Acute appendicitis in the COVID-19 era: A complicated situation?

The rise and rapid spread of the COVID-19 virus, and subsequent pandemic can be seen to have impacted the health of millions, both directly through infection and indirectly, via numerous factors that have led to delayed treatment of non-COVID related pathology. As a specific example, Tankel et al. showed a 40.7% decrease in the weekly incidence of acute appendicitis, presenting across several centres in Israel, in the first weeks of onset of the COVID-19 pandemic [1]. While the attention of the world and much of the healthcare sector was focussed on the novel virus, other more familiar pathologies did not wait for us to catch up. Acute appendicitis is a common surgical pathology and the most common intra-abdominal emergency in the world [2]. Despite this, the underlying causative pathology is not always clear, and is frequently misunderstood [3]. Within Western Europe, the prevalence has been more or less stable since the year 2000, at 151 per 100,000 person years [4]. The presentation of acute appendicitis is varied, ranging from subclinical and self-resolving to overwhelming sepsis and death. It is estimated that perforated appendicitis is associated with a 5% mortality rate. This is a figure that is vastly different to the mortality rate associated with “acute but not gangrenous” appendicitis, which is 0.1% [5,6]. Due to this spectrum of severity, it is common practice to divide appendicitis into ‘uncomplicated’ and ‘complicated’ categories. Definitions and methods of grouping vary and are the subject of many years of debate [7]. This is beyond the scope of our paper, and our accepted definitions are ‘uncomplicated’ to include simple, focal or suppurative, and ‘complicated’ to include a gangrenous or perforated appendix and any displaying peritonitis or periappendiceal abscess formation [8]. It is well established that an increased time from symptom onset to operative management increases both the risk of progression of pathology and of complications in the post-operative period [8,9]. Existing literature strongly suggests that delaying appendicectomy is associated with a higher rate of complicated appendicitis, and that this is the progression responsible for the subsequently greater morbidity and mortality reported[[8], [9], [10]]. This study aims to investigate the impact of the COVID-19 pandemic on the nature of pathology found in patients undergoing appendicectomy for acute appendicitis at our centre.