Long Duration and Increase in Pediatric Complicated Appendicitis During the Period of Lockdown in April 2022 in Shanghai

Long Duration and Increase in Pediatric Complicated Appendicitis During the Period of Lockdown in April 2022 in Shanghai | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long Duration and Increase in Pediatric Complicated Appendicitis During the Period of Lockdown in April 2022 in Shanghai Hui Li, Weijue Xu, Xiong Huang, Qingxing Li, Yibo Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1688805/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: The Corona Virus Disease 2019 (COVID-19) has tremendously transformed medical care worldwide, and elective surgery has been affected. The aim of the current study was to determine whether complicated appendicitis rates in children were influenced by the lockdown in April 2022 in Puxi region of Shanghai due to COVID-19. Background: The progression of acute appendicitis from simple to complicated is affected by the presentation timeliness. In the context of city-mandated control, the influences of lockdown in Puxi April on children suffering from acute appendicitis will be investigated in this study. Methods: The medical records of all children presenting in 2 hospitals with acute appendicitis between April 1 and April 30, 2022 (The first lockdown month in Puxi region) were reviewed and analyzed as the lockdown group. Moreover, the medical records of the latest 2 years of acute appendicitis in the same period were reviewed and analyzed as the control group. In addition, the clinical and laboratory parameters, treatment ways, intraoperative and pathological findings, and postoperative outcomes were analyzed. Results: A total of 22 children were diagnosed with acute appendicitis in the first month of the lockdown period in 2 hospitals. Compared with a 2-year control cohort of acute appendicitis, we observed a longer mean duration of symptoms (67.2±77.6 vs 31.9±34.7 h, P=0.01) and higher rate (72.73% vs 43.75%, P=0.038) in children with complicated appendicitis and a long operation time (92.5±35.46 vs 71.25±34.44 min, P=0.03), as well as a higher CRP (61.82±49.75 vs 23.43±28.19 mg/dL, P<0.001) and serum bilirubin (19.07±11.07 vs 10.74±4.37 umol/L, P<0.0001). The mean length of stay was longer in the lockdown group than that in the control group (10.77±5.37 vs 7.70±3.74 d, P=0.0072). The admission WBC and neutrophil percentage had no significant differences, the mean number of hospital or clinic visits had no differences, and the interval between diagnosis and operation has no statistical differences (5.28±2.94 vs 3.73±3.11 h, P=0.076). However, the overall conservative treatment cases, postoperative morbidity and mortality did not change. Conclusions: The lockdown affected the symptoms’ duration time of pediatric acute appendicitis. The children in the lockdown period demonstrated higher complicated appendicitis compared with the historical controls, as well as longer mean length of hospital stay. Appendicitis Pediatric Complicated appendicitis Corona Virus Disease 2019 (COVID-19) Lockdown Figures Figure 1 Figure 2 Figure 3 Introduction Substantial changes in medical care have occurred worldwide owing to the Corona Virus Disease 2019 (COVID-19) [ 1 – 3 ]. Many studies have reported that medical emergencies had been decreased by the pandemic [ 4 , 5 ]. It is believed that the fear of traveling outside during the pandemic and the fear of contracting the virus in the hospital setting have led to delay in seeking medical care, thus resulting in more complicated presentations of common pediatric pathologies [ 6 ]. Acute appendicitis is regarded as one of the most common emergency cases in general surgery in children and the progression is time-sensitive. Delayed diagnosis often lead to more severe diseases, including perforation, intra-abdominal abscess formation and acute peritonitis [ 7 ]. Clinical, environmental, and socioeconomic determinants influence the progression of appendicitis in children from simple inflammation to complicated perforation [ 8 ]. Since the pandemic has posed additional challenges to emergency surgical care, conservative treatments for acute appendicitis have been established in therapeutic algorithms [ 9 ]. It is believed that open appendectomy is a wise option in case of aerosol formation during laparoscopy [ 10 ]. It is reported that limited access to pediatrician’s offices may deter families from obtaining timely assessment in the course of appendicitis [ 11 ]. Due to the country’s most extensive