The pandemic caused by the SARS-CoV-2 virus had a significant impact on providing health services the world over and is reflected in pediatric surgery also. The aim of this study was to determine the differences in the prevalence of forms of appendicitis among children during and prior to the pandemic, and to compare the demographic characteristics. A retrospective study which covered a period from September 1, 2018 until September 1, 2021 and all the patients who underwent surgery for acute appendicitis was carried out. Demographic and clinical data were collected and analysed. The study included a total of 267 patients. Prior to the pandemic a total of 160 children underwent surgical treatment, 61.9% boys and 38.1% girls, while during the pandemic a total of 107 underwent surgical treatment, mostly boys 68,2%, and to a lesser extent, girls 31.8%. The average age of the patients was 11.0±3.9 years. Even though there is a difference in the number of children who underwent surgical treatment for perforated appendicitis prior to and during the Covid-19 pandemic, 54:44 or 33.8:41.1%, the difference is not statistically significant. During the pandemic, two patients who tested positive for the SARS-CoV-2 virus received surgical treatment for a perforated appendicitis. The Covid-19 pandemic had an impact on the healthcare system worldwide. In most centers for pediatric surgery, there was an increased incidence of perforated appendicitis without significant deviations in the demographic characteristics, which correlates with the results of this stud

Djerić, Danijela

Janković, Goran

Jovanović, Zorica

Lazarević, Dragana

Lilić, Jelena

Mančić, Danijel

Marjanović, Vesna

Marjanović, Zoran

Zečević, Maja

English

University of Niš: Facta Universitatis (E-Journals) / Универзитет у Нишу

FACTA UNIVERSITATIS Series: Medicine and Biology Vol. 23, No 2, 2021, pp. 31−34 UDC 616.98:578.834: 616.346.2-002-053.2 https://doi.org/10.22190/FUMB211031008Z  © 2021 by University of Niš, Serbia | Creative Commons License: CC BY-NC-ND Original Scientific Article THE IMPACT OF THE COVID-19 PANDEMIC  ON PEDIATRIC APPENDICITIS MANAGEMENT AND OUTCOMES Maja Zečević1, Zoran Marjanović1,2, Goran Janković1, Danijela Djerić1, Zorica Jovanović1,  Vesna Marjanović2,3, Jelena Lilić3, Danijel Mančić4,1, Dragana Lazarević2,5  1Clinic for Pediatric Surgery, University Clinical Center Niš, Niš, Serbia 2Faculty of Medicine, University of Niš, Niš, Serbia 3Clinic for Anaesthesiology and Intensive Therapy, University Clinical Center Niš, Niš, Serbia 4Health Center Zaječar, Zaječar, Serbia 5Clinic of Pediatrics, University Clinical Center Niš, Niš, Serbia Abstract. The pandemic caused by the SARS-CoV-2 virus had a significant impact on providing health services the world over and is reflected in pediatric surgery also. The aim of this study was to determine the differences in the prevalence of forms of appendicitis among children during and prior to the pandemic, and to compare the demographic characteristics. A retrospective study which covered a period from September 1, 2018 until September 1, 2021 and all the patients who underwent surgery for acute appendicitis was carried out. Demographic and clinical data were collected and analysed. The study included a total of 267 patients. Prior to the pandemic a total of 160 children underwent surgical treatment, 61.9% boys and 38.1% girls, while during the pandemic a total of 107 underwent surgical treatment, mostly boys 68,2%, and to a lesser extent, girls 31.8%. The average age of the patients was 11.0±3.9 years. Even though there is a difference in the number of children who underwent surgical treatment for perforated appendicitis prior to and during the Covid-19 pandemic, 54:44 or 33.8:41.1%, the difference is not statistically significant. During the pandemic, two patients who tested positive for the SARS-CoV-2 virus received surgical treatment for a perforated appendicitis. The Covid-19 pandemic had an impact on the healthcare system worldwide. In most centers for pediatric surgery, there was an increased incidence of perforated appendicitis without significant deviations in the demographic characteristics, which correlates with the results of this study. Key words: appendicitis, children, Covid-19 pandemic. Introduction The pandemic caused by the SARS-CoV-2 had a signifi-cant impact on the healthcare provided worldwide and is reflected on all specialized fields, including pediatric sur-gery. The negative effects of the Covid-19 were espe-cially noted on the health systems of low- or middle-level income countries [1]. An analysis of Anglo-Saxon litera-ture provides insight into the trend of growth of compli-cated appendicitis (gangrenous and perforated appendici-tis) during the pandemic caused by the SARS-CoV-2 vi-rus, due to the possible fear of infection. As a result, there may potentially be a delay in diagnosis and an increased rate of complications [2]. However, the literature con-tains contradictory data which indicate that even though the routine in pediatric surgical centers during the pan-demic changed significantly, and that there was a de-crease in the number of admissions, this did not have an impact on the change in the diagnosis and treatment of acute appendicitis among children [3].  