COVID‐19 and the treatment of acute appendicitis in Ireland: a new era or short‐term pivot?

Dear Editor,

COVID‐19 (SARS‐CoV‐2) has caused major disruption to healthcare practices globally. The reality of a pandemic rapidly overwhelming healthcare systems has been alarming, and countries earlier in their curves have sought to implement the lessons from others’ experiences. Surgery is among the many services impacted by restructuring to provide surge capacity in Ireland. Since the commencement of our national mitigation phase in March 2020, with subsequent escalation to lockdown on 17 March, elective care has been reduced to only those most time‐sensitive (e.g. oncological care). There has also been a push to manage surgical emergencies non‐operatively due to safety concerns regarding general anaesthesia in patients with occult COVID‐19 infection and the risks of aerosol generating procedures (especially perhaps laparoscopy) to staff [1, 2].

Acute appendicitis is the most common acute surgical presentation [3]. While some groups and recent guidelines advocate conservative care [4, 5] which is based on large cohort and randomized controlled trials that have suggested short‐term outcomes equivalent to surgery [6, 7], in Ireland operative intervention had remained the predominant strategy before the pandemic [8]. Our surgical community held concerns over the seemingly high rates of failure with a conservative approach, and the risk of increasing overall hospital stay coupled with our lack in widespread availability of CT. We have examined how national practice preferences have changed over the last 6 weeks including analysis at patient experience level at our own institution, a major urban tertiary unit.

To assess current national practice, we surveyed 161 surgeons and senior surgical trainees obtaining a 59% response rate (95/161). Seventy‐six per cent of participants have modified their practice to a predominant conservative approach with the majority (74%, n = 71) obtaining CT at presentation. Interestingly, 83% (n = 79) stated that they would return to operative management after the COVID‐19 crisis.

Similar to other units, we also adjusted practices from the beginning of March 2020. Between then and now (24 April 2020), 18 patients have been admitted with clinical acute appendicitis with 11 (61%) having non‐operative management. Interestingly, their median length of stay vs those undergoing appendicectomy in the same period was 3.5 vs 2 days. On follow‐up phone review at 1‐week post‐discharge, 54% of those in the conservative care group had ongoing discomfort (although none had reattended the emergency department or their family physician). 63% (n = 7) would choose up‐front appendicectomy if they could decide again, and 45% (n = 5) are interested in interval appendicectomy.

From these results, it is apparent that the COVID‐19 pandemic has impacted our national practice but perhaps not our psyche regarding acute appendicitis. As our infection curves flatten and international professional societies update guidance to support the re‐introduction of normal surgery (with the added protection of personal protection equipment and use of antiviral filters), we will be resuming our prior practice. While one should ‘never waste a crisis’, it seems likely our national preference remains ‘to solve a problem by removing the cause, not the symptom’.

Conflicts of interest

All authors declare no conflict of interest.

Author contributions

All authors have seen, edited and approved the final version of this paper.