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.
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Introduction
Acute appendicitis is one of the most frequent surgical emergencies, and its management is one of the most commonly-performed emergency general surgery procedures [1,2,3,4]. While predominantly affecting younger patients [5], appendicitis may occur at any age and exhibits substantial variation in symptoms and severity [1, 6]. Similarly, the etiologies of appendicitis span lymphoid proliferation to appendicolith-associated obstruction and suppuration, to malignant obstruction. Accordingly, a wide range of clinical management approaches are utilized and reflect, in part, clinical equipoise regarding a single optimal management strategy [7].
The initial wave of the SARS-CoV-2 (COVID-19) pandemic raised concerns regarding transmission of infection to operating team members during aerosol generating procedures such as airway control, tracheostomy, endoscopy, or laparoscopy. Concomitantly, safety concerns also surfaced during the COVIDSurg study during the initial phase of the pandemic regarding the advisability of undertaking operative management for patients acutely infected with SARS-CoV-2 [8]. Therefore, acute care surgeons pivoted from established practice patterns to pursue either delayed operative management or, for certain conditions such as appendicitis, non-operative management [10,11,12]. Importantly, the initial recommendations to pursue non-operative and antibiotic-driven care for those with appendicitis were articulated ahead of an evidence-base documenting enhanced safety. Furthermore, such recommendations may have been predicated upon the anticipation of a short time course for SARS-CoV-2 infection—an assumption that has been well disproved by virus variant evolution and multiple subsequent waves of infection. At the same time, knowledge and experience in caring for patients with SARS-CoV-2 infections improved and global vaccination programs were enacted. Therefore, it is worthwhile examining whether appendicitis patients who underwent appendectomy during later pandemic waves and who were actively infected with SARS-CoV-2, or had been previously infected with SARS-CoV-2, demonstrated prolonged hospitalization related to complications, compared to patients without SARS-CoV-2 infection.
Methods
This multi-center cohort study adhered to the standardized methodology for snapshot audits [9]. All centers received exemption from informed consent approval from the relevant institutional review board or equivalent as an observational study. All data were anonymized for entry into a secure user-encrypted server running on the Smart-Trial® web application [9]. This study was also conducted in accordance with the Declaration of Helsinki as well as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [10].
Any site treating emergency general surgery patients was eligible to participate in data collection. No minimum case volume, or center-specific limitations were applied. Data collection was conducted according to a predefined protocol registered with ClinicalTrials.gov (Trial # NCT04365491). The protocol and an invitation to participate was shared by email with registered members of the European Society of Trauma and Emergency Surgery and through national surgical societies. The study enrolled all consecutive patients aged 15 years or older admitted with acute appendicitis during a 3-month window (November 1, 2020–May 28, 2021); enrolled patients were followed for 90 days postoperatively. Data collected included age, sex, American Society of Anesthesiologists (ASA) classification, a history of previous abdominal surgery, ischemic heart disease, insulin-dependent diabetes, congestive heart failure, chronic kidney disease, current smoking status, immunosuppression, the American Association for the Surgery of Trauma (AAST) appendicitis grade, time to surgery from admission, laparoscopic surgery, conversion to open surgery, open surgery, admission white blood cell count and neutrophil percent, admission C-reactive protein concentration, as well as the country where the surgery was performed (Table 1). SARS-CoV-2 seropositivity was determined with a screening PCR or antigen test on admission, based on institutional protocols. The database was closed for analysis on August 31, 2021.
Patients were grouped according to SARS-CoV-2 seropositivity into three sets: uninfected, actively infected, previously infected and recovered; patients whose seropositivity status were unknown or unreported were excluded. Only patients admitted with appendicitis who also underwent appendectomy (laparoscopic or open)—as opposed to non-operative management—formed the dataset explored in this study. Patient demographics, type of operation, hospital length of stay (LOS), as well as complication occurrence, were abstracted from the database for analysis parsed by SARS-CoV-2 seropositivity.
Statistical analysis
Patient data within each group were summarized as means and standard deviations (SDs) for continuous normally distributed variables, medians, and interquartile ranges (IQRs) for continuous non-normally distributed variables, as well as counts and percentages for categorical variables. An analysis of variance (ANOVA) or a Kruskal-Wallis test was used to assess for differences in continuous variables. A Chi-square test or Fisher’s exact test was used for categorical variables. The primary outcome of interest was any postoperative complication within 30 days, while secondary outcomes of interest were severe complications (Clavien–Dindo classification > 3a) within 30 days and LOS.
The association between a patient’s SARS-CoV-2 seropositivity and complications was analyzed using Poisson regression models with robust standard errors to account for heteroscedasticity [11]. Any complication or severe complications was the dependent variable, while the predictors were the patient’s SARS-CoV-2 seropositivity along with potential confounding variables (Table 2). Results are presented as incident rate ratios (IRRs) and 95% confidence intervals (CIs). The relationship between a patient’s SARS-CoV-2 seropositivity and LOS was explored using a quantile regression model, using LOS as the dependent variable, while SARS-CoV-2 seropositivity and potential confounding variables were included as explanatory variables (Table 3). Results are presented as the change in median LOS along with 95% CIs.