The Aim The aim of this study is to determine whether there is a difference in the prevalence of clinical forms of appendi-citis in the pediatric population during the pandemic compared to a control group from an identical period of time prior to the onset of the pandemic on the territory of the Republic of Serbia, and to compare the demographic characteristics of children who underwent appendecto-mies due to acute appendicitis. Materials and Methods  By analysing the medical documents of the Clinic for Pe-diatric Surgery, University Clinical Center Niš, a retro-spective study was conducted which included a three-year period, starting from September 1, 2018 to Septem-ber 1, 2021. The study included all the patients who dur-ing that time underwent surgical treatment at the Clinic for Pediatric Surgery UCC Niš for acute forms of appen-dicitis. The study did not include any incidental appen-dectomies carried out during the surgical treatment of some other acute abdominal condition. The study was performed in accordance with all the recommended guidelines, and the data were first entered into an Excel© table which was solely available to the   Correspondence to: Maja Zecevic Clinic for Pediatric Surgery, University Clinical Center Niš  81 Dr. Zorana Đinđića Blvd, 18000 Niš, Serbia E-mail: maja.zecevicmd@gmail.com Received October 31st, 2021 / Revised December 17th, 2021 /  Accepted December 18th, 2021 32 M. Zečević, Z. Marjanović, G. Janković, et al.  researchers, which ensured that the identity of the pa-tients was kept anonymous. Data referring to age, gender, clinical forms of appendicitis, and place of living were collected. The statistical data analysis was carried out in the program package SPSS 16.0. The hypothesis was tested at the p<0,05 level of significance. A period of 18 months prior to the pandemic caused by the virus on the SARS-CoV-2 territory of Serbia was compared to an identical period of time following the onset of the epi-demic. A comparison of the continued values prior to and during the pandemic caused by the virus SARS-CoV-2 was carried out using the t-test, while the Chi-squared test was used to compare the categorical features between the groups.  Results  The study included a total of 267 patients who underwent surgical treatment for acute appendicitis in the aforemen-tioned period. Prior to the pandemic caused by the SARS-CoV-2 virus, 160 children underwent surgical treatment, of which 61.9% were boys and 38.1% were girls. From the beginning of the pandemic, a smaller number of chil-dren underwent surgical treatment, 107 of them, mostly boys with 68.2%, and to a lesser extent, girls, 31.8%. There is no statistically significant difference in the fre-quency of occurrence of appendicitis in terms of gender (p=0.352). The average age of the studied population is 11.0 ±3.9 yrs. The youngest patient to undergo surgical treatment was one year old, while the oldest was 17. The patients were divided into three age categories: the first one in-cluded children aged from birth to the age of four, the second included children aged from 5 to 10, and the third included children aged 11 to 17. The distribution of the age categories of children who underwent surgical treat-ment is shown in Fig. 1. Most patients treated during the pandemic were aged 11−17 years (64.5%, p=0.001). Children who underwent surgical treatment for acute ap-pendicitis during the pandemic caused by the SARS CoV2 virus are statistically significantly older (p=0.002) than the children who underwent surgery prior to the pan-demic.   Fig. 1 Age categories prior and during the pandemic  Three-quarters of the patients prior to the pandemic caused by the SARS-CoV-2 (75.6%) were from urban environments, followed by patients from rural environ-ments (24.4%). The percentage of children from urban and rural environments who underwent surgical treat-ment during the pandemic is almost identical: 75.7% were children from urban environments, and 24.3% were children from rural areas. The prevalence of patients from Niš in percentages is 21.2% prior to the pandemic and 27.1% during the pandemic, whereby there is no sta-tistical significance (p=0.339). Place of residence was not statistically significantly connected with the number of patients who underwent surgical treatment due to appen-dicitis prior to and during the pandemic (p=0.989). The analysis also included the prevalence of clinical forms of appendicitis which correlate with the patho-histological forms prior and during the pandemic caused by the SARS-CoV-2 virus. The comparative results ex-pressed in percentages for both periods of time are shown in Table 1. Even though there is a difference in the num-ber of children who underwent surgical treatment for a perforated appendicitis prior to and during the pandemic caused by the SARS-CoV-2 virus, 54:44 or 33.8:41.1%, this difference is not statistically significant (p=0.583). The other forms of appendicitis do not differ statistically significantly prior to and during the pandemic caused by the SARS-CoV-2 virus. Table 1 The distribution of forms of acute appendicitis prior to and