MANAGEMENT OF APPENDICITIS DURING THE COVID-19 PANDEMIC
MANAGEMENT OF APPENDICITIS DURING THE COVID-19 PANDEMIC
During the Covid-19 pandemic, non-operative management for acute appendicitis (AA) was
 implemented in the UK. The aim of this study was to determine the efficacy and outcomes of
 conservative versus surgical management of AA during the pandemic.
This prospective observational cohort study was conducted in a single UK tertiary referral
 centre and was registered locally as a clinical audit. Patients included in this study were
 adults (≥16 years) with a diagnosis of acute appendicitis made clinically and/or
 radiologically in our hospital. Patients presented sequentially to the emergency department,
 and subsequently were referred to the emergency surgical service for further management. The
 data collection periods were between 1st November 2019 and 10th March 2020 ('the pre-COVID
 period') and 10th March 2020 to 5th July 2020 ('COVID period'). The start of the COVID period
 was determined as the day of our hospital pandemic policy introduction, following the
 identification of the first SARS-CoV-2 positive patient at our site.

 Data were collected retrospectively for the pre-COVID period and prospectively during the
 COVID pandemic using the electronic patient record (HYPERSPACE® Epic 2014 Version IU1, Epic
 Systems Corporation, Verona, WI, USA). Data collected included patient demographics,
 radiology reports, timings of consultations, operative records, post-operative care,
 post-operative complications, re-operation rate, length of hospital stay (LOS), histology
 results, re-attendance to hospital and mortality within 90 days of the initial presentation.

 Study participants were scored using the Alvarado score (9), Appendicitis inflammatory
 response (AIR) score (10), the Adult appendicitis score (AAS) (11), American Society of
 Anaesthesiologists (ASA) physical status classification (12) and Rockwood Clinical Frailty
 Scale (13) based on their initial presentation history and investigations, as previously
 described in the literature. Conservative management was determined as the use of antibiotics
 only (i.e. an intervention was not offered at initial consultation). Interventional radiology
 (IR) guided drain insertion refers to CT or ultrasound (US) guided insertion of an
 intra-abdominal drain. Time to theatre was calculated in hours from the admission time to the
 start of the operation. Operative time was calculated in minutes from skin incision to the
 end of skin closure. Time of day when the procedure was performed was determined by the start
 time of the operation, with those starting after 17:00 until the following day at 08:00
 classified to have been performed out of hours.

 Operative details were recorded based on the operating surgeon's documentation. Conversion
 from a laparoscopic to open approach was determined as additional incisions performed either
 in the right iliac fossa or midline laparotomy. The level of the surgeon was determined based
 on the years of practice post-qualification (Junior Trainee; Senior Trainee; Consultant).
 Critical care admission was determined if the patient was cared for in a Level 2 (high
 dependency unit) or a Level 3 care (intensive care unit) setting. Re-attendance referred to
 any patient re-presenting following their initial admission. This study has been reported in
 line with the STROCSS criteria (14).
Inclusion Criteria:

 -  Patients aged 16 years old and above

 -  Confirmed diagnosis of acute appendicitis

 Exclusion Criteria:

 -  Patients aged less than 16 years old