outbreak of COVID-19 during the spring of 2022, Shanghai was overwhelmed. In response to a dynamic zero-COVID strategy to respond to SARS-CoV-2 variants, the local government had to close schools, factories, and business, and issued the stay-at-home order in April in Pu Xi, Shanghai. Fewer people went out for their normal lives and went to hospitals [ 12 ]. The aim of the current study was to determine whether complicated appendicitis cases in children were influenced by the lockdown in April 2022 in Puxi. Methods We reviewed the records of all children younger than 16 years old with acute appendicitis in Shanghai Children’s Hospital, and Shanghai Jiahui International Hospital, in Puxi region during 2 discrete time periods: a lockdown period between April 1, 2022 and April 30, 2022 as the lockdown group; and a period from April 1, 2020, to April 30, 2021 as the control group. The volume of emergent room (ER) visits or general pediatric surgical ER visits in the 2 hospitals were collected too. The study approval was granted through institutional review board agreements of both hospitals. All patients in the two hospitals with the diagnosis of acute appendicitis were included. However, the patients who received the diagnosis of acute appendicitis as inpatients before the first day of the studies or patients with COVID-19 were excluded. Chronic appendicitis or simultaneous appendectomy during abdominal operations were excluded for other diseases. In addition, the patients who were older than the age of 17 were excluded. The charts were identified from electronic medical record system of the 2 hospitals via the code “K35” (acute appendicitis) according to the International Statistical Classification of Diseases (ICD-10). The medical records, including progress notes, lab values, and imaging, were reviewed. Radiographic evidence of acute appendicitis was defined by appendiceal dilatation (> 6mm diameter), wall thickening (> 3mm), or peri-appendiceal inflammation. All cases were categorized into uncomplicated or complicated grades based on radiographical or intraoperative and histopathological findings. The patients with complicated appendicitis were delineated from those with non-complicated appendicitis based on the identification of gangrenous or perforated appendix, or with a peri-appendicular abscess. The data analysis included demographics, presentation variables, number of hospital visits, preoperative assessments, treatment type, intraoperative findings, appendeceal pathology, and inpatient length of stay. The primary outcome was to observe the rates of complicated appendicitis, which was determined by Radiographic report, attending surgeon documentation, or pathologic report. All data were collected and transferred to a database. They were imported to IBM SPSS Statistics, Version 25 (IBMCorp. Released 2017. Armonk, NY), for statistical analysis. According to the data distribution, the statistical tests were applied using the t test for continuous variables and the chi-squared test or Fisher exact testing for categorical variables. Continuous variables are presented as mean (S.D.) and categorical variables as number with percentages. P values < 0.05 were regarded to be statistically significant. Results During the first month of lockdown, the number of general pediatric surgical ER visit in Shanghai Children’s Hospital decreased by 38.4% and the number of ER visit in Shanghai Jiahui International Hospital decreased by 29.2%, with 33.4% of decrease on average, compared with the cohort period of the last 2 years (Table 1 ). However, the volume of surgery in Shanghai Jiahui Hospital increased by 79.6% (413 vs 230) during the period of lockdown, compared with the control period. Table 1 Number of ER visits or pediatric general surgical ER visits in 2 hospitals in the two periods Hospital Control Period (Mean of 2 years) Lockdown Period Decrease percentage% Shanghai Children’s* 500 308 38.4 Jia Hui** 612 433 29.2 In all 1112 741 33.4 * Pediatric general surgical ER visits **ER visits We identified 22 acute appendicitis, excluding 1 chronic appendicitis and 1acute appendicitis with SARS-CoV-2 PCR positive in the lockdown group (Table 2 ), as well as 48 cases, excluding 1 chronic appendicitis in the control group. Table 2 Comparison of appendicitis in children during the lockdown period versus the control period Variable Control Period (N = 48) Lockdown Period (N = 22) p value Age, y 8.91 ± 2.86 8.08 ± 3.72 0.31 Sex, m:f 27:21 8:14 0.12 Symptom duration, h 31.9 (2-192) 67.2 (7-264) 0.01 