during the pandemic  Prior to the pandemic Covid-19 During the pandemic Covid-19 Acute appendicitis 4.4% 2.8% Phlegmonous appendicitis 22.5% 22.4% Gangrenous appendicitis 39.4% 33.6% Perforated appendicitis 33.8% 41.1% During the pandemic, two female patients aged 4 to 11 underwent surgical treatment in our facility during the aforementioned period due to a perforated appendicitis, who at the time of the surgical treatment tested positive to the SARS-CoV-2. Both children underwent surgical treatment in an operating room meant solely for the care of patients who tested positive to the SARS-CoV-2, with the implementation of the complete protective equipment required by epidemiologists. Discussion Acute appendicitis is one of the most frequent types of surgical emergencies in the pediatric population [4]. The onset of the pandemic caused by the SARS-Cov-2 virus had a significant impact on the organization of work in the wards of the pediatric surgery departments, where mostly surgical emergencies are treated, including acute appendicitis. In order to reduce the possibility of spread-ing the Covid-19 infection, certain surgical centers also decided on the conservative treatment of acute appendi-The Impact of the Covid-19 Pandemic on Pediatric Appendicitis Management and Outcomes 33 citis in children. Coldvin and associates published their results on the non-surgical treatment of appendicitis with a double parenteral antibiotic therapy (amoxiclav and gentamicin) during hospitalization, and the continued pe-rioral antibiotic therapy during outpatient treatment dur-ing the pandemic caused by the SARS-Cov-2 virus. The aim was to decrease the exposure of the staff in the oper-ating theatre during anaesthesia, considering the possibil-ity that the patient might be Covid positive. The general success of the antibiotic therapy was 72%, 96% in the case of uncomplicated appendicitis, and 40% in the case of complications, whereby there were no patients who tested positive for the virus SARS-Cov-2 [5]. Other cen-ters opted for the non-surgical treatment of appendicitis among children during the pandemic. Kvasnovsky stated that during the peak of the pandemic, in their facility they treated 45.5% of the children non-surgically, even though 78.2% of the children did not meet the previously pub-lished criteria for the non-surgical treatment of acute ap-pendicitis [6]. During the pandemic, acute appendicitis was treated in our facility by relying on the prescribed protective measures against the SARS-CoV-2 virus. An increase in perforated appendicitis of 41.1% was noted, compared to 33.8%, which proved not to be statistically significant. An increase in the incidence of perforated appendicitis among children was noted in other centers worldwide.  Esparaz and associates determined a statistically sig-nificant increase in perforated appendicitis during the pandemic caused by the Covid-19 virus (45.6% vs 26.4%; p <0.001) [7]. Similar reported increases in the incidence of perforated appendicitis were published by Schäfer, where the rate of perforation in 2020 was 27.8%, while during 2018–2019 it was 20.7%. The difference was that among younger patients (≤11.2 yrs) in 2020 the rate of perforated appendicitis was significantly greater, 37.6%, as opposed to 22.2% in 2018/2019. The age struc-ture of the patients that underwent surgical treatment of 11.2 correlates with the average age of our patients, 11,0 ±3,9 yrs [8]. An increased rate of complicated appendici-tis (gangrenous and perforated histopathological forms) of 60.5% during the pandemic, compared to 30.4% dur-ing the same period of time the previous year, but without statistically significant demographic deviations was de-termined by Lee-Archer and associates [9].  The reason for the increased rate of perforated appen-dicitis among children could also be the prolonged dura-tion of the symptoms prior to the first visit to the doctor. Prior to the pandemic, symptoms usually lasted for one day, while during the pandemic it was two days which proved to be statistically significant (p = 0.003) [10]. A multi-centric retrospective study from the USA com-pared the number of visits to the emergency room in 18 federal states of the USA from January to June 2020, and the number of visits from the same period of time for the previous calendar year. It was determined that the num-ber of visits in the pediatric population initially fell by 74% among children under the age of 10 and by 67% among children aged 14–17, in order for that number to decrease to 72% and 50% by the end of the studied period [11]. A significantly smaller number of cases of appendi-citis among children during the same period of time, compared to the same period of time over a span of 4 years was also published by Hassoun and associates [12].  