Acute appendicitis surgery in the COVID-19 era: delays without deterioration of outcomes

Article information

Kosin Med J. 2025;40(1):1-3

Publication date (electronic) : 2025 March 27

doi : https://doi.org/10.7180/kmj.25.103

Sang-Yong Son

Department of Surgery, Ajou University School of Medicine, Suwon, Korea

Corresponding Author: Sang-Yong Son, MD, PhD Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5205 Fax: +82-31-219-5755 E-mail: sonsy@aumc.ac.kr

Received 2025 February 10; Accepted 2025 March 11.

The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery worldwide, raising concerns about the timely treatment of surgical emergencies. Acute appendicitis (AA), one of the most common surgical emergencies, emerged as a key focus for evaluating the pandemic’s effects on emergency care [1-4]. While delayed appendectomy can lead to progression to perforation or sepsis, hospitals simultaneously had to mitigate the risk of COVID-19 exposure and transmission. In response to these challenges, Choi and Kim [5] conducted an observational cohort study in Korea to assess how the pandemic influenced the management and outcomes of AA. Their findings provide valuable insights into balancing prompt surgical intervention with necessary infection control measures during a respiratory pandemic.

Significant diagnostic and surgical delays were observed during the pandemic period, particularly among febrile patients. This outcome is unsurprising, as clinicians struggled to differentiate complicated appendicitis from possible COVID-19 infection, necessitating additional imaging and reverse-transcription polymerase chain reaction tests under enhanced protective protocols. Crucially, these delays did not lead to markedly worse surgical outcomes overall. Choi and Kim [5] reported no significant differences between the pandemic and pre-pandemic cohorts in key outcomes—including open conversion rates, length of hospital stay, and the need for more extensive surgery—except among febrile patients. In patients without fever, the clinical course and recovery after appendectomy remained essentially unchanged from pre-pandemic norms. Even among febrile patients, who experienced higher rates of complicated appendicitis during COVID-19, the rate of severe complications did not differ significantly compared to the pre-2020 period. In other words, despite the challenges and delays in managing appendicitis, prudent management prevented worse patient outcomes. A further notable finding was the identification of risk factors for severe appendicitis; older age and the presence of fever emerged as independent predictors in the multivariate analysis, with fever associated with an approximately eight-fold increase in the odds of complicated AA. These factors proved more influential than the pandemic period itself, underscoring that patient characteristics often determine disease severity. The authors appropriately emphasize heightened vigilance for older, febrile patients, who are more susceptible to severe disease and may benefit from expedited evaluation and surgical management. In summary, the study’s findings offer reassuring implications: even when a respiratory pandemic hinders timely access, it does not necessarily result in substandard care, as surgical teams can overcome delays and still deliver safe, effective treatment.

One limitation of the study is that, while it convincingly analyzes patient-centered outcomes, it does not assess the burden on healthcare providers and medical service systems operating under pandemic conditions. It is crucial to acknowledge these unmeasured challenges, which are inherent to the context and could indirectly affect care. The universal use of personal protective equipment, the implementation of aerosol-minimizing anesthesia, and additional operating room decontamination protocols all slow the usual pace of surgery. Surgeons may experience increased fatigue while wearing personal protective equipment, potentially impairing concentration and performance during surgery [6]. Furthermore, frontline surgical teams face a continuous risk of COVID-19 exposure, yet the study did not report any staff illnesses [7-9]. By not analyzing these provider-centric outcomes, the study offers an incomplete picture of the overall “pandemic impact.” Future investigations should address how emergency surgical teams managed these challenges behind the scenes, in addition to evaluating patient outcomes. A better understanding of these issues will help refine protocols to ensure excellent patient care without overburdening providers during crises.

Another important clinical consideration is that the reassuring appendicitis outcomes should not be generalized to all emergency surgical conditions. Although AA typically has a short window for safe intervention, it is a condition in which a moderate delay—particularly in non-severe cases—can sometimes be managed with antibiotics or careful monitoring [10]. In contrast, other surgical emergencies are far less tolerant of delays. The impact of the COVID-19 pandemic on outcomes may be very different for conditions with rapid, life-threatening progression. For instance, delayed surgery in cases of intestinal perforations has a direct and substantial impact on morbidity and mortality [11-13]. One analysis of perforated diverticular disease found that each day of delay in surgical intervention was associated with a 31% increase in the odds of death [14]. Such a steep rise in mortality with every lost day underscores that some emergencies cannot endure the diagnostic or preoperative delays observed during COVID-19. Clinicians must therefore exercise caution when applying lessons from appendicitis to other emergencies.

In conclusion, the COVID-19 pandemic has demonstrated that timely surgical care can be maintained through careful planning and adaptability. While respiratory outbreaks will continue to challenge healthcare access, they do not necessarily compromise the quality of emergency surgical care. The experience with AA during COVID-19 is a testament to the ability of surgical teams to uphold high standards under duress. By acknowledging limitations and tailoring approaches to each clinical scenario, we can protect both patients and providers in future public health crises while maintaining excellent outcomes.