This retrospective clinical study was conducted using data from 90 patients with acute appendicitis during the initial outbreak of COVID-19 in Jiaxing, China from January 27 to March 31, 2020. Informed consent was obtained from all participants. Clinical data regarding acute appendicitis from January 27 to March 31, 2019 were also collected. Our research was approved by the Ethics Committee of The First Hospital of Jiaxing.

The diagnosis of acute appendicitis was mainly based on clinical manifestations, routine blood tests, and ultrasound (US) or computed tomography (CT) scans. Exclusion criteria included: (1) Patients with a history of chronic appendicitis; (2) Incidental findings of appendicitis during other procedures; (3) Surgical contraindications including, acute myocardial infarction, blood coagulation disorders, and cardiopulmonary insufficiency; and (4) Refusal of surgery.

Emergency preoperative management: Emergency evaluation was conducted by trained emergency attendants and included an appendicitis evaluation and COVID-19 screening (Figure 1). Medical history, physical examination, and routine blood tests were also performed.

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Figure 1 Emergency preoperative management. COVID-19: Coronavirus disease 2019; CT: Computed tomography.

We preliminarily divided patients into two groups: Simple (non-perforated) and complex (gangrenous or perforated). All patients were asked to undergo either abdominal CT scan or US imaging. Patients with signs and symptoms of appendicitis along with an US- or CT-indicated perforation were enrolled in the complex group. The preparation time for surgery was less than 60 min. Patients diagnosed with appendicitis without perforation were enrolled in the simple group. These patients were prepared for surgery or prescribed antibiotics based on the progression of the appendicitis and the patient’s choice. Patients who were prescribed antibiotics were closely monitored at the outpatient clinic. Patients were reexamined with routine blood tests and US or CT imaging if symptoms of the chief complaint persisted or worsened. The reevaluation interval time was less than 12 h. The preoperative assessment time was recorded.

COVID-19 screening was performed prior to admission. Epidemiological questions, such as history of exposure to COVID-19 patients or pandemic areas, were also asked. Clinical signs and symptoms of respiratory tract infection such as fever and cough were recorded. We also carefully identified gastrointestinal symptoms of COVID-19 and appendicitis. Body temperature was checked, and chest CT was performed prior to admission. The CT report was reviewed by two trained radiologists. Additionally, an abdominal CT scan was performed if the patient was highly suspected to have perforated appendicitis. If the results of the pre-admission COVID-19 screening were abnormal, we consulted an expert group for COVID-19, which was a newly built professional team during the pandemic for the sample, diagnosis, and treatment of COVID-19 patients. The expert group’s assessment would help us take appropriate measures for further treatment. Other preoperative tests were prepared as done previously. If COVID-19 was excluded, surgery was performed under secondary protection, as was done previously. If COVID-19 could not be excluded, surgery was performed with tertiary protection, without waiting for nucleic acid test results. The patient was temporarily placed in a special surgical ward singly before the nucleic acid test result was available. A nucleic acid test was required before and after surgery. If any of the two results were positive, the patient was admitted to a special negative pressure ward singly for the simultaneous treatment of COVID-19. If the result was negative, the patient was sent to the special surgical ward singly, and the nucleic acid test was repeated on the basis of the status of the illness. The test sample was selected using a nasopharyngeal test paper. The nucleic acid test was conducted using a novel coronavirus nucleic acid detection kit (Hunan Shengxiang Biotechnology Co. LTD, China), and the results were obtained after 6 h.

Intraoperative protective measures: Body temperature and epidemiological history were rechecked by a surgical nurse preoperatively. We opted to perform laparoscopic appendectomy under secondary protection if the COVID-19 screening was normal. Patients with suspected or confirmed COVID-19 were scheduled for surgery in the negative pressure operating room under tertiary protection. Most of the COVID-19 positive or suspected positive patients underwent an open appendectomy. The number of surgical assistants was controlled based on the type of surgery. Visitors were prohibited from entering the operation room.

Postoperative management: Postoperative fever was carefully monitored, and the expert group for COVID-19 was consulted if a suspicious case occurred. If patients could ingest liquids or semi-liquids without abdominal pain or fever, they were discharged with education regarding their stitches 5-7 d after surgery. The length of the hospital stay and cost were recorded.

Postoperative follow-up: All patients were required to attend a follow-up visit 2 wk after surgery. Online consultation via the internet or telephone was encouraged. Additionally, COVID-19 related symptoms were also investigated.

Statistical analysis: Statistical analysis was performed using t-test or Pearson’s chi-square test, and P values < 0.05 was considered statistically significant. The SPSS (version 17.0, Chicago, IL, NY, United States)) software program was used for the calculations. The statistical methods of this study were reviewed by Professor Chen Ling from the Zhejiang University of Finance and Economics.

Emergency preoperative screening was conducted for 90 patients with acute appendicitis during the initial outbreak period of COVID-19 (Table 1). There were 59 men and 31 women, with an average age of 42.9 years and a range of 3-80 years. Of the patients screened, 76 patients were enrolled in the simple group, of whom nine received medication therapy and all others underwent surgery. Of this group, 66 patients were diagnosed with suppurative appendicitis, and one patient presented with perforated appendicitis after surgery. There were 14 patients in the complex group, for which the postoperative diagnosis indicated perforated appendicitis. In total, six patients were identified as unqualified due to fever.

A total of six patients were referred to the COVID-19 expert group, and a total of six appendectomies were conducted under tertiary protection. The results of the nucleic acid test were negative, and there were no COVID-19-positive cases among the acute appendicitis patients. Assessment by the expert group revealed that four cases in simple group and one case in complex group were assessed as having intraperitoneal inflammation. One patient in simple group was considered as amygdalitis. After the surgery, all patients were transferred to a special surgical ward singly for follow-up treatments.