One of the aggravating factors which can affect the correct diagnosis of acute appendicitis among children during this pandemic is also the emergence of a systemic hyperinflammatory syndrome caused by the SARS-CoV-2 virus, known as MIS-C (Multisystem inflammatory syndrome in children). In such cases, gastrointestinal tract is affected in 92% cases, which could imitate the clinical image of inflammatory bowel disease as well as appendicitis. Jackson and associates published a case study of a nine-year-old girl who underwent surgical treatment on the suspicion of acute appendicitis diag-nosed based on the clinical image, radiological findings, and pathohistological findings of the appendix, the clini-cal image of which differed from acute appendicitis in the sense of necrotic lymphadenitis and vasculitis, as well as Covid-19 antibodies which indicated MIS-C [13].  Anderson published two case studies, one of a girl who was diagnosed with perforated appendicitis and MIS-C, and the other of a patient diagnosed, based on the pathohistological review, with MIS-C even though the clinical image corresponded to acute appendicitis [14]. In our facility there were no cases where children diagnosed with MIS-C underwent surgical treatment due to suspi-cion of acute appendicitis. For the duration of the study, two children infected by the Covid-19 virus underwent surgical treatment in our facility for perforated appendicitis. The girls were aged 11 and 4, and the diagnosis was made based on their clin-ical image, laboratory values, plane abdominal radiog-raphies, and abdominal ultrasounds. Acevado and asso-ciates presented 3 cases of acute appendicitis among chil-dren with a concomitant Covid-19 infection. All three children were males, and one boy had perforated appen-dicitis. In two of the cases, an MSCT of the abdomen was also performed for diagnostic purposes [15]. Conclusion  The emergence of the pandemic caused by the SARS-Cov-2 virus had a significant impact on the way healthcare facilities work on a global level, both because of the new challenges in solving typical acute conditions such as appendicitis among children who are routinely tested prior to hospitalization, as well as the new chal-lenges such as diagnosis and surgical treatment of acute appendicitis with a concomitant infection of the Covid-19, and the possibility of misdiagnosis of appendicitis among children with a diagnosis of MIS-C. In most of the centers of pediatric surgery, there is an increased inci-dence of perforated appendicitis without significant de-viations in the demographic characteristics, which corre-lates with the results of this study.  34 M. Zečević, Z. Marjanović, G. Janković, et al.  References1. Bong CL, Brasher C, Chikumba E, McDougall R, Mellin-Olsen J, Enright A The COVID-19 pandemic: efects on low and middle-income countries. Anesth Analg 2020; 131:86−92. 2. Snapiri O, Rosenberg Danziger C, Krause I, et al. Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic. Acta Paediatr 2020; 109(8):1672–1676. 3. La Pergola E, Sgrò A, Rebosio F, et al. Appendicitis in Children in a Large Italian COVID-19 Pandemic Area. Front Pediatr 2020; 8:600320. 4. McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emer Med Clinics North Am 2003; 21(4):909−935. 5. Colvin D, Lawther S. A surge in appendicitis: Management of paediatric appendicitis during the COVID-19 surge in the Royal Belfast Hospital for Sick Children. Ulster Med J 2021; 90(2):86–89. 6. Kvasnovsky C, Shi Y, Rich BS, et al. Limiting hospital resources for acute appendicitis in children: Lessons learned from the U.S. epicenter of the COVID-19 pandemic. J Pediatr Surg 2021; 56(5):900−904.  7. Esparaz JR, Chen MK, Beierle EA, et al. Perforated Appendicitis during a Pandemic: The Downstream Effect of COVID-19 in Children. J Surg Res 2021; 268:263–266. 8. Schäfer FM, Meyer J, Kellnar S, et al. Increased Incidence of Perforated Appendicitis in Children During COVID-19 Pandemic in a Bavarian Multi-Center Study. Front Pediatr 2021; 9:683607. doi:10.3389/fped.2021.683607  9. Lee-Archer P, Blackall S, Campbell H, Boyd D, Patel B, McBride C. Increased incidence of complicated appendicitis during the COVID-19 pandemic. J Paediatr Child Health 2020; 56(8):1313–1314. 10. Gerall CD, DeFazio JR, Kahan AM, et al. Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic. J Pediatr Surg 2021; 56(5):905-910. doi:10.1016/j.jpedsurg.2020.10.008 11. Pines JM, Zocchi MS, Black BS, et al. Characterizing pediatric emergency department visits during the COVID-19 pandemic. Am J Emerg Med 2021; 41:201–204. 12. Hassoun A, Kadenhe-Chiweshe A, Sharma M. New York's COVID-19 shelter-in-place and acute appendicitis inchildren. J Pediatr Surg 2021; 56:635–636. 13. Jackson RJ, Chavarria HD, Hacking SM. A Case of Multisystem Inflammatory Syndrome in Children Mimicking Acute Appendicitis in a COVID-19 Pandemic Area. Cureus 12(9): e10722. DOI 10.7759/cureus.10722 14. Anderson JE, Campbell JA, Durowoju L, et al. COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) presenting as appendicitis with shock. J Pediatr Surg Case Rep 2021; 71:101913. doi:10.1016/j.epsc.2021.101913 15. Acevedo MJ, Steffey D, Dillon JE, Lee JT, Worhunsky DJ. Concurrent COVID-19 infection in children with acute appendicitis: A report of three cases. Radiol Case Rep 2021; 16:2972–2977.   

THE IMPACT OF THE COVID-19 PANDEMIC ON PEDIATRIC APPENDICITIS MANAGEMENT AND OUTCOMES

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THE IMPACT OF THE COVID-19 PANDEMIC ON PEDIATRIC APPENDICITIS MANAGEMENT AND OUTCOMES

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