Non-operative treatment for simple acute appendicitis (NOTA) in … – Nature.com

The coronavirus disease 2019 (COVID-19) pandemic had a substantial effect on surgeons and patients who require surgical care. Providing care for patients with surgical disease requires a unique and intimate relationship between patients and surgeons, and this interaction and contact in many scenarios cannot be replaced by telehealth. As such, the surgical workforce has faced distinct challenges compared with nonsurgical specialties during the COVID-19 pandemic.

Our hospital implemented a new policy during the COVID-19 pandemic to protect the patient and the hospital staff and to limit the spread ofthe COVID-19infection. This was done by providing personal protective equipment (PPE) such as masks and gowns, decreasing the length of hospital stay, saving intensive care unit (ICU) hospital beds and other resources needed for the care of hospitalized patients withthe COVID-19infection, and directing all available resources to control the COVID-19 pandemic.

Our hospital COVID-19 protective measures and staff reallocation in preponderance for surgery led to:

There is a shortage of hospital staff (anesthesia doctors, nursing staff, and surgical doctors) due to many reasons. As some of the staff were assigned to work on the COVID-19 team, the anesthesia doctors divided themselves into many teams to decrease exposure risk and isolate infected staff at home.

Shortage of hospital beds as the pediatric surgical beds were assigned to COVID-19 patients care and our surgical patients were admitted in the medical pediatric ward.

Preoperative preparation of urgent cases like acute appendicitis takes longer as COVID-19 PCR takes 972h to be released at the start of the pandemic, but this duration has decreased to 12h after that.

Lack of a CO2 filter in laparoscopic surgery changed our policy from laparoscopic to open procedure with its unsatisfactory outcome and drawbacks.

Therefore, we were obliged to apply the medical management for simple acute appendicitis after approval from the hospital ethical committee as the first-line treatment. The aim was to reduce the length of hospital stays, decrease costs, and save hospital resources. It also aimed to reduce exposure risk and surgical complications, decrease stress and the psychological effects of surgery on parents and children, and reduce the rate of negative appendectomies.

We faced many problems with the implementation of this modality of treatment: a small number of cases, a short period of follow-up, staff resistance, and a lack of experience and confidence. We overcame those problems by conducting many lectures with a review of recent literature, which strongly supported this modality of treatment with close observation and serial examination of patients during admission. Keeping patients in the hospital until we are sure that they are symptom-free and ready to go home with close follow-up at the virtual clinic. The length of hospital stay decreased gradually from 72 to 12h due to the initial positive outcome of gaining confidence and experience in medical treatment.

Patients were discharged after a minimum of 12h of intravenous antibiotics, and patients should tolerate oral feeding and antibiotics before being discharged home. During the first 6months of our study period, there were six cases (17%) that converted to surgical management due to fear of complications and a lack of clinical judgement in medical management. The intraoperative finding was that the appendicular inflammation was resolving. In the next 7months, conversion was zero. The follow-up of patients ranged from 1 to 6months with a mean period of 3.5months, and we had four recurrences and operated upon admission. These results showed that the application of the non-operative treatment increased the resolution of symptoms and the improvement of inflammatory markers. Besides, it decreases the psychological stress on children and families, especially in the situation of the COVID-19 pandemic. Certainly, this compares well with other reports applying non-operative management in acute appendicitis to be associated with a shorter hospital stay and a low risk of short-term recurrence15,16,17.

Though there is a report15 showing a 40% recurrence rate after 5years of follow-up, likewise, Salminen et al., 2018 study16, which is an observational multicenter randomized clinical trial that also includes follow-up for 5years, also showed a recurrence rate of 39.1% at 5years. This obviously revealed the need for a second-phase follow-up to evaluate the role of non-operative therapy in treating acute appendicitis.

We strongly support NOTA to decrease costs, and it is a feasible modality of treatment for simple acute appendicitis in children. We decided to adopt NOTA in our center as the standard management of appendicitis in the pediatric age group, even after the COVID-19 pandemic. We found the results of our research promising, and NOTA significantly decreased hospital stays, costs, and psychological stress.

The study still has many limitations; it is a single-center study with a small number of cases and a short period of follow-up. Staff still have resistance, a lack of experience, and confidence in the new approach. Also, there is resistance from the guardian to NOTA, and they prefer the surgery over medical treatment. There is a lack of data on complications, readmission, recurrence, parents stress, etc. So, the conclusion on safety needs more follow-up and more cases.

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Non-operative treatment for simple acute appendicitis (NOTA) in ... - Nature.com