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ORIGINAL ARTICLE
Year : 2022 | Volume
: 55
| Issue : 4 | Page : 134-139
Outcomes of laparoscopic appendectomy during the level 3 alert of the coronavirus disease 2019 pandemic in Taiwan: Experience in a referral center
Hui-Ju Tsou1, Shou-Sen Huang2, Chung-Hsin Tsai1, Shih-Ping Cheng1, Tun-Pang Chu1
1 Division of General Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
2 Division of General Surgery, Department of Surgery, Taitung Mackay Memorial Hospital, Taitung, Taiwan
Correspondence Address:
Shou-Sen Huang
No. 92, Section 2, Zhongshan North Road, Taipei City 10449
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/fjs.fjs_90_22
Background: Emerging studies have reported an increased proportion of complicated cases of acute appendicitis and increased prehospital delay during the coronavirus disease 2019 (COVID-19) pandemic. We wondered whether there was a difference in the perioperative outcomes of laparoscopic appendectomy during the 69-day level 3 alert in our community.
Materials and Methods: Adult patients who underwent laparoscopic appendectomy for acute appendicitis between May 19 and July 26, during the years of 2019, 2020, and 2021 at our institution, were included. Patient demographics, clinical presentation, interval from emergency department (ED) arrival to operation, operation duration, hospital stay, and postoperative complications were analyzed using SPSS Statistics. The Kruskal–Wallis and Pearson Chi-square tests were used for the analysis of numerical and nominal variables, respectively.
Results: A total of 94, 102, and 63 cases were included during the corresponding periods in 2019, 2020, and 2021, respectively. Patient age, sex, symptom duration at presentation, percentage of leukocytosis, bacteremia, complicated appendicitis, and white blood cell count showed no group differences. The interval between ED arrival and surgery was not significantly different (P = 0.753). There were no significant differences in the operation duration (P = 0.094), estimated blood loss (P = 0.273), or proportion of drain insertion (P = 0.626). The length of hospital stay (P = 0.681), incidence of postoperative complications (P = 0.894), and postoperative complications according to the Clavien–Dindo classification (P = 0.241) were not significantly different among the groups.
Conclusion: Adult patients undergoing laparoscopic appendectomy at our institution during the level 3 alert of the COVID-19 pandemic had no statistically significant differences in perioperative outcomes, including operation time, estimated blood loss, hospital stay, and complication rates.
Keywords: Coronavirus disease 2019 pandemic, laparoscopic appendectomy, level 3 alert
The coronavirus disease 2019 (COVID-19) pandemic has affected the world since the beginning of 2020. Medical authorities have made efforts to build a strong defense against this seemingly irresistible threat. The Taiwan Centers for Disease Control and Prevention (CDC) has maintained vigilance since its emergence. Fortunately, preventive measures taken from different perspectives have successfully blocked the spread of this virus. Nevertheless, waves of outbreaks worldwide eventually swept over Taiwan. In response to the surge in confirmed cases in May 2020, the Taiwan CDC declared a level 3 alert to reduce the spread of the disease and optimize medical capacities. Our institution has corresponding policies, including comprehensive inhospital and preoperative screening, postponement of elective surgery, and appropriate personal protective equipment.
The treatment of acute appendicitis, one of the most common causes of acute abdomen, would probably not be affected by the abovementioned policies, as long as a preoperative screening is performed. In our institution, once acute appendicitis is diagnosed in our emergency department (ED), a general surgeon is consulted. Emergency surgery is usually recommended in such cases; however, we observed an unexpected decrease in the number of laparoscopic appendectomy cases. We wondered whether these cases had a more severe presentation and whether there would be more perioperative complications.
Materials and MethodsWe retrospectively reviewed cases of patients undergoing laparoscopic appendectomy for acute appendicitis at our institution during the level 3 alert in 2021 (May 19 to July 27) and the corresponding periods in 2019 and 2020. Adult patients (aged ≥18 years) diagnosed with acute appendicitis and referred for emergent surgical intervention were included. Patients who underwent diagnostic laparoscopy without appendectomy and those whose pathology reported a diagnosis other than acute appendicitis were excluded.
