Perspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic

Abstract

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 30, No. 4 Research BriefFree AccessPerspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 PandemicStephanie F. Polites and Kenneth S. AzarowStephanie F. PolitesDepartment of Surgery, Oregon Health & Science University, Portland, Oregon.Search for more papers by this author and Kenneth S. AzarowAddress correspondence to: Kenneth S. Azarow, MD, Department of Surgery, Oregon Health & Science University, L223, 3181 Sam Jackson Pk Rd., Portland, OR 97239 E-mail Address: [email protected]Department of Surgery, Oregon Health & Science University, Portland, Oregon.Search for more papers by this authorPublished Online:16 Apr 2020https://doi.org/10.1089/lap.2020.0197AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail Hospitals that care for children face the intersection of acute appendicitis and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This is complicated by reports of gastrointestinal symptoms in SARS-CoV-2, including in children.1,2 The management of pediatric appendicitis during this pandemic must be considered in the context of individual hospitals' SARS-CoV-2 testing, bed, staff, and personal protective equipment (PPE) capacity. Hospitals that also care for adults may be strained by SARS-CoV-2 patients while children's hospitals may receive an influx of patients in an attempt to consolidate pediatric care.3Some hospitals will test all children with appendicitis for SARS-CoV-2 or test based on symptoms and observe on antibiotics until results return. Others will assume SARS-CoV-2 positivity. Although appendectomy should not be impacted by restrictions on elective procedures,3 several institutions routinely perform nonoperative management (NOM) for uncomplicated appendicitis (UA). Duration of disability is decreased with NOM though length of stay is increased and 1 in 10 children require appendectomy before discharge.4 NOM avoids aerosolization during intubation and laparoscopy, avoids general anesthesia for children with a possible respiratory illness, and is particularly suited to hospitals with capacity to observe UA patients for >24 hours. Endpoints for successful NOM in children with SARS-CoV-2 may require modification due to viral symptoms, including fever.For hospitals with strained resources, appendectomy for UA may be favored due to earlier anticipated discharge, which increases availability of beds, staff, and PPE in the system. Such hospitals may find immediate appendectomy with SARS-CoV-2 precautions more efficient than waiting for SARS-CoV-2 results. This is contingent on operating rooms having adequate resources and technology to protect staff. Postoperatively, strong consideration should be given to same-day discharge.5When surgery is performed, anterooms for donning and doffing PPE should be utilized if available and minimum necessary staff should participate.6 Hospitals must allocate PPE, including N-95 respirator masks with face shield, or powered air purifying respirators, for intubation based on recent recommendations.7 For confirmed or suspected SARS-CoV-2 patients, surgical staff require similar PPE, as laparoscopy carries a theoretical risk of viral transmission through aerosolization.8 Measures to reduce aerosol exposure include reduced insufflation and cauterization settings, liberal use of suction, meticulous hemostasis at trocar sites, and filtering of carbon dioxide insufflation for aerosols.8,9 Greater operating room turnover time should be expected.Resources should be rationed between SARS-CoV-2 patients and those ill from other conditions with similar severity, including complicated appendicitis (CA).10 Patients with CA with abscess may undergo initial NOM or operative management, although data supporting NOM should not be extrapolated to patients without abscess.11 Interval appendectomy (IA) after NOM has outcomes similar to upfront appendectomy. Based on the status of the pandemic, postponement of IA may be considered. Appendectomy should not be delayed in recurrent appendicitis.11In conclusion, management of acute appendicitis in children will be challenged by the SARS-CoV-2 pandemic. With comparable outcomes for operative and NOM of UA, hospitals must consider capacity and resources in determining the best course of action.Disclosure StatementNo competing financial interests exist.Funding InformationNo funding was received for this article.References1. Zhou Z, Zhao N, Shu Y, Han S, Chen B, Shu X. Effect of gastrointestinal symptoms on patients infected with COVID-19. Gastroenterology 2020. DOI:10.1053/j.gastro.2020.03.020. Crossref, Google Scholar2. Sun D, Li H, Lu X-X, et al. Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: A single center's observational study. World J Pediatr 2020:1–9. DOI:10.1007/s12519-020-00354-4. Crossref, Medline, Google Scholar3. Children's Hospital Association. COVID-19 Resources and Updates. https://www.childrenshospitals.org/Quality-and-Performance/COVID19 (accessed March 25, 2020). Google Scholar4. Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children a meta-analysis. JAMA Pediatr 2017;171:426–434. Crossref, Medline, Google Scholar5. Alkhoury F, Burnweit C, Malvezzi L, et al. A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg 2012;47:313–316. Crossref, Medline, Google Scholar6. American College of Surgeons. Frequently Asked Questions. How do I manage surgery for COVID-19 PUI/confirmed patients? https://www.facs.org/covid-19/newsletter/032020/faq (accessed March 24, 2020). Google Scholar7. American Society of Anesthesiologists. UPDATE: The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic. https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/update-the-use-of-personal-protective-equipment-by-anesthesia-professionals-during-the-covid-19-pandemic (accessed March 24, 2020). Google Scholar8. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: Lessons learned in China and Italy. Ann Surg 2020 [Epub ahead of print]. Crossref, Google Scholar9. Pryor A. AGES Recommendations Regarding Surgical Response to Covid-19 Crisis. SAGES. https://www.sages.org/recommendations-surgical-response-covid-19/ (accessed March 25, 2020). Google Scholar10. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020:NEJMsb2005114. Crossref, Google Scholar11. López JJ, Deans KJ, Minneci PC. Nonoperative management of appendicitis in children. Curr Opin Pediatr 2017;29:358–362. 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Wulkan16 April 2020 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 30, No. 4Anales de Pediatría, Vol. 93, No. 2Surgical Practice in the Current COVID-19 Pandemic: A Rapid Systematic ReviewClinics, Vol. 75 Volume 30Issue 4Apr 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Stephanie F. Polites and Kenneth S. Azarow.Perspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.Journal of Laparoendoscopic & Advanced Surgical Techniques.Apr 2020.356-357.http://doi.org/10.1089/lap.2020.0197Published in Volume: 30 Issue 4: April 16, 2020Online Ahead of Print:April 1, 2020PDF download

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