A two-tailed p value < 0.05 was considered statistically significant in all analyses. Missing data were managed using multiple imputation by chained equations. Logistic regression models were used for binary variables, and Bayesian polytomous regression was used for nominal variables. Proportional odds models were used for ordinal variables. Analyses were performed using statistical software R (R Foundation for Statistical Computing, Vienna, Austria) with the tidyverse, mice, lubridate, readxl, writexl, robustbase, and quantreg packages [12].
Results
Four thousand forty seven consecutive patients from 71 centers in 14 countries were included in the dataset; these countries included Bahrain, Estonia, Finland, Iran, Ireland, Israel, Italy, Portugal, Romania, Spain, Sweden, Switzerland, the UK, and the USA [13]. 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. Patients with an active SARS-CoV-2 infection were younger compared to patients with and without prior infection [median (IQR) 30 (21–43) years vs 37 (28–48) years in those with a history of prior infection and 35 (25–51) years in those never infected, p = 0.019]. There were no statistically significant between-cohort differences in body mass index, ASA classification, comorbidities, smoking history, or admission laboratory data. However, the proportion of patients with a respiratory rate above 20 was significantly higher among patients with active and previous SARS-CoV-2 infections compared to patients who had never had SARS-CoV-2 (5.7% and 7.8% vs 2.9%, respectively, p = 0.004) (Table 1).
The prevalence of perforation and the time to surgery from admission were similar across groups. Patients with active and prior SARS-CoV-2 infections were significantly more likely to undergo an open surgical procedure (24.3% and 26.7% vs 9.6%, respectively, p < 0.001). Relatedly, procedure duration and the crude rate of any or severe complications were also similar across groups. Patients with active SARS-CoV-2 infection demonstrated a longer crude LOS compared to patients without prior SARS-CoV-2 infection (2.7 days vs 1.9 days, p = 0.002) (Table 1). No associations between SARS-CoV-2 seropositivity and LOS, any complication, or severe complication were identified after adjusting for confounders in the regression analyses (Tables 2 and 3).
Discussion
The treatment of patients with acute surgical emergencies in the context of the COVID-19 pandemic has been challenging throughout different phases of the pandemic—from early knowledge gaps and resource-exhaustion, through concern for excess postoperative morbidity and potential aerosolization of viral particles through laparoscopy, to cancellation of elective surgery and deviation from usual practice patterns, the introduction of population vaccination, and most recently, phased reintroduction of scheduled surgical services [14,15,16].
The ‘evidence-to-practice gap’ between guideline-based recommendations and widespread adoption and implementation is well chronicled in the surgical literature and a burgeoning focus of implementation science [17]. Under usual conditions, there are several known barriers to recommendation implementation, including care inertia, lack of knowledge of new recommendations, resource limitation, as well as disagreement with guideline recommendations [17, 18]. In stark comparison, the recent SARS-CoV-2 global pandemic engendered rapid creation, adoption and implementation of recommendations ahead of mature large-data evidence [19]. Concerns regarding staff safety as well as untoward patient outcomes following operative procedures performed during active SARS-CoV-2 infection shuttered elective and semi-elective procedures [20,21,22]. Multiple medical professional organizations, including the European Society for Trauma and Emergency Surgery (ESTES), rapidly crafted guidelines and statement. These supported delaying operative therapy, and prioritizing non-operative approaches, during acute SARS-CoV-2 infection as well as recommending the avoidance of laparoscopic interventions due to the potential risk of the uncontrolled release of pressurized gas, which could result in the infection of surgical staff [23,24,25,26]. Accordingly, urgent procedures, including appendectomy for acute appendicitis, were diverted along a non-operative pathway. As a result, the recommendation for non-operative appendicitis management was readily embraced by surgeons who would previously have pursued routine operative management [27]. Only emergency operations such as those for injury, or life-saving organ transplantation, were undertaken during the early phase of the pandemic. There was a clear need for data to inform practice.
Multinational collaborations rapidly arose to assess outcomes of different therapeutics for those with acute SARS-CoV-2 infection. Some early therapies, such as glucocorticoid administration, remdesivir, monoclonal antibody rescue, and prone position therapy were found to be beneficial when large datasets were interrogated [28, 29]. Other practices driven by early observations, such as routine therapeutic anticoagulation or early invasive mechanical ventilation, have been intensively investigated, determined to be lacking an evidence base, and abandoned as part of routine care [30,31,32]. Our data aligned with the latter studies in that we identified no untoward consequences for those with active SARS-CoV-2 infection who underwent appendectomy with active infection compared to those without infection, as well as those who recovered from a prior infection [33]. Since those who undergo appendectomy regularly demonstrate excellent outcomes, any deleterious impact of active SARS-CoV-2 infection is anticipated to be readily recognizable, even in a small cohort. It was also apparent that the recommendations regarding operative technique had an effect, given that the proportion of patients who underwent an open surgery, among those that had an active or prior SARS-CoV-2 infection, was nearly triple the proportion observed in uninfected patients.
