A prospective cohort study of the impact of covid19 world pandemic on the management of emergency surgical pathology

Editor

The global pandemic due to the SARS-Cov-2 virus is having an unprecedented impact on surgical procedures¹. Despite having started multiple analyzes on surgery during the pandemic², there have been no studies on the impact of its on the management of emergency surgical pathology. Thus, a comparative cohort study of prospective databases was done. Study group (n = 127) included emergency surgeries done during COVID-19 pandemic: between March 11, 2020 (declaration of a global pandemic by the WHO) and April 17 (start of “de-escalation” in Spain). Results were compared with a control group (n = 307) that included emergency surgeries done during the same period in the previous year 2019.

Regarding the overall number of patients attended at emergency department for surgical pathology (n = 434), a significant decrease in the total number of its patients was observed during pandemic period (44,6% less than in 2019). The mean waiting time in the emergency department, was significantly shorter during pandemic (3·3 ± 2·15 hours vs 5·2 ± 6·13 hours; p = 0·01), probably related to the decrease in the no-COVID activity in the emergency department during confinement status.

Both groups showed similar demographic data. Emergency pathologies, were classified as complicated or uncomplicated³. An increase in preoperative complicated diagnosis was observed during pandemic (50% vs 38·3%; p = 0·09).

Overall comparation showed that there was an increase in the complications rate during pandemic (36·2% vs 4·1%; p = 0·04) with an increase of 7·5 days in ICU stay. Nevertheless, mortality was lower in patients operated during pandemic (2·5% vs 7%) (Table 1).

Table 1.

Results of the global variables and by pathology

	GLOBAL		APPENDICITIS		DIVERTICULITIS		CHOLECYSTITIS		INTESTINAL OBSTRUCTION		HERNIA		HOLLOW VISCUS PERFORATION
VARIABLES	Contol Group	Pan COVID	Contol Group	Pan COVID	Control Group	Pan COVID	Control Group	Pan COVID	Grupo Control	Pan COVID	Control Group	Pan COVID	Control Group	Pan COVID
n	141	78	42	20	19	7	19	11	26	16	21	9	13	10
SURGICAL TREATMENT	104 (73·9%)	54 (66·7%)	40 (95·2%)	20 (100%)	3 (15·8%)	1 (14·3%)	12 (63·2%)	5 (45·5%)	18 (72%)	10 (62·5%)	19 (90·5%)	8 (88·9%)	12 (92·3%)	7 (70%)
LAPAROSCOPY	42 (40·8%)	22 (40·7%)	40 (100%)	17 (85%)	0 (0 %)	0 (0 %)	13 (81·3%)	4 (80%)	1 (4·3%)	0 (0 %)	2 (10·0%)	0 (0 %)	2 (15·4%)	1 (14·3%)
ICU	11 (7·7%)	10 (12·3%)	0 (0 %)	0 (0 %)	2 (11·1%)	0 (0 %)	0 (0 %)	1 (9·1%)	3 (12·0%)	3 (18·8%)	0 (0 %)	1 (11·1%)	6 (46·2%)	2 (20%)
AVERAGE ICU STAY (DAYS)	2	9,5	-	-	2	-	-	4	5	5	-	2	2·5	23·5 ***
RE-ADMISSION TO ICU	2 (22·2%)	2 (20%)	-	-	0 (0 %)	0 (0 %)	0 (0 %)	0 (0 %)	0 (0 %)	1 (33·3%)	-	1 (100%)	2 (40%)	0 (0 %)
MEDIAN STAY (DAYS)	3	4	2	4**	4	8	4	5	7	4	2	2	9	7
MORBIDITY (Clavien-Dindo >1)	34 (24·1%)	29 ** (36·2%)	2 (4·8%)	9** (45%)	4 (21%)	1 (14·3%)	3 (15·9%)	2 (20%)	12 (48%)	4 (25%)	4 (19%)	2 (22·2%)	9 (69·7%)	6 (60%)
SURGICAL SITE INFECTION	10 (9·6%)	7 (13·7%)	2 (5·1%)	6** (30%)	0 (0 %)	0 (0 %)	0 (0 %)	0 (0 %)	4 (22·2%)	0 (0 %)	0 (0 %)	1 (14·3%)	4 (33·3%)	0 (0 %)
HOSPIRAL RE-ADMISSION	12 (8·5%)	4 (5·1%)	1 (2·4%)	2 (10%)	4 (21·1%)	0 (0 %)	1 (5·3%)	0 (0 %)	5 (20%)	2 (12·5%)	0 (0 %)	0 (0 %)	0 (0 %)	0 (0 %)
REPEAT SURGICAL INTERVENTION	10 (9·5%)	8 (15·1%)	1 (2·4%)	2 (10%)	1 (33·3%)	0 (0 %)	0 (0 %)	0 (0 %)	4 (22·2%)	1 (10·0%)	0 (0 %)	1 (12·5%)	4 (33·3%)	2 (28·6%)
EXITUS	10 (7·0%)	2 (2·5%)	0 (0 %)	0 (0 %)	1 (5·3%)	0 (0 %)	0 (0 %)	0 (0 %)	5 (20%)	0*(0 %)	1 (4·8%)	1 (11·1%)	3 (23·1%)	1 (10%)

^* p = 0·05

^** p < 0·05

^*** p = 0·001.

The worse results during COVID-19 pandemic were founded in acute appendicitis with an increase in complicated appendicitis (55% vs 23·8%, p = 0·02), hospital stay (4 vs 2 days, p = 0·01) and surgical site infections (30% vs 5·1%, p = 0·01). Interestingly, a 50% reduction in the number of diagnosed cases of appendicitis was observed during pandemic period when compared with the previous year. This could be explained by the fact that these patients have received conservative management by primary care physicians, since no data exists that would cause one to believe that the real incidence of acute appendicitis is lower⁴. During the period of the pandemic some groups have proposed conservative management for this pathology to reduce the need for emergency room visits and operating rooms⁵. This treatment is controversial and should be limited to cases of uncomplicated appendicitis, as a recurrence rate of 16% to 40% per year has been documented.

A decrease in the indication for surgical treatment of cholecystitis was observed. Also, a longer evolution of the disease at home (average of 3 days), before surgical evaluation at the hospital was observed. This determined a more conservative attitude in the management of these patients. When operated, the percentage of the laparoscopic approach remaining at 80%, similarly to the previous year.

In the comparative analysis of the remaining subgroups, it was only noted that in the peritonitis group, the median stay in the ICU was significantly longer in the COVID group (23·5 ± 3·12 days vs 2·5 ± 3·9 days, p = 0·001).

The general analysis of the data suggests that, due to confinement measures and the risk of nosocomial infection in hospital centers, patients have chosen to go to primary care centers, avoiding a visit to the hospital as much as possible when they did not consider it necessary. Thus, pandemic due to SARS-CoV-2 virus has had a negative impact on emergency surgical pathology due to an increase in the days of preoperative evolution and therefore more evolvedforms of these pathologies. This has caused an increase in hospital stays and morbidity, without affecting mortality.

Conflict of Interest

The author declare that there are no conflicts of interest regarding the publication of this paper.