Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective
Authors: Forssten Maximilian Peter , Kaplan Lewis J. , Tolonen Matti , Martinez-Casas Isidro , Cao Yang , Walsh Thomas N. , Bass Gary Alan , Mohseni Shahin ,   For the ESTES SnapAppy Group, Ahl Hulme Rebecka , Biloslavo Alan , Kurihara Hayato , Pereira Jorge , Pourlotfi Arvid , Ryan Éanna J. , Louri Nayef , Nedham Fatema , Walsh Thomas Noel , Hashem Jamal , Corbally Martin , Farhan Abeer , Al Hamad Hamad , Elhennawy Rawan , AlKooheji Mariam , AlYusuf Manar , Aknouche Wissal , Zeidan Anas A. , Alsaffar Yusuf S. , Lipping Edgar , Talving Peep , Saar Sten , Graumann Katrina , Kibuspuu Liis , Harkov Eduard , Aaltonen Gisele , Sillman Iines S. , Haapanen Sami , Lampela Hanna , Sammalkorpi Henna , Eskola Sofia , Laakso Altti , Back Johan , Kettunen Ulla , Nummi Antti M. , Szwedyc Anika , Nykänen Taina , Rantala Rolle , Mäkäräinen-Uhlbäck Elisa J. , Meriläinen Sanna A. , Huhta Heikki I. , Rintala Jukka M. J. , Laitakari Kirsi E. M. , Lietzen Elina , Salminen Paulina , Rapola Risto K. A. , Zangouri Vahid , Karami Mohammad Y. , Tahmasebi Sedigheh , Akrami Majid , Golchini Alireza , Bahrami Faranak , Johnston Sean M. , Lim Sean T. , Ahonkhai Irele Ifijeh , Eltagani Eltahir , Ryan Odhran K. , O’Driscoll-Collins Ailbhe , O’Neill Aine , Penny Zakiya , Kelly Orlaith , Cullinane Carolyn , Reynolds Ian , Heneghan Helen , Martin Sean , Winter Des , Davey Matthew , Alkhattab Maha , Lowery Aoife J. , Kerin Michael J. , Hogan Aisling M. , Davey Martin S. , Oh Ke En , Kabir Syed Mohammad Umar , Huan Huilun , Aziz Charlotte , Sugrue Michael , Ryan Jessica M. , Connelly Tara M. , Alhazmi Mohammad , Al-Mukhaizeem Youssef , Cooke Fiachra , Neary Peter M. , Hill Arnold D. K. , Boland Michael R. , Lloyd Angus J. , Fallon Frances , Cleere Eoin F. , Toale James , Boland Patrick A. , Devine Michael , Keady Conor , Hunter Sarah , Kevin Barry M , Kelly Michael E. , O’Dowling Aidan T. , Creavin Ben , Kavanagh Dara O. , Neary Paul , Ridgway Paul F. , McCarrick Cathleen A. , Bolger Jarlath , Maguire Barry , Keogh Cian , Chawla Surbhi , Conneely John , McCormack Emilie , Shanahan Ben , Raftery Nicola , Rice Darragh , McInerney Niall , Stakelum Aine , Mares Jan , Tan Jonavan , Hanna Mark , Balasubramanian Ishwarya , Fleming Christina , Barsky Guy , Shaked Gad , Giudici Simone , Ceolin Martina , Mei Simona , Mazzarella Francesca , Zucca Annalisa , Terranova Susanna , de Manzini Nicolo , Visconti Diego , Doria Emanuele , Santarelli Mauro , Scotton Giovanni , Notte Francesca , Bertelli Giacomo , Malpaga Anna , Armatura Giulia , Frena Antonio , Tartaglia Dario , Coccolini Federico , Cremonini Camilla , Cicuttin Enrico , Mazzoni Alessio , Chiarugi Massimo , Azevedo Constança M. , Mendes Filipa D. , Faria Luis Q. , Nazario Carlos , Machado Daniela , Semiao Miguel , Pereira Jorge , Casimiro Carlos , Pinto Jose , Pavão Tiago , Pereira Raquel , Barbosa Bruno , Tenreiro Nadia , Ferreira Catia , Guidi Goncalo , Martins Daniela C. , Leal Clara , Vieira Bruno B. , Castro Luís S. , Faria Aldara , Figueira Alberto , Sousa Mauro , Rodrigues Pedro , Roquette Rodrigo , Ribeiro Ricardo , Cardoso Paulo , Domingues Joana , Manso Maria Isabel , Pereira Rute , Revez Tatiana , Dumbrava Bogdan D. , Turcu Florin , Hutopila Ionut , Banescu Bogdana , Filip Gerald , Copaescu Catalin , Valmorisco Marcos Alba , Martín Isabel Manzano , de Arboleya Rocio Martín García , Seda José Ortega , González Pablo Rodríguez , Toro Jose Antonio Becerra , Lara Enrique Rodríguez , Minchón Jose Antonio González , Segura-Sampedro Juan José , Jerí-McFarlane Sebastián , Gil-Catalán Alejandro , Craus-Miguel Andrea , Fernández-Vega Laura , González-Argenté Xavier , Estaire-Gómez Mercedes , Fernández-Pacheco Borja Camacho , Vitón-Herrero Rebeca , Jimenez-Higuera Elisa , Barbero Alejandro , Valverde José M , Colás-Ruiz Enrique , del Mar Escales-Oliver Maria , Claramonte-Bellmunt Olga , Castro-Suárez Marta , Pagés-Valle Naila , Cifuentes-Ródenas José Andrés , Alvarez Marta Merayo , Campos Jose Luis Michi , González Luis Alejandro García , Aguilera Beatriz Carrasco , Menéndez Jaime Iturbe , Miravalles Jose Luis Rodicio , Haro Carmen Rodríguez , O’Sullivan Sara Núñez , Virosta Mariana García , O’Reilly María Hernández , Balciscueta-Coltell Izaskun , Lorenzo-Perez Javier , Martinez-Alcaide Sonia , Martinez-Ramos Susana , Sebastian-Fuertes Maria , Gomez-Romer Laura , Pelloni Maria M. , Rahy-Martín Aida Cristina , Yepes-Cano Andrés Felipe , Reguera-Rosal Julio , Lopez-Ruiz Jose A. , Marenco Beatriz , Retamar-Gentil Marina , Romero-Vargas Estela , Gil-Olarte Angeles , Landaluce-Olavarria Aitor , Estraviz-Mateos Begoña , De Francisco-Rios Jose-Mario , Sainz-Lete Aitor , Emaldi-Abasolo Ane , Leon-Valarezo Manolo , Moreira Claudia C. Lopes , Perez Aintzane Lizarazu , Gonzalez Araceli Rodriguez , Ponce Iñigo Augusto , Iglesias Ignacio Maria Goena , González-Prado Cristina , Cabriada Guillermo , López Beatriz , Otero Michelle C. , -Plaza Nerea Muñoz , Palomo Alberto , Mendoza-Moreno Fernando , Díez-Alonso Manuel , García-Moreno-Nisa Francisca , Matías-García Belén , Ovejero-Merino Enrique , Quiroga-Valcárcel Ana , Sánchez-Guillén Luis , Oller-Navarro Inmaculada , Soler-Silva Álvaro , Sanchís-López Antonio Francisco , Blanco-Antona Francisco , Muñoz-Bellvis Luis , López-Sánchez Jaime , Garrosa-Muñoz Sonsoles , Barón-Salvador Beatriz , Nieto-Arranz Juan Manuel , Campos-Serra Andrea , Gràcia-Roman Raquel , Muñoz-Campaña Anna , Zerpa-Martin Carla , Torrecilla-Portoles Andrea , Landa Tessa , Muñoz-Cruzado Virginia Durán , Pareja-Ciuró Felipe , Aparicio-Sánchez Daniel , del Pozo Eduardo Perea , Dios-Barbeito Sandra , García-Sánchez Carlos , García-Moriana Antonio Jesús , Turrado-Rodriguez Victor , Termes-Serra Roser , Gonzalez-Atienza Paula , Morales-Sevillano Xavier , Torroella Alba , Ginestà César , Escartín Alfredo , Gomez Ferney , Pinillos Ana , Ortega Jaume , Lopez Guillermo , Gutierrez Eric , Membrilla-Fernandez Estela , Ocho-Segarra Francisco , González-Castillo Ana María , Pelegrina-Manzano Amalia , Guzmán-Ahumada Juan , Sancho-Insenser Juan Jose , García-Jiménez María Lourdes , Castro-Diez Laura , González-Bermúdez Manuel , Torres-Díaz Mónica , Pena Carla Madarro , Rodríguez Angélica Blanco , Trivedi Dhanisha , Reda Souheil , Edvardsson Hans , Strömmer Lovisa , Caragounis Eva-Corina , Sillén Karin , Warfvinge Sofia , Bergstedt Fredrik , Enström Philip , Olsson Harald , Rosemar Anders , Young Nathalie , Popowicz Agnieszka , Lerström Johanna , Jäderbo Johanna , Hammarqvist Folke , Zacharias Hanna , Wikström Maria B. , Hurtsén Anna Stene , Bayadsi Haytham , Jansson Emma , Brunstrom Nils , Malers Ellen B. , Loftås Per I. , Möller Anders , Atanasova Elena , Zwicky Simone N. , Schnüriger Beat , Rutka Olga , Kattakayam Arjun T. , Alam Mushfique , Taylor John V. , Mihailescu Andrei , Karip Eszter T. , Zeb Ehtisham , O’Connor Adam , Pokusevski Goran , Khan Mansoor , Florance Charlotte , Swaminathan Christie , Jaunoo Shameen , Sajid Mohammed , Duffy Caoimhe C. , Rees John , Seamon Mark J. , Martin Niels D. , McCurry Ian J. , Vail Emily A. , Bormann Bradford C. , Cullinane Daniel C. , Sawhney Jaswin S. , Dreifus Jonathan , Sheppard Forest R. , Coimbra Raul , Albini Paul , Edwards Sara 
Published: January 2023

Abstract
Introduction
The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy.

Methods
Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020–May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model.

Results
Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications.

Conclusion
During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.