The outcomes from this study span 90 days, a sufficient time frame to capture delayed events including hospital readmission for operative domain or pulmonary system failures; these adverse events were not observed. Importantly, our data are different from observations made early in the pandemic. One reason for such differences may be viral evolution, a process that has been repeatedly observed with different variants with some demonstrating enhanced infectivity but less virulence, and vice versa [34, 35]. Other explanations include changes in the vulnerable patient population and enhanced acute care paradigms—a key aspect as our data were collected during the European second and sometimes third wave (delta variant dominant periods). It is also possible that patient selection informed which patients were deemed suitable for operation, potentially selecting a less physiologically encumbered group. While that is possible, we did not observe differences between groups with regard to ASA score or overall comorbidity burden. It is also possible that intra-operative pulmonary management shifted to routinely utilizing PEEP in the wake of additional understanding of acute SARS-CoV-2 infection. Such an approach may have reduced atelectasis and supported pulmonary flow particularly during abdominal insufflation and may have contributed to the observed lung-related outcomes. This is a supposition that is plausible, and one that is not investigable from the current database—a shortcoming of using a database with pre-specified fields as is typical for snapshot audits and other prospective analyses [9].
Our prospective time-bound multi-center observational cohort study allowed for a comprehensive defined dataset to be gathered in line with pre-publication, open-access protocols filed with clinical trial repositories. Based on the pre-specified data fields, we did not capture all comorbidities, nor how patients were selected for non-operative versus operative management. Moreover, our data is limited to those with acute appendicitis and may not be applicable to those who required longer or more complex operative procedures, nor those who may require postoperative invasive mechanical ventilation. Similarly, we did not capture SARS-CoV-2 related therapy such as steroids, remdesivir, or the use of non-invasive ventilation or prone position therapy. Relatedly, we did not capture whether patients were ill from their SARS-CoV-2 infection, or asymptomatically infected as existing recommendations addressed such infection in a binary fashion. We were instead interested in assessing outcome across multiple centers for those who underwent operation regardless of how their acute SARS-CoV-2 infection was managed. Indeed, current management leverages some different than what was used during our study period. Additionally, our results present the median effects observed in the study population. We can therefore not eliminate the risk that a particular subgroup, for example frail or elderly patients, might exhibit an increased risk when undergoing surgical management for acute appendicitis with a concomitant SARS-CoV-2 infection. Nevertheless, owing to the age distribution of appendicitis patients, this cohort is relatively small with only 3.5% of patients in this sample being older than 75 and none of them having an active SARS-CoV-2 infection on admission [5]. Furthermore, the usual caveats applicable to observational studies also apply, such as the risk of residual confounding, selection bias, and limitations on causal inference.
Conclusions
The current study failed to detect any association between SARS-CoV-2 infection status and post-appendectomy complications or hospital length of stay. This provides evidence that the most common management approach for acute appendicitis—appendectomy—may be safely performed in patients who present with acute or recently recovered SARS-CoV-2 infection.
Data availability
All data and codes are available for retrieval on reasonable request.
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Acknowledgements
SnapAppy Steering Committee: Gary Alan Bass1,2,3,4, Shahin Mohseni2, Lewis J. Kaplan1,13, Rebecka Ahl Hulme10, Alan Biloslavo7, Yang Cao12, Maximilian Peter Forssten2, Hayato Kurihara11, Isidro Martinez-Casas6, Jorge Pereira8, Arvid Pourlotfi2, Éanna J. Ryan2,5, Matti Tolonen9.