Relevant factors were also collected. From a clinical perspective, patient age and sex, medical attention from symptom onset, serum white blood cell (WBC) count, presence of leukocytosis or bandemia, bacteremia, or complicated appendicitis were recorded. Complicated acute appendicitis was defined as necrosis, abscess, or perforation by the grading system proposed by Gomes et al.[1] From the medical end, the time to computed tomography (CT) diagnosis from ED arrival, whether a polymerase chain reaction (PCR) test for COVID-19 was performed and its test time, and the time from ED arrival to the operating room (OR) were calculated. The primary outcome was the postoperative complication rate. We further graded surgical complications using the Clavien–Dindo classification.[2] Other perioperative outcomes, including operation time, estimated blood loss, drain insertion, and length of hospital stay, were retrieved.
This study was approved by our institutional review board (IRB) (approval number: 22MMHIS022e). The retrospective nature of the data analysis obviated the need for informed consent according to the IRB regulations.
We used SPSS® (IBM SPSS Statistics for Macintosh, version 25.0, released in 2017; Armonk, IBM Corp, NY, USA) for statistical analysis.
Numerical and categorical variables were analyzed using the Kruskal–Wallis and Pearson Chi-square tests, respectively. The results were expressed as median and interquartile range for numerical variables and as number and percentage (%) for categorical variables. Binary logistic regression was used to analyze potential risk factors. P < 0.05 was considered statistically significant.
ResultsA total of 101, 110, and 69 patients underwent laparoscopic appendectomy at our institution during the 69-day period in 2019, 2020, and 2021, respectively. After excluding elective operations and diagnoses other than acute appendicitis, 94, 102, and 63 cases remained [Figure 1].
Patient demographics, including age and sex, were not significantly different among the three groups. Other patient characteristics, including symptom onset, WBC count, percentage of leukocytosis or bandemia, bacteremia, and complicated appendicitis, did not show significant differences [Table 1].
From the medical end, the time from ED arrival to CT diagnosis increased, with statistical significance (P = 0.001). The percentage of COVID-19 PCR tests performed has increased from 18.6% in 2020 to 96.8% in 2021. The COVID-19 PCR test time was substantially shortened, with a median of 11 h to 1.4 h. However, the time from ED arrival to OR arrival was not significantly delayed (P = 0.753) [Table 2].
Perioperative outcomes, including surgery time, estimated blood loss, percentage of drain placement, and length of hospital stay, were not significantly different [Table 3]. Overall postoperative complication rates were similar (P = 0.894). Complications graded according to the Clavien–Dindo classification were not significantly different among the three groups (P = 0.241) [Table 4]. The percentage of wound-related complications, the most common complication [Figure 2], did not differ significantly. The two Grade 3 complication cases had retroperitoneal abscess formation and underwent CT-guided drainage. There was one mortality, a 96-year-old man diagnosed with perforated appendicitis with cecal necrosis. We performed a laparoscopic appendectomy and right hemicolectomy. The patient experienced massive gastric ulcer bleeding and died on postoperative day 25.
Figure 2: Categories and proportion of postoperative complications. AUR: Acute urinary retention; ABD pain: Abdominal painWe analyzed the potential risk factors for the occurrence of postoperative complications using binary logistic regression and found that the presentation of complicated appendicitis was still significant in multivariate analysis [Table 5]. Operation time, drain placement, and wound classification were excluded from multivariate analysis due to multicollinearity. Similarly, complicated appendicitis was a significant risk factor for Grade ≥2 complications [Table 6]. Drain placement was excluded from the multivariate analysis due to collinearity.
We attempted to interpret the factors related to this multicollinearity. In addition to patient age, symptom onset, and presence of bacteremia, drain placement and wound classification were the two factors that were also significantly related to the presentation of complicated appendicitis [Table 7]. That is, the presence or absence of complicated appendicitis greatly influenced the decision of drain placement and choice of wound classification.
