The COVID-19 pandemic continues despite restrictions, protective measures, and vaccination. During the pandemic period, difficulties were experienced in the management of patients with both appendicitis and other diseases requiring urgent intervention. During the pandemic period, the number of patients diagnosed with appendicitis increased in public hospitals due to the closure of private hospitals in rural areas [13]. Montalya et al. reported in their study that parents preferred pediatric hospitals because they thought there was less risk of transmission, and the number of patients who underwent appendectomy increased by 77% during the pandemic period [14]. However, the results of our study showed that there was no difference in the frequency of appendicitis in the first year before and during the pandemic. In our study, it was concluded that the frequency of appendicitis did not change due to the fact that the parents thought that the COVID-19 virus infects children less and that there may be fewer contact with COVID-19 patients in the pediatric emergency department, so there was no decrease in the hospital admission of children with abdominal pain.
In patients with suspected appendicitis, the time between the onset of symptoms and the time of admission to the hospital was prolonged during the COVID-19 pandemic [9, 13, 15]. In the early stages of the epidemic, it was observed that patients did not go to the hospital unless they had significant symptoms due to the limitation of protective masks and personal protective equipment [1]. Some published studies have reported that there is no difference in symptom duration of patients who underwent appendectomy compared to the pre-pandemic [7, 10, 12, 14, 16]. In our study, the time between the onset of symptoms and hospital admission in the pandemic period was longer than the pre-pandemic. However, this difference was not statistically significant. Reasons such as the fear of contact with the patient with COVID-19 in the hospital, the imposition of a pandemic curfew, and difficulty in transportation may have contributed to the prolongation of the admission period.
The WBC count and C-reactive protein levels are higher in blood tests of patients with appendicitis who were operated during the pandemic period [13]. As in many studies and our study, it was observed that there was no significant difference in WBC count between patients who underwent appendectomy during the pandemic period and patients who underwent appendectomy before the pandemic [2, 10, 11, 14, 17,18,19,20]. The results of our study suggest that there is no difference in the count of WBC before and during the pandemic period, since the patients came to the hospital early before the infection progressed during the pandemic period. There was no change in the duration of hospitalization of patients who underwent appendectomy during the pandemic period [7, 9, 10, 14]. In some studies, it was found that patients were discharged as soon as possible due to reasons such as reducing the risk of postoperative nosocomial infections and the need for an empty bed during the pandemic period, and therefore, the duration of hospitalization was shortened [13, 15]. Gerall et al. stated that during the pandemic period, patients with acute appendicitis came to the hospital late, so there were more complications, and the duration of hospitalization was longer than before the pandemic [11]. Although it was not statistically significant, in our study, it was determined that the hospitalization after appendectomy was shorter than the pre-pandemic period. The thought of doctors to reduce the risk of patients and their attendants related to contact with patients with COVID-19 and families’ desire to be discharged with the same fear were effective in the early discharge of the patient in this process.
Patients and their parents do not prefer to come to the hospital due to the risk of transmission, and the doctors’ limited examination due to the fear of contact causes the patients to be diagnosed late [3]. It has been reported that appendix perforation is more common during the pandemic period [2, 10, 11, 20] and one-third of the patients are perforated [4]. Although it was not statistically significant during the pandemic period, two times the appendix perforation was detected compared to the pre-pandemic period [3, 21]. In another study, as in our study, no significant increase was observed in the frequency of complicated appendicitis during the pandemic period [1]. The fact that the period between the onset of complaints and admission to the hospital in our patients in the first year of the pandemic is similar to that before the pandemic explains the absence of an increase in the rate of complicated appendicitis.
It has been stated that complications such as complicated appendicitis, intra-abdominal abscess, and wound infection in the postoperative period are more common since patients cannot go to the hospital due to fear of COVID-19 transmission in the first period of the pandemic and only if they go to the hospital when the pain is unbearable [1]. However, in some studies, it was observed that there was no difference in the complications that developed pre-pandemic and the pandemic period [6, 7, 14, 17]. In our study, no difference was observed in the rate of development of postoperative complications in the pre-pandemic and in the pandemic. The fact that the symptom duration of the patients was similar to the pre-pandemic and therefore they were treated in the initial period of the infection explains that the rate of complications does not increase during the pandemic period.
Limitations
The limitations of our study are as follows: a single center, retrospective. There is a need for prospective and multi-center studies. In the future, studies comparing children infected with COVID-19 between appendicitis and non-infected children may be conducted.