Steering Committee and Manuscript Writing Group Author Affiliations: 1Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; 2Division of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden; 3Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA; 4Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; 5Tallaght University Hospital, Dublin, Ireland; 6Servicio de Cirugía General, Unidad de Cirugía de Urgencias. Hospital Universitario Virgen del Rocío, Sevilla Spain; 7Department of General Surgery, Trieste University Hospital, Trieste, Italy; 8Centro Hospitalar Tondela, Viseu, Portugal; 9Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland; 10Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; 11Humanitas Clinical and Research Center, IRCCS, Milano, Italy; 12Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Sweden; 13Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
Bahrain: Bahrain Defence Force-Royal Medical Services: Nayef Louri (ORCID 0000-0001-9280-875X); Fatema Nedham (ORCID 0000-0002-5511-684X); Thomas Noel Walsh (ORCID 0000-0002-1600-8029); Jamal Hashem (ORCID 0000-0003-1544-8177). King Hamad University Hospital Martin Corbally (ORCID 0000-0003-2599-6134); Abeer Farhan (ORCID 0000-0002-5121-6528); Hamad Al Hamad (ORCID 0000-0003-0568-3982); Rawan Elhennawy (ORCID 0000-0001-7076-6886). Salmaniya Medical Complex: Mariam AlKooheji (ORCID 0000-0002-3125-7939); Manar AlYusuf (ORCID 0000-0002-7206-8448); Wissal Aknouche (ORCID 0000-0001-9479-112X); Anas A. Zeidan (ORCID 0000-0002-9560-8187); Yusuf S. Alsaffar (ORCID 0000-0001-7492-4773). Estonia: North Estonia Medical Center: Edgar Lipping (ORCID 0000-0002-9593-5460); Peep Talving (ORCID 0000-0002-9741-2073); Sten Saar (ORCID 0000-0002-8958-5169); Katrina Graumann (ORCID 0000-0003-1429-4874); Liis Kibuspuu (ORCID 0000-0001-7321-3953); Eduard Harkov (ORCID 0000-0003-1194-2864). Finland: HUS Meilahden Tornisairaala: Gisele Aaltonen (ORCID 0000-0002-8265-6681); Iines S. Sillman (ORCID 0000-0001-7779-0432); Sami Haapanen (ORCID 0000-0001-8983-6733). HUS Jorvin Sairaala: Hanna Lampela (ORCID 0000-0001-9619-1099); Henna Sammalkorpi (ORCID 0000-0001-8848-9346); Sofia Eskola (ORCID 0000-0001-8092-4550); Altti Laakso (ORCID 0000-0003-0417-9274). Hyvinkää Hospital Area: Johan Back (ORCID 0000-0002-9646-1914); Ulla Kettunen (ORCID 0000-0002-4107-8627); Antti M. Nummi (ORCID 0000-0002-4461-3373); Anika Szwedyc (ORCID 0000-0002-4399-1639); Taina Nykänen (ORCID 0000-0003-3160-2816); Rolle Rantala (ORCID 0000-0002-7689-1685). Oulun Yliopistollinen Sairaala: Elisa J. Mäkäräinen-Uhlbäck (ORCID 0000-0003-4408-2514); Sanna A. Meriläinen (ORCID 0000-0002-0789-9042); Heikki I. Huhta (ORCID 0000-0002-6273-198X); Jukka M. J. Rintala (ORCID 0000-0003-1865-8444); Kirsi E. M. Laitakari (ORCID 0000-0001-7837-7025). Turku University Hospital: Elina Lietzen (ORCID 0000-0002-7514-7176); Paulina Salminen (ORCID 0000-0001-6435-9264); Risto K. A. Rapola (ORCID 0000-0002-0204-7027). Iran: Namazi Hospital, Shiraz University of Medical Sciences: Vahid Zangouri; Mohammad Y. Karami; Sedigheh Tahmasebi; Majid Akrami; Alireza Golchini; Faranak Bahrami. Ireland: Tullamore General Hospital: Sean M. Johnston (ORCID 0000-0001-9445-9645); Sean T. Lim (ORCID 0000-0002-8448-7121); Irele Ifijeh Ahonkhai (ORCID 0000-0002-9572-1235); Eltahir Eltagani (ORCID 0000-0001-6627-8804); Odhran K. Ryan (ORCID 0000-0003-2750-4607). St Vincent’s University Hospital: Ailbhe O’Driscoll-Collins (ORCID 0000-0002-8447-0944); Aine O’Neill (ORCID 0000-0001-9190-6008); Zakiya Penny (ORCID 0000-0002-0235-6671); Orlaith Kelly (ORCID 0000-0002-9123-7024); Carolyn Cullinane (ORCID 0000-0002-9320-1586); Ian Reynolds (ORCID 