Introduction

COVID-19 pandemic has heavily impacted on surgical services and surgery [1, 2]. Since the declaration of pandemic by WHO on the March 12, 2020, 435,626,514 confirmed cases and 5,952,215 deaths have been reported globally [3]. Healthcare systems shifted resources and personnel to manage the increasing number of COVID-19 patients, cancelling or postponing elective operations and outpatient clinics, reducing surgical beds as a tailored strategy to avoid unnecessary resource consumption and mitigate the risk of SARS-COV-2 infection in surgical patients [4]. In urgent surgical diseases, such as acute cholecystitis, acute diverticulitis and acute appendicitis (AA), national and international surgical societies recommended to improve non-operative management (NOM), whenever applicable, avoiding admission in the hospital and supporting alternative strategies such as phone and remote-follow-up [5,6,7,8].

In 2020, the “Association of Italian Surgeons in Europe” (Associazione Chirurghi Italiani in Europa, ACIE) explored the global attitudes in the management of AA on an international cohort of 709 surgeons in the Appy study [9], showing a statistically significant shift toward NOM during the first phase of the outbreak in comparison with the pre-pandemic period (23.7 and 5.3 percent vs. 6.6 and 2.4 percent, respectively, both P < 0.001) with one-third of respondents moving toward open surgery in line with the initial recommendations/guidelines released in the early stages of the pandemic.

With the evolution of pandemic and a major knowledge of the disease, several strategies are now in place to mitigate the risk and might have produced an important effect in the management of AA, still the most common surgical abdominal emergency with a long-life risk of 8–9% [10].

In the present study (ACIE Appy II), we surveyed the same sample of surgeons to explore if any differences occurred in the management of AA in the last waves of pandemics during 2021.

Method

A follow-up internet-based survey based on a previous research project [9] from the ACIE study group was carried out to investigate the impact of the COVID-19 pandemic over the clinical decision for patients with AA, one year after the beginning of the pandemic. An online questionnaire was sent to all 709 participants of the ACIE Appy study by email (Appendix 2). The data sampling collected information from Surgical trainees or certified Surgeons across Europe, Asia, Africa, Oceania, North and South America. The purpose of the study was communicated beforehand to each participant, whose enrollment was voluntary as no incentives were offered to collaborate with the study.

Questionnaire development and composition

Based on the previously used strategy [9], the components and topics for the questionnaire were developed by the steering committee using web-based and remote discussion. The technical functionality of the electronic questionnaire was tested before sending the invitations. Names, locations, and baseline information were stored with the questionnaire. Once an agreement was reached, the questionnaire was completed using Google Form [The COVID-19 Appy-2 Study Form] survey software (Google LLC, Mountain View, California US).

The questionnaire included 5 Sections, with 36 closed-ended questions in total. The first three sections included general questions about the hospital organization and screening policies; personal protective equipment and personal attitudes about the management of AA. The fourth and fifth ones focused on the real-life analysis of patient presentation and management strategies of patients with AA one year after the beginning of the COVID-19 pandemic.

Uncomplicated appendicitis was defined as appendicitis without abscess, whereas complicated appendicitis included the presence of an intraabdominal abscess or free perforation with diffuse peritonitis. Non-operative management (NOM) was defined as conservative management with antibiotics; this could include percutaneous abscess drainage.

The list of alternatives for every single quantitative question included a percentage category as follows: “≤ 25%”, “26–50%”, “51–75%”, “76–100%”. The steering committee decided to use ranges of predetermined percentages in order to allow an easier aggregation and analysis of the information collected.

The estimated time to complete the survey was 8–10 min. The aim was to define the status of the management of AA one year after the beginning of the pandemic as compared with the pandemic period.

Study circulation

From August 15, 2021, the questionnaire was online and open to completion until September 30, 2021. The link was sent to all 709 ACIE Appy participants by email. Two other remainders were sent, always by email, to maximize the response rate.

Data handling and extraction

A member of the steering committee (MP) downloaded the questions and shared them with the other members for data analysis and discussion. Multiple entries from the same individual or members of the same surgical unit were manually searched and eliminated if contradictory findings were observed.

Statistical analysis

Descriptive data are presented as numbers and proportions for categorical variables. Contingency tables and the Chi-square test were used for the comparisons. Statistical analyses were performed in Stata version 16.0 (StataCorp), and nominal two-sided P < 0.05 values were considered statistically significant.

Results

Baseline information

Overall, in 2021, 476 answers (response rate 67.1%) were received from 59 Countries. Most respondents were from countries that were the most affected at the time of the first wave of the pandemic and collaborate with the previous survey. A total of 189 answers (39.7%) were returned from Italy and 64 (13.4%) from Spain, summing together about half of the answers received.

