This study shows that Covid-19 pandemic has change our activity in emergency surgery, while
elective surgery did not significantly change. As the COVID-19 pandemic has put the Italian
national health care system under pressure, we hypothesized three possible scenarios after the
reopening of surgical activities at the end of the total lockdown between March and May 2020
(first pandemic period):
1) A rapid increase in hospital admission of surgical patients compared to the same period
2) A progressive increase in surgical patients’ admission distributed over a several months
period of time;
3) A non-recovery of unoperated surgical patients’ admission, compared to the same
period in 2019.
The data analysed shows a reduction in operating volumes in the first quarter of 2020 (first
pandemic wave), as a consequence of government restrictions (Fig. 1), which was not followed
by an increase in cases in the following months, until the interruption of the observation period
in April 2021 (Fig. 1-2).With the reopening of the main activities in Italy, starting from May
2020, separate diagnostic-therapeutic paths for positive Covid-19 patients and negative Covid-
19 patients were instituted. Comparing the first quarters of the three consecutive years (i.e.,
2019, 2020, and 2021), there was an overall recovery in terms of volumes of surgical
interventions during the second pandemic wave (2021) as compared to the prepandemic period
(2019) (Fig. 2).
Regarding emergency surgery, we focused on emergency appendectomy and cholecystectomy.
Data shows that patients operated on during the pandemic (March - May 2020) were younger
as compared to the prepandemic period (March - May 2019) (Tab. 1-3). In pandemic versus
prepandemic period, both urgent cholecystectomies (51 vs. 39, p) and appendectomies (42 vs.
24, p) decreased, but There were no significant changes in the age of colon and stomach cancer
patients (Tab. 7,8). we did not detect a greater number of histological exams with a
"gangrenous" pattern. We identified, however, an association between gangrenous pattern of
the gallbladder and older age and male sex (Tab. 5). This data has not been identified in the
appendices. The decline in emergency operated patients for appendectomy and
appendicectomy is in accordance with other district hospitals in the Province of Ferrara.
The number of cases of stomach cancer who had surgery remained constant in between periods.
Interestingly, the number of patients who underwent preoperative chemotherapy in the
prepandemic period compares well with the prepandemic period.
The curative treatment of colon cancer did not show a delay in the diagnostic-therapeutic path
during pandemic versus prepandemic period (Tab. 9). In particular, there were no statistically
significant differences in time intervals between endoscopic diagnosis, preoperative contrast
enhanced CT, surgery, and definitive histological report. In prepandemic period, 62 patients
had surgery, compared to 44 cases in pandemic. Four patients in pandemic underwent
neoadjuvant chemotherapy, while in prepandemic we did not register any cases. Of note,
looking at the stages of colonic tumours of patients undergoing surgery, there was a clear
reduction in stage I and IIA in the pandemic versus prepandemic period (Fig. 4).
The presence of a pre-established multidisciplinary team and a perioperative pathway for
colorectal cancer patients may have helped to preserve the diagnostic and treatment steps
during the Pandemic.
A possible explanation for the drop in surgical admissions in the pandemic period may rely on
the advanced age of Covid-19 patients, who is the population with highest incidence of colon
cancer and cholelithiasis. The increase in mortality and morbidity in the elderly during the
Pandemic, could explain the decline in surgical admission as well as the reduction in the age
of patients who underwent emergency surgery during the Pandemic.
Another possible explanation, however, could be the fear of the population, in particular the
elderly, to go to the hospital during the Pandemic due to the risk of contagion in crowded
environments. This could explain the decline in hospitalizations for acute appendicitis in
pandemic and the younger age, as younger people may have less fear of Covid-19 as compared
to the elderly as they were affected by a mild form of the disease.
Finally, as the decrease of surgical activity in the first quarter of 2020 was not recovered
subsequently, including urgent appendectomy and cholecystectomy, may suggest greater use
of medical treatment or non-operational management.
The limitations of the study are related to the retrospective nature which introduces bias.