency surgeries in Center 1, which was the only COVID designed Center ("Hot" hospital) in the examined Region 51. Huang et al. already reported this potential perception of personal danger, dramatically reducing the willingness of patients to visit an emergency department of the "Hot" hospital, in 2003, during the last epidemic of SARS from Taipei, Taiwan [16]. The authors reported a reduction of up to 51.6% in daily visits of emergency departments at the peak of the SARS epidemic, which persisted for 3 months after the end of the epidemic. The longlasting effect of people´s fear of designed SARS centers was reported from the same hospital in Taipei and published in 2008. The results show, that in long-term observation the outpatient department of the general surgery department had still signi cantly less patients treated at 4 years after SARS epidemic [17].
The further consequences of the COVID-19 pandemic for acute surgical patients, who did not received an appropriate, guidelines conform, therapy remain still unclear and should be further examined. We cannot forget the potentially high mortality of severe intra-abdominal infections, which could reach up to 40% in case of sepsis [3]. The Statistic Austria reported recently the mortality data for Austria during Lockdown  [18][19][20]. Just to re ect the COVID Situation during our examined period, the total number of COVID positive deaths in Austria was 384 and 27 in whole State Salzburg, Austria [21,22].

Conclusions:
The emergency general surgery is an essential health service that continues to run under any circumstances. Our data showed that the COVID-19 related restrictions lead to a signi cant decrease of the utilization of acute surgical care. The increased overall mortality of people being 65 years or older, must be a caution for public health care providers, that should encourage people to continue the use of public health care services, especially when suffering from serious medical complains. New policies are needed to enable a save access to specialized health services for patients twenty-four seven, especially in the situations like caused by COVID-19.