Hospital organization and screening policies

Baseline characteristics of included hospitals in 2021 were comparable to those included in the previous survey from 2020 with 91.8% hospitals attending COVID-19 patients and 8.1% not specifically treating COVID-19 patients (Table 1). The screening policy in 2021 showed significant differences in comparison with 2020 with a higher percentage of systematic SARS-CoV-2 screening for all patients with AA (89.5% vs. 37.4%, P < 0.001) (Fig. 1) and not only to symptomatic subjects. Moreover, the number of patients screened exclusively with PCR and antigenic tests in 2021 was significantly higher in comparison with 2020 (74.1% vs. 26.3%, P < 0.001) when 66.7% of patients were screened with a chest X-ray or computed tomography (CT) in addition to PCR or serological tests (Fig. 2).

Table 1 Changes in the screening policies and use of personal protective equipment (PPE) from pandemic 2020 to 2021
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Fig. 1
figure 1

Screening policies in patients with acute appendicitis for SARS-CoV-2 infection during 2020 and 2021

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Fig. 2
figure 2

Types of screening in patients with acute appendicitis for SARS-CoV-2 infection during 2020 and 2021

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Personal protective equipment (PPE)

The survey on changes in the use of PPE showed that in 2021, a higher number of surgeons started to use no specific personal protective devices (12.2% vs. 0% P < 0.001), even in untested patients (2.9% vs. 0%, P < 0.001) (Table 2) in comparison with 2020. Conversely, in COVID-19 positive patients, specific personal protections were always used, with an increase in the utilization of FFP2/FFP3 mask in 2021 (61.2% vs. 59.8, P < 0.001).

Table 2 Changes in the use of personal protective equipment (PPE) during COVID-19 pandemic, according to patient SARS-CoV2 status, from pandemic 2020 to 2021
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Personal attitude: operative versus non-operative management of acute appendicitis

In patients with uncomplicated appendicitis (no right iliac fossa abscess), in 2021, a higher percentage of surgeons did not change their attitude in the management of these patients (55.7% vs. 42.5%, P < 0.001) (Table 3), whereas 13.9% still admitted changing their treatment strategy, especially in COVID-19 positive or untested patients (30.5%) (Fig. 3). The rate of subjects treated with NOM significantly decreased (14.3% vs. 23.7%, P < 0.001), whereas there was a significant raise in the number of surgeons performing straightforward laparoscopic appendectomy (39.3% vs. 22.4%, P < 0.001).

Table 3 Changes in personal attitude for acute appendicitis from pandemic 2020 to 2021
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Fig. 3
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Management of uncomplicated appendicitis in 2020 and 2021

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In case of appendicitis complicated by right iliac fossa abscess, once again, in 2021, a higher percentage of surgeons did not change their attitude in the management of these patients (67.9% vs. 47.4%, P < 0.001). Additionally, similarly to uncomplicated appendicitis, the rate of subjects treated with NOM significantly decreased (20% vs. 32.7%, P < 0.001), while surgeons tended to perform more straightforward laparoscopic appendectomy (64.9% vs. 33.5%, P < 0.001).

Personal attitude: surgical approach

In 2021, surgeons tended to change less frequently their standard surgical approach (86.8% vs. 61.1%, P < 0.001) from laparoscopic to open or vice versa than in 2020 (Table 4).

Table 4 Changes in surgical approach for acute appendicitis and aspiration of plumes from pandemic 2020 to 2021
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There was an increase in surgeons that did not have to operate con COVID-19 positive patients (16.8% vs. 0%, P < 0.0001), whereas the number of those performing laparoscopic appendectomy increased (59% vs. 48.6%, P < 0.001).

If a laparoscopic appendectomy was performed, a higher number of survey respondents in 2021 stated not to use specific smoke filter system (31.7% vs. 25.8%, P < 0.001). However, when such kind of devices were used, they were more frequently represented by commercially available systems (64.6% vs. 56.3%, P < 0.001) than homemade package.

Changes in patient presentation from 2020 to 2021 at participants Institutions

In 2021, there was a higher percentage of patients with AA that tested positive for SARS-CoV-2 before or after surgery (P < 0.001) (Table 5).

Table 5 Changes in epidemiology from 2020 to 2021
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Respondents from 2021 tended to use less frequently a NOM and send patients home in uncomplicated appendicitis than those from 2020 (P < 0.001 and P = 0.007, respectively). Conversely, more patients with complicated appendicitis were treated with conservative treatment with antibiotics ± percutaneous drainage (P = 0.002) (Fig. 4).

Fig. 4
figure 4

Management of complicated appendicitis in 2020 and 2021

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Discussion

Our study revealed some attitudinal changes in the management of AA in 2021 in comparison with the first waves of pandemic in 2020. Improvement of the knowledge of SARS-CoV-2 infection, a timely healthcare systems’ response in term of screening and a wider availability of personal protective equipment (PPE) are the probable causes. The knowledge of the evolution trends in AA management may helpful for countries interested by a SARS-CoV-2 flare-up and may support healthcare stakeholders to inform pandemic plans for future outbreaks.