0000-0002-8790-2538); Helen Heneghan (ORCID 0000-0002-2009-3406); Sean Martin (ORCID 0000-0002-6351-8857); Des Winter. Galway University Hospitals: Matthew Davey; Maha Alkhattab; Aoife J. Lowery; Michael J. Kerin; Aisling M. Hogan; Martin S. Davey; Ke En Oh. Letterkenny University Hospital: Syed Mohammad Umar Kabir (ORCID 0000-0003-4801-042X); Huilun Huan (ORCID 0000-0002-3007-2342); Charlotte Aziz (ORCID 0000-0003-2384-0718); Michael Sugrue (ORCID 0000-0002-9337-8939). University Hospital Waterford: Jessica M. Ryan (ORCID 0000-0001-6161-9630); Tara M. Connelly (ORCID 0000-0002-3178-7091); Mohammad Alhazmi (ORCID 0000-0002-8226-328X); Youssef Al-Mukhaizeem (ORCID 0000-0003-3935-8619); Fiachra Cooke (ORCID 0000-0001-9289-4221); Peter M. Neary (ORCID 0000-0002-9319-286X). Beaumont Hospital: Arnold D. K. Hill (ORCID 0000-0001-9617-7983); Michael R. Boland (ORCID 0000-0001-9024-8189); Angus J. Lloyd (ORCID 0000-0002-3043-6900); Frances Fallon (ORCID 0000-0003-4481-0796); Eoin F. Cleere (ORCID 0000-0003-2750-3057); James Toale (ORCID 0000-0002-2026-7584). Mayo University Hospital: Patrick A. Boland; Michael Devine; Conor Keady; Sarah Hunter; M. Kevin Barry. Tallaght University Hospital: Michael E. Kelly (ORCID 0000-0002-0757-6411); Aidan T. O’Dowling (ORCID 0000-0003-0534-0568); Ben Creavin (ORCID 0000-0001-8209-4810); Dara O. Kavanagh (ORCID 0000-0001-9535-0844); Paul Neary (ORCID 0000-0002-7464-1287); Paul F. Ridgway (ORCID 0000-0002-8500-8532); Cathleen A. McCarrick (ORCID 0000-0002-9713-9038). St James’ University Hospital: Jarlath Bolger; Barry Maguire; Cian Keogh; Surbhi Chawla. Mater Misericordiae University Hospital: John Conneely (ORCID 0000-0001-6352-9444); Emilie McCormack (ORCID 0000-0001-5217-1977); Ben Shanahan (ORCID 0000-0001-6890-5007); Nicola Raftery (ORCID 0000-0002-4684-5573); Darragh Rice (ORCID 0000-0001-7857-8273); Niall McInerney (ORCID 0000-0003-4051-3882); Aine Stakelum (ORCID 0000-0002-1593-758X); Jan Mares (ORCID 0000-0001-8217-647X); Jonavan Tan (ORCID 0000-0002-4202-804X); Mark Hanna (ORCID 0000-0002-2878-392X); Ishwarya Balasubramanian (ORCID 0000-0002-3864-5651); Christina Fleming (ORCID 0000-0003-2326-2655). Israel: Soroka University Medical Center: Guy Barsky (ORCID 0000-0001-6290-0619); Gad Shaked (ORCID 0000-0002-4992-252X). Italy: Emergency Surgery and Trauma Section, Humanitas Research Hospital, Rozzano: Simone Giudici (ORCID 0000-0002-5721-2229); Martina Ceolin (ORCID 0000-0002-4689-480X); Simona Mei (ORCID 0000-0001-7952-0014); Francesca Mazzarella (ORCID 0000-0002-7132-3945). Trieste University Hospital: Annalisa Zucca (ORCID 0000-0002-7179-1191); Susanna Terranova (ORCID 0000-0003-1417-1903); Nicolo de Manzini (ORCID 0000-0002-8362-9044). Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino: Diego Visconti (ORCID 0000-0003-4041-1691); Emanuele Doria (ORCID 0000-0002-7941-1886); Mauro Santarelli (ORCID 0000-0017-9842-2240). San Maurizio Hospital, Bolzano: Giovanni Scotton (ORCID 0000-0003-2222-3822); Francesca Notte (ORCID 0000-0002-3559-1782); Giacomo Bertelli (ORCID 0000-0001-7681-1211); Anna Malpaga (ORCID 0000-0003-1171-6197); Giulia Armatura (ORCID 0000-0002-8536-7551); Antonio Frena (ORCID 0000-0001-9461-5345). Cisanello Hospital, University of Pisa: Dario Tartaglia (ORCID 0000-0003-1615-3370); Federico Coccolini (ORCID 0000-0001-6364-4186); Camilla Cremonini (ORCID 0000-0003-1503-7087); Enrico Cicuttin (ORCID 0000-0003-4584-9940); Alessio Mazzoni (ORCID 0000-0003-3325-2063); Massimo Chiarugi (ORCID 0000-0001-6905-2499). Portugal: Centro Hospitalar Universitário da Cova da Beira: Constança M. Azevedo (ORCID 0000-0002-9808-4083); Filipa D. Mendes (ORCID 0000-0002-7864-467X); Luis