DiscussionWe performed more than 400 laparoscopic appendectomies per year at our institution. There was no obvious monthly preference in the case distribution, but we found a slight decrease in the number of cases after the announcement of the level 3 alert in Taiwan. Collateral damage caused by the COVID-19 pandemic[3] may have just begun on this island. We chose the corresponding period in each individual year to minimize potential seasonal differences in appendicitis incidence. The virus first emerged in December 2019 and had an increasing impact thereafter. The period in 2019 was considered a non-COVID era, whereas the period in 2020 was a level 1 alert, and the period in 2021 advanced to a level 3 alert.
Emerging studies have reported an increasing incidence of complicated cases[4] during the COVID-19 pandemic, probably because of delayed presentation.[5] From our analysis, the symptom onset to medical attention was not significantly delayed, and the proportion of complicated cases did not significantly increase. This may be attributed to medical accessibility and the reduced impact of the pandemic on Taiwan, such that we could have enough medical capacity for non-COVID-19 conditions.
CT has become an increasingly essential tool for assisting the diagnosis of acute appendicitis. Owing to its promptness and accuracy, it has been widely used in the ED for the differential diagnosis of acute abdominal pain. In countries heavily affected by COVID-19, the proportion of acute appendicitis diagnosed using abdominal CT has increased.[6],[7] Considering the collateral damage with limited medical resources, surgeons preferred a more conservative management,[8] and hence relied more on image supporting diagnosis. However, we observed a slight increase in the time of CT diagnosis from ED arrival (P = 0.001). In 2020, our ED has initiated a COVID-19 screening policy for high-risk patients. Only 18.6% of the patients who later underwent surgery were swabbed for COVID-19 testing. In 2021, considering the outbreak of the COVID-19 pandemic, the ED took a more vigilant attitude, and swabbed nearly every patient, and waited for at least a negative screening result even before a CT examination, which might explain the delay in CT diagnosis. Nevertheless, the PCR test time was substantially shortened owing to the use of more sophisticated technology. A negative COVID-19 PCR test result was required before the surgery. Fortunately, we did not wait longer to send our patient to the OR.
Despite delayed presentation and more complicated cases in the COVID-19 pandemic countries, the rate of postoperative complications and length of stay were not significantly different.[5],[9] In our study, perioperative outcomes, including operation time, estimated blood loss, length of hospital stay, and postoperative complication rates, were similar to those in previous years. This is reasonable because our patients did not have a significant delay in presentation, and the proportion of complicated cases did not significantly increase.
Comorbidities and complicated appendicitis were confirmed as independent predictors of mortality.[10] In multivariate analysis, we found that the presentation of complicated appendicitis remained a significant risk factor for the occurrence of postoperative complications (odds ratio [OR], 2.685; 95% confidence interval [CI]: 1.300–5.543) and Grade ≥2 complications (OR, 2.979; 95% CI: 1.170–7.585).
The average overall complication rate was 20.8% and the wound-related complication rate was 7.3% in these 3-year groups. The most common complication following appendectomy is surgical site infection,[11] which typically occurs in perforated cases. We found that the most relevant factor between complicated appendicitis and wound complications was wound classification (P < 0.001; OR, 2.277). Wound complications did not directly have a significant relationship with wound classification or complicated appendicitis. On the one hand, complicated appendicitis included not only perforated cases; on the other hand, not only wound infection but also wound dehiscence and other wound complications were also included in wound complication.
This study had several limitations. First, in this single-center analysis, we could not determine whether the actual proportion of patients with acute appendicitis who presented to our ED remained similar. Second, the retrospective nature of the data collection, medication use, comorbidities, COVID-19 vaccination status, and other factors that may influence prognosis were not recorded. Third, children were not included in our analysis. Finally, those diagnosed with acute appendicitis but later chose conservative management deserved further analysis.
ConclusionThe perioperative outcomes of laparoscopic appendectomy, including the operation time, length of hospital stay, and complication rates, were not significantly different at our institution during the level 3 alert of the COVID-19 pandemic.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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