The number of surgeries was reduced in 2020 compared with 2019 (81 vs 121). The total ratio of males was higher than that for 2019 (P < 0.05). The ratio of perforated appendicitis cases was also higher than that for 2019. The proportion of males with perforated appendicitis was higher than that in 2019 (P < 0.05). There was no significant difference in age or regional distribution of patients or pediatric perforated appendicitis ratio between 2019 and 2020 (Table 2).

The chief complaint duration for perforated appendicitis patients in 2020 was longer than that for 2019 (63.0 ± 36.2 h vs 35.6 ± 23.8h, P < 0.05). The routine blood tests showed white blood cell counts (WBC) and neutrophil ratios were higher in perforated appendicitis patients in 2020 than in 2019 (13.5 × 10⁹/L ± 3.9 × 10⁹/L vs 9.8 × 10⁹/L ± 4.8 × 10⁹/L, P < 0.05; 89.3 ± 5.4% vs 83.3 ± 8.3%, P < 0.05). There were no significant differences in chief complaint duration, WBC count, or neutrophil ratio for suppurative appendicitis patients between 2019 and 2020 (22.5 ± 20.6 h vs 19.4 ± 16.8 h, 10.9 × 10⁹/L ± 4.1 × 10⁹/L vs 11.2 × 10⁹/L ± 4.5 × 10⁹/L, 80.2 ± 11.6% vs 80.7 ± 10.7%) (Figures 2-4).

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Figure 2 Chief complaint duration comparison between 2019 and 2020. ^aP < 0.05.

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Figure 3 White blood cell count comparison between 2019 and 2020. ^aP < 0.05. WBC: White blood cell.

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Figure 4 Neutrophil ratio comparison between 2019 and 2020. ^aP < 0.05.

The emergency preoperative assessment time was longer in 2020 than in 2019 (53.9 ± 8.8 min vs 37.0 ± 8.5 min, P < 0.05) (Figure 5).

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Figure 5 Comparison of emergency pre-operation assessment time between 2019 and 2020. ^aP < 0.05.

It was found that the ratio of open appendectomies and the amount of mean blood loss during surgery was greater in 2020 than in 2019 (12/69 vs 7/114, 14.9 ± 13.0 mL vs 11.5 ± 6.6 mL, P < 0.05). There were no significant differences in operating time and short-term complications between 2019 and 2020 (Table 3).

There were no significant differences in hospital stay duration and cost between 2019 and 2020 (Table 4).

Figure 6 (A1, A2, A3) was selected from a 20-year-old male with chief complaint of abdominal pain for 4 h in February 2020. He was assigned to simple group, and postoperative diagnosis was suppurative appendicitis. Figure 6 (B1, B2, B3) was selected from a 38-year-old male with chief complaint of abdominal pain for 72 h in March 2020. He was assigned to complex group and postoperative diagnosis was perforated appendicitis.

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Figure 6 Clinical images from simple group and complex group. A: Simple group; B: Complex group. Operative photo: A1: Thickened appendix (black arrow) with slightly swollen mesentery; B1: Thickened and congestive appendix (black arrow) with exudation. The distal end of appendix is necrosis with purplish black color. Abdominal computed tomography scan: A2: Slightly thickened appendix (orange arrow) with exudation; B2: Appendix is remarkably thickened and the boundary is obscure. Pathological section (× 40): A3: Structure of appendix remains. The whole layer of appendix indicates obvious infiltration of neutrophils; B3: Structure of appendix disappears. The whole layer of appendix shows hemorrhage and necrosis with infiltration of neutrophils.

A total of 90 patients were followed-up after discharge, of which 31 (34.4%) came to the hospital for reexamination or stitch removal 2 wk after surgery. The remaining 59 patients (65.6%) opted for an online consultation.

There were three cases with short-term complications. There was one case of surgical incision infection, one case of intraperitoneal infection, and one case of venous thrombosis of the lower limbs. All three patients recovered after a timely treatment. There were no long-term complications in these cases. No COVID-19 infection occurred.

At present, coronavirus disease 19 (COVID-19) has profoundly influenced our routine surgical activities. How to handle acute appendicitis emergencies during this and future pandemics is emerging as an urgent issue.

There have been rare reports about acute appendicitis emergencies during COVID-19 pandemics. Our experience will help other surgeons or physicians choose ideal treatments for other emergencies or delays.

To assess the efficacy of the management of acute appendicitis during the COVID-19 pandemic.

We retrospectively analyzed the clinical data of acute appendicitis patients admitted to The First Hospital of Jiaxing during the initial outbreak of COVID-19. Clinical data were also collected for the corresponding time frame from 2019. Preoperative management, intraoperative protective measures, and postoperative management data were conducted.

After screening, six patients were identified as unqualified due to fever, and their results of nucleic acid test were negative. Seventy-six patients were enrolled in the simple group, and 14 patients were enrolled in the complex group. The proportion of men with perforated appendicitis was higher in 2020 than that in 2019. The chief complaint duration for perforated appendicitis patients in 2020 was longer than that in 2019. The routine blood test showed white blood cell counts and neutrophil ratios were higher in perforated appendicitis patients in 2020 than in 2019. The ratio of open appendectomies to the amount of mean blood loss during surgery was greater in 2020 than in 2019. Online consultation after discharge was selected in 59 cases. No perioperative infection with COVID-19 or long-term postoperative complications were found.

The management of acute appendicitis from Jiaxing effectively reduced the influence of the pandemic and minimized the risk of nosocomial infection.

The delay in care and challenges we all are facing are not only in emergency surgeries but also in other health care specialties. We should make our clinical management compatible with the challenges and threats of this pandemic while trying to achieve the optimal therapeutic effect.