Q. Faria (ORCID 0000-0002-8089-9815); Carlos Nazario (ORCID 0000-0002-5751-5326); Daniela Machado (ORCID 0000-0002-3124-8952); Miguel Semiao (ORCID 0000-0002-1342-6081). Centro Hospitalar Tondela-Viseu: Jorge Pereira; Carlos Casimiro; Jose Pinto; Tiago Pavão; Raquel Pereira; Bruno Barbosa. Centro Hospitalar de Trás-os-Montes e Alto Douro: Nadia Tenreiro (ORCID 0000-0002-6869-0795); Catia Ferreira (ORCID 0000-0002-5651-3791); Goncalo Guidi (ORCID 0000-0003-3564-1468); Daniela C. Martins (ORCID 0000-0003-3189-4599); Clara Leal (ORCID 0000-0003-2387-5144); Bruno B. Vieira (ORCID 0000-0001-9705-6489). North Lisbon University Hospital Centre: Luís S. Castro (ORCID 0000-0002-4214-2539); Aldara Faria (ORCID 0000-0002-8621-7846); Alberto Figueira (ORCID 0000-0003-0737-4200); Mauro Sousa (ORCID 0000-0002-8872-1093); Pedro Rodrigues (ORCID 0000-0001-7536-5635); Rodrigo Roquette (ORCID 0000-0002-7885-3076). Centro Hospitalar Universitário do Algarve—Hospital de Faro: Ricardo Ribeiro (ORCID 0000-0001-7411-0577); Paulo Cardoso (ORCID 0000-0002-7204-0402); Joana Domingues (ORCID 0000-0001-8231-3040); Maria Isabel Manso (ORCID 0000-0003-4796-5857); Rute Pereira (ORCID 0000-0003-3989-565X); Tatiana Revez (ORCID 0000-0002-8751-2097). Romania: Ponderas Academic Hospital, Bucharest: Bogdan D. Dumbrava (ORCID 0000-0003-4587-8792); Florin Turcu (N/A); Ionut Hutopila (N/A); Bogdana Banescu (N/A); Gerald Filip (N/A); Catalin Copaescu (ORCID 0000-0002-7270-0706). Spain: Hospital Universitario Juan Ramón Jiménez: Marcos Alba Valmorisco (ORCID 0000-0002-4449-7042); Isabel Manzano Martín (ORCID 0000-0003-4952-1934); Rocio Martín García de Arboleya; José Ortega Seda (ORCID 0000-0002-8759-8206); Pablo Rodríguez González (ORCID 0000-0001-6887-6074); Jose Antonio Becerra Toro (ORCID 0000-0003-4644-8903); Enrique Rodríguez Lara (ORCID 0000-0002-5121-9657); Jose Antonio González Minchón (ORCID 0000-0002-4059-6246). Hospital Universitario Son Espases: Juan José Segura-Sampedro (ORCID 0000-0003-0565-3791); Sebastián Jerí-McFarlane (ORCID 0000-0003-0319-2872); Alejandro Gil-Catalán (ORCID 0000-0001-8642-3925); Andrea Craus-Miguel (ORCID 0000-0002-2506-8621); Laura Fernández-Vega (ORCID 0000-0002-1998-5976); Xavier González-Argenté (ORCID 0000-0003-0003-9055). Hospital General Universitario de Ciudad Real: Mercedes Estaire-Gómez (ORCID 0000-0001-9153-9201); Borja Camacho Fernández-Pacheco (ORCID 0000-0003-3242-2892); Rebeca Vitón-Herrero (ORCID 0000-0003-4046-2691); Elisa Jimenez-Higuera (ORCID 0000-0003-2547-5814); Alejandro Barbero (ORCID 0000-0003-0818-0870); José M. Valverde (ORCID 0000-0001-6867-7710). Hospital Universitario Son Llàtzer: Enrique Colás-Ruiz (ORCID 0000-0001-8821-2531); Maria del Mar Escales-Oliver (ORCID 0000-0002-3991-071X); Olga Claramonte-Bellmunt (ORCID 0000-0002-0805-0710); Marta Castro-Suárez (ORCID 0000-0003-1837-8362); Naila Pagés-Valle (ORCID 0000-0003-0898-9303); José Andrés Cifuentes-Ródenas (ORCID 0000-0003-4886-0176). Hospital Universitario Central de Asturias: Marta Merayo Alvarez; Jose Luis Michi Campos; Luis Alejandro García González; Beatriz Carrasco Aguilera; Jaime Iturbe Menéndez; Jose Luis Rodicio Miravalles. Infanta Sofía University Hospital: Carmen Rodríguez Haro (ORCID 0000-0002-2086-694X); Sara Núñez O’Sullivan (ORCID 0000-0001-8418-6145); Mariana García Virosta (ORCID 0000-0003-2021-4623); María Hernández O'Reilly (ORCID 0000-0003-0913-4446). Hospital Universitario de La Ribera: Izaskun Balciscueta-Coltell (ORCID 0000–0002-5787-5647); Javier Lorenzo-Perez (ORCID 0000-0003-0036-144X); Sonia Martinez-Alcaide (ORCID 0000-0002-8213-5616); Susana Martinez-Ramos (ORCID 0000-0001-5651-1246); Maria Sebastian-Fuertes (ORCID 0000-0003-2729-657X); Laura Gomez-Romer (ORCID 0000-0002-6061-8174). Hospital Universitario de Gran Canaria Dr Negrín: Maria M. Pelloni (ORCID 0000-0002-5950-820X); Aida Cristina Rahy-Martín (ORCID 0000-0002-2791-529X); Andrés Felipe Yepes-Cano (ORCID 0000-0001-5827-8951). Hospital Universitario Virgen Macarena: Julio Reguera-Rosal (ORCID 0000-0003-4364-0908); Jose A. Lopez-Ruiz (ORCID 0000-0002-5905-7007); Beatriz Marenco (ORCID 0000-0002-0372-5707); Marina Retamar-Gentil (ORCID 0000-0002-0209-2047); Estela Romero-Vargas (ORCID 0000-0002-9012-6090); Angeles Gil-Olarte (ORCID 0000-0002-1324-9660). Urduliz Alfredo Espinosa Hospital: Aitor Landaluce-Olavarria (ORCID 0000-0002-8631-0151); Begoña Estraviz-Mateos (ORCID 0000-0002-5687-7667); Jose-Mario De Francisco-Rios (ORCID 0000-0001-6589-4250); Aitor Sainz-Lete (ORCID 0000-0003-2215-0870); Ane Emaldi-Abasolo (ORCID 0000-0001-5669-4441); Manolo Leon-Valarezo (ORCID 0000-0002-1755-5200). Donostia University Hospital: Claudia C. Lopes Moreira (ORCID 0000-0003-0404-736X); Aintzane Lizarazu Perez (ORCID 0000-0001-9091-4727); Araceli Rodriguez Gonzalez (ORCID 0000-0001-5249-6368); Iñigo Augusto Ponce (ORCID 0000-0003-0639-1834); Ignacio Maria Goena Iglesias (ORCID 0000-0002-7753-1606). Hospital Universitario de Burgos: Cristina González-Prado (ORCID 0000-0002-9548-505X); Guillermo Cabriada (ORCID 0000-0002-7161-7628); Beatriz López (ORCID 0000-0002-1541-8691); Michelle C. Otero (ORCID 0000-0002-3031-0953); Nerea Muñoz-Plaza (ORCID 0000-0001-8612-9849); Alberto Palomo (ORCID 0000-0002-7660-2134). Hospital Universitario Príncipe de Asturias: Fernando Mendoza-Moreno (ORCID 0000-0002-1046-6344); Manuel Díez-Alonso (ORCID 0000-0002-0993-8498); Francisca García-Moreno-Nisa (ORCID 0000-0001-5360-0577); Belén Matías-García (ORCID 0000-0001-9209-7724); Enrique Ovejero-Merino (ORCID 0000-0002-4254-3594); Ana Quiroga-Valcárcel (ORCID 0000-0001-5921-6920). Elche University General Hospital, Alicante: Luis Sánchez-Guillén (ORCID 0000-0003-0623-9074); Inmaculada Oller-Navarro (ORCID 0000-0003-0417-3489); Álvaro Soler-Silva (ORCID 0000-0002-5228-2746); Antonio Francisco Sanchís-López (ORCID 0000-0002-3421-1389). Complejo Asistencial Universitario de Salamanca: Francisco Blanco-Antona (ORCID 0000-0001-5946-9944); Luis Muñoz-Bellvis (ORCID 0000-0002-7709-5201); Jaime López-Sánchez (ORCID 0000-0002-4506-4951); Sonsoles Garrosa-Muñoz (ORCID 0000-0002-3496-5068); Beatriz Barón-Salvador (ORCID 0000-0002-8591-0278); Juan Manuel Nieto-Arranz (ORCID 0000-0002-6545-9790). Hospital Universitari Parc Taulí: Andrea Campos-Serra (ORCID 0000-0001-6970-7141); Raquel Gràcia-Roman (ORCID 0000-0003-2861-9270); Anna Muñoz-Campaña (ORCID 0000-0003-4136-3046); Carla Zerpa-Martin (ORCID 0000-0002-5731-409X); Andrea Torrecilla-Portoles (ORCID 0000-0002-6585-1944); Tessa Landa (ORCID 0000-0001-5611-4486). Virgen del Rocío University Hospital: Virginia Durán Muñoz-Cruzado (ORCID 0000-0003-4499-0483); Felipe Pareja-Ciuró (ORCID 0000-0001-9192-3465); Daniel Aparicio-Sánchez (ORCID 0000-0001-7061-345X); Eduardo Perea del Pozo (ORCID 0000-0003-3219-2601); Sandra Dios-Barbeito (ORCID 0000-0002-5944-1826); Carlos García-Sánchez (ORCID 0000-0001-7573-295X); Antonio Jesús García-Moriana (ORCID 0000-0002-4866-3511). Hospital Clinic Barcelona: Victor Turrado-Rodriguez (ORCID 0000-0002-0573-7373); Roser Termes-Serra (ORCID 0000-0002-6982-3860); Paula Gonzalez-Atienza (ORCID 0000-0003-1957-6774); Xavier Morales-Sevillano (ORCID 0000-0002-4514-007X); Alba Torroella (ORCID 0000-0002-1911-2446); César Ginestà (ORCID 0000-0002-5867-7503). Hospital Universitario Arnau de Vilanova: Alfredo Escartín (ORCID 