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 patient