SARS-CoV-2 (COVID-19) has had a major impact on the health care system worldwide. Of note, one of the most prominent effects has been avoidance of timely medical treatment secondary to fear of contracting the novel COVID-19 virus. Emergency departments internationally have reported significant decreases in volume in comparison to previous years [1, 2], attributing the lower census to this phenomenon. The impact of delayed presentation of certain conditions during the pandemic, especially those requiring surgical intervention, has yet to be truly elucidated.
At our institution, it was anecdotally noted that many patients who presented to the hospital during the COVID-19 pandemic had perforated appendicitis. Perforated appendicitis is associated with increased morbidity for patients, with delays in presentation increasing mortality up to 4% [3, 4]. This raises the concern of an increased population of patients with progressed disease, adding a significant burden to the health care system.
If patients with appendicitis in fact delayed presentation to health care settings secondary to fear, it would theoretically increase the incidence of perforated appendicitis. This study aims to compare the rates of perforated appendicitis during the COVID-19 pandemic to the previous year to evaluate if the fear of seeking medical treatment has increased the number of perforated appendicitis cases seen during the pandemic.
Methods
This is a single center retrospective chart review that evaluated the number of perforated appendicitis cases during the first nine months of the pandemic and the nine months prior. IRB approval was obtained at Henry Ford Macomb Hospital in Clinton Twp Michigan. The first COVID-19 case in Michigan was diagnosed on March 10, 2020 and a stay-at-home order was established on March 24, 2020 [5]. Every patient with the diagnosis of acute appendicitis between the dates of March 10-December 31, 2019 (cohort A) and March 10-December 31, 2020 (cohort B) was evaluated. A total of 377 patients were evaluated for the diagnosis of acute appendicitis and 22 patients were excluded from evaluation during these time frames.
Exclusion Criteria
Patients were excluded from the study if appendicitis was ruled out based on physical exam, if the patient was transferred to another facility, if they had a normal appendix on diagnostic laparoscopy, or if there was concern/diagnosis of neoplasm. In our patient population, five patients were transferred to another facility, eight patients had normal appendix on diagnostic laparoscopy, and acute appendicitis was ruled out on physical exam in seven patients. One patient had an incidental appendectomy as a part of another procedure, and three patients had concern for appendiceal carcinoma. A total of 352 patients were included in this study. Cohort A included 188 patients and cohort B included 164 patients.
Data Collection
Age, sex, race, comorbidities including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, renal failure, and obesity, COVID status, imaging findings, operative findings, length of stay, and complications were studied. Perforated appendicitis was defined as findings on CT scan if applicable and/or intraoperatively. Post-operative abscess was observed on CT scan or in an additional operation. Ileus was defined as delayed bowel function requiring length of stay longer than two days or requiring readmission. Surgical site infection was defined as erythema or drainage from an incision requiring treatment with antibiotics. Bleeding was diagnosed intraoperatively after initial intervention.
Statistical Analysis
Categorical data were summarized as counts and percentages, and numerical data (patient age) as means with corresponding standard deviations. Between-group mean differences were compared by calculating t-tests for independent variables. Categorical data were compared using the chi-square test for association or Fisher’s exact test, as appropriate. Throughout this study, a p-value < 0.05 (two-tail) was considered statistically significant. Following initial data entry using Microsoft Excel, Minitab 19 Statistical Software (2019), State College, PA: Minitab, Inc. (www.minitab.com) was used for performing the analyses.