Local policies and screening

Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic tests as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery, but this could reflect a systematic screening of patients admitted in the hospital, not possible for reduced availability of diagnostic tests in the first months of the pandemic, where half of the responders screened only patients suspected or with respiratory symptoms. Because COVID-19 patients undergoing surgery have an estimated mortality of 23.8% and a 51.2% of pulmonary complications [11], a patient with AA tested positive for SARS-CoV-2 may benefit from a NOM trial to avoid surgery.

Open versus laparoscopic appendicectomy

During the first wave of the pandemic, in the perspective of a short-term outbreak and due to the concern potential spreading of SARS-COV-2 particles by smoke plumes and pneumoperitoneum during laparoscopy, open surgery was initially suggested by some surgical societies and some authors [12,13,14,15]. The effect was evident in our previous study, with one third of responders moving toward an open approach. Although SARS-COV-2 RNA has been detected in the peritoneal fluid [16, 17] and transmission is biologically plausible [18], no case of transmission by laparoscopy has been reported. Moreover, smoke plumes evacuation might be more challenging in open surgery and several homemade and commercial ultrafiltration systems are now available to err on the side of safety [19,20,21,22], although some of these systems may be time and cost-consuming, especially in emergency surgery by an already stretched staff [23].

While 68.2% of responders use ultrafiltration system during laparoscopic appendicectomy systematically or in COVID-19 patients, one third of responders (31.7%) declare not to use ultrafiltration device during laparoscopy, and this percentage was higher than in previous study (31.7% vs. 25.8%). This may reveal a reduced perceived risk of transmission associated to minimally invasive surgery or a low estimate of these devices as crucial mitigation strategy in operative room.

Laparoscopic appendicectomy is now unanimously recommended for its advantages, including shorter recovery time, better diagnostic accuracy and the possibility to be performed as ambulatory appendectomy [24,25,26] to reduce the risk of system overburden. In the light of the long-term pandemic, a 30% of recurrence in the NOM patients as reported by the CODA trial [27] may represents a further point in favor of laparoscopy, reducing costs and risk of SARS-CoV-2 exposure in patients attending emergency department [28]. In comparison with the previous survey, the proportion of centers performing 76–100% of appendicectomy by open approach declined significantly moving from 22.5 to 10.9%, a percentage similar to the declared 9.1% of pre-pandemic times [9].

Non-operative management (NOM)

The pandemic scenario has had a major impact on presentation rate and strategies of AA worldwide. A meta-analysis on this topic [29] showed a significatively increased use of conservative management of AA in all ages during the outbreak than before. Especially in the more troublesome times of pandemic, NOM remained a reasonable option in patients with AA, with fewer complications and shorter length of stay [30, 31] although with a low effective rate than surgery [32]. In a recent meta-analysis on the role of NOM in the COVID-19 era including 2140 patients, 44.8% of patients had a trial of NOM, with a failure rate of 16.4% and a complication rate of 4.5% with no mortality [33].

Interestingly, only 10.5% of respondents used NOM in more than half (51–100%) of cases with uncomplicated AA, a twofold reduction in comparison with the 23.6% of the previous study. This change may reflect a shift toward the use of laparoscopic appendicectomy as the first option, due to its superiority in the definitive control of the disease [34, 35], a better organization of the healthcare systems and less concern about the risk of viral spreading by minimally invasive surgery.

Appendicular abscess

A higher rate of complicated appendicitis during pandemic have been reported by several authors [36,37,38]. However, due to the decrease in the overall number of cases, this might be related to a prehospital selection bias: as many cases of uncomplicated AA probably settled outside the hospital by antibiotic or spontaneously [39] the rate of those decreased, while complicated AAs are admitted at the same number with an apparent increase in their rate.

NOM may be an option in case of appendicular abscess with a failure rate of 7.4% and the need for percutaneous drain in 19.8%. However, laparoscopy shows the best outcomes in terms of readmission and reintervention [40]. Only 22.8% of responders applied NOM ± percutaneous drainage strategy in appendicular abscess versus the 38.1% from the previous study. These may reflect again an implementation of surgical system response to pandemic, despite the increasing number of AA treated, as the 84.1% of centers declares to treat 5–20 cases per month versus 49.9% in 2020.

Study limitations

This study presents some limitations. For a fair comparison, we used the same self-selected sample of the first study: the missed participation in the first survey by surgeons as their countries were marginally interested by the first COVID-19 waves did not consent their participation in the present study, introducing a selection bias. However, most of the respondents were from countries (Italy, Spain) heavily impacted by all pandemic waves, so that important data about the change in clinical decision-making in the management of acute appendicitis during the different phases of pandemic can be obtained. To keep pragmatic the design of the study, we did not investigate about SARS-CoV-2 vaccination among responders and patients treated, so that important information about the system response in 2021 was not captured. To our knowledge, this is the first survey re-evaluating for the second time the changes in the attitudes in the management of AA occurred in the COVID-19 pandemic worldwide.

Conclusions

The management of acute appendicitis in the last part of pandemic has been improved moving toward pre-pandemic standard due to a better understanding of SARS-CoV-2 infection and improved response by healthcare systems worldwide.