0000-0002-5234-2366); Ferney Gomez (ORCID 0000-0002-0022-1327); Ana Pinillos (ORCID 0000-0003-2507-1318); Jaume Ortega (ORCID 0000-0001-9196-4689); Guillermo Lopez (ORCID 0000-0002-6368-5591); Eric Gutierrez (ORCID 0000-0001-9005-6523). Hospital Del Mar de Barcelona: Estela Membrilla-Fernandez; Francisco Ocho-Segarra; Ana María González-Castillo; Amalia Pelegrina-Manzano; Juan Guzmán-Ahumada; Juan Jose Sancho-Insenser. Complejo Hospitalario Universitario de A Coruña: María Lourdes García-Jiménez; Laura Castro-Diez; Manuel González-Bermúdez; Mónica Torres-Díaz; Carla Madarro Pena; Angélica Blanco Rodríguez. Sweden: Örebro University Hospital: Dhanisha Trivedi (ORCID 0000-0003-3875-5831); Souheil Reda (ORCID 0000-0001-6145-1233). Capio S:t Göran Hospital: Hans Edvardsson (ORCID 0000-0001-9511-9730); Lovisa Strömmer (ORCID 0000-0001-5424-7111). Sahlgrenska University Hospital: Eva-Corina Caragounis (ORCID 0000-0001-5637-2637); Karin Sillén (ORCID 0000-0003-2942-0810); Sofia Warfvinge. Sahlgrenska University Östra Hospital: Fredrik Bergstedt; Philip Enström; Harald Olsson; Anders Rosemar. Karolinska University Hospital: Nathalie Young (ORCID 0000-0002-4675-7581); Agnieszka Popowicz (ORCID 0000-0001-7960-0962); Johanna Lerström; Johanna Jäderbo (ORCID 0000-0002-0115-4242); Folke Hammarqvist (ORCID 0000-0001-9175-4534). Danderyds Hospital: Hanna Zacharias (ORCID 0000-0003-1180-0970). Karlstad Hospital: Maria B. Wikström (ORCID 0000-0001-8864-7068); Anna Stene Hurtsén (ORCID 0000-0003-0646-2508). Östersund County Hospital: Haytham Bayadsi (ORCID 0000-0002-4877-5150); Emma Jansson (ORCID 0000-0002-9944-5733); Nils Brunstrom (ORCID 0000-0002-0398-7328); Ellen B. Malers (ORCID 0000-0002-7148-3252). Linköping University Hospital: Per I. Loftås (ORCID 0000-0002-8289-3054); Anders Möller (ORCID 0000-0001-9608-3864); Elena Atanasova. Switzerland: Bern University Hospital, University of Bern: Simone N. Zwicky (ORCID 0000-0003-4465-6813); Beat Schnüriger (ORCID 0000-0002-1672-2775). UK: Aintree University Hospital: Olga Rutka (ORCID 0000-0002-8791-1987); Arjun T. Kattakayam (ORCID 0000-0002-7664-609X); Mushfique Alam (ORCID 0000-0001-9924-8791); John V. Taylor (ORCID 0000-0003-3059-9766). Tameside and Glossop Integrated Care NHSFT: Andrei Mihailescu (ORCID 0000-0002-4364-6042); Eszter T. Karip (ORCID 0000-0002-7610-1604); Ehtisham Zeb (ORCID 0000-0002-2947-2082); Adam O’Connor (ORCID 0000-0001-5267-2819); Goran Pokusevski (ORCID 0000-0003-3585-1860). Brighton and Sussex University Hospitals, Brighton: Mansoor Khan (ORCID 0000-0002-0496-7652); Charlotte Florance; Christie Swaminathan; Shameen Jaunoo; Mohammed Sajid. USA: University of Pennsylvania Hospital System, Philadelphia: Caoimhe C. Duffy (ORCID 0000-0001-6302-1683); John Rees (ORCID 0000-0003-4343-395X); Mark J. Seamon (ORCID 0000-0001-7536-5467); Niels D. Martin (ORCID 0000-0002-2157-0825); Ian J. McCurry (ORCID 0000-0002-9701-338X); Emily A. Vail (ORCID 0000-0002-1849-5780); Bradford C. Bormann (ORCID 0000-0001-7746-0249). Maine Medical Center: Daniel C. Cullinane (ORCID 0000-0002-0414-1949); Jaswin S. Sawhney (ORCID 0000-0003-3693-0229); Jonathan Dreifus; Forest R. Sheppard (ORCID 0000-0001-5461-2297). Riverside University Health System Medical Center: Raul Coimbra (ORCID 0000-0002-3759-6851); Paul Albini (ORCID 0000-0002-1115-2419); Sara Edwards.
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Forssten, M.P., Kaplan, L.J., Tolonen, M. et al. Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective. Eur J Trauma Emerg Surg 49, 57–67 (2023). https://doi.org/10.1007/s00068-022-02149-w
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DOI: https://doi.org/10.1007/s00068-022-02149-w