No. of late presentation cases (> 48 h) 11(22.92%) 9 (42.86%) 0.1479 No. of hospitals visited 1.46 ± 0.58 1.23 ± 0.43 0.13 Admission WBC 10 9 /L 15.95 ± 5.1 17.03 ± 4.25 0.39 Neutrophil % 80.94 ± 8.18 82.58 ± 8.25 0.44 CRP, mg/L 23.43 ± 28.19 61.82 ± 49.75 < 0.001 Serum bilirubin, u mol/L 10.74 ± 4.37 19.07 ± 11.07 < 0.0001 Complicated appendicitis 21(43.75%) 16(72.73%) 0.038 Intervals between diagnosis and operation (h) 3.73 ± 3.11 5.82 ± 2.94 0.076 Appendectomy performed 44(91.67%) 18(81.82%) 0.24 Operation time 71.25 ± 34.44 92.50 ± 35.46 0.03 Length of stay, d 7.70 ± 3.74 10.77 ± 5.37 0.0072 Postoperative complications 6(13.04%) 3(13.64%) 0.946 A descriptive analysis of the variables of interest was performed in both groups, and the results are shown in Table 2 . The mean duration of symptoms before treatment in the lockdown group was nearly 2 times longer than that in the control group (67.2 ± 77.6 vs 31.9 ± 34.7 h, P = 0.01). However, the number of delayed presentation (༞ 48h) had no statistical significances between the two groups, (42.86% vs 22.92%, P = 0.1479). The reasons for late presentation in the lockdown group included parental ignorance, traffic inconvenience, and the fear of contracting the virus. One main reason for delayed presentation in the control group was misdiagnosis (5 cases were misdiagnosed as gastroenteritis and 3 were misdiagnosed as adenomesenteritis), and another reason was parental ignorance that was observed in 3 cases (Fig. 1 ). There were no statistical differences in parental ignorance between the two groups. The frequency of medical visits in the lockdown group was lower than that in the control group, without statistical differences (1.23 ± 0.43 vs1.44 ± 0.58, P = 0.1007). Every patient accepted at least once image examination, either ultrasound or CT scan (Fig. 2 ). The blood test of WBC and neutrophil percentage at admission had no statistical significances in the two group. However, the serum level of C-reactive protein (CRP) at admission in the lockdown group was greatly higher, compared with the control group, (61.82 ± 49.75 vs 23.43 ± 28.19, P < 0.001). Meanwhile, the serum bilirubin level was significantly higher in the lockdown group, compared with the control group (19.07 ± 11.07 vs 10.74 ± 4.37 umol/L, P < 0.0001). The percentage of complicated appendicitis rose to 72.73% in the lockdown group, but 43.75% in the control group (P = 0.037). Eleven (68.75%) complicated appendicitis were diagnosed in the first half of stay-at-home period in the lockdown group. Most patients accepted surgery without differences, with 18 (81.82%) in the lockdown group and 44 (91.67%) in the control group. Totally, 8 cases, with 4 cases in each group, were treated with conservative antibiotics. Six patients had complicated appendicitis with abscess formation and 2 patients in the control group had non-complicated appendicitis whose parents chose the conservative treatment. The interval between diagnosis and operation was 5.28 ± 2.94 hours in the lockdown group and 3.73 ± 3.11 hours in the control group, without statistical differences (P = 0.076). The operation time in the lockdown group was longer than that in the control group, (92.50 ± 35.46 vs 71.25 ± 34.44, P = 0.03). The operation time was significantly longer in the lockdown group when the patients who accepted single-incision laparoscopic appendectomy were excluded, (96.53 ± 37.24 vs 71.25 ± 34.44, P = 0.01). The mean length of stay was 10.77 ± 5.37 d in the lockdown group and 7.70 ± 3.74 d in the control group, with statistical significances (P = 0.0072). There were no differences in the risks of complications and mortality in the two groups (Fig. 3 ). Every patent in the lockdown group obtained a SARS-CoV-2 PCR test, and only 1 had a positive result and it was excluded for the different treatment strategy. Discussion A wave of SARS-CoV-2 infection rapidly appeared in the last two months in Shanghai, China. Nearly 0.6 million cases, including 537,726 asymptomatic carriers, have been identified as of April 30, 2022 [ 13 ]. Shanghai has issued the stay-at-home order in Puxi region in order to restrict the pandemic from April 1, 2022. The local citizens suffered from daily inconveniences during lockdown [ 12 ]. Many hospitals had to close medical service temporarily, due to the hospitalized COVID-19 positive patients. COVID-19 has greatly changed medical care worldwide too. It has reported that the ER visits reduced nearly 50%-60%, especially in younger children below the age of 10 years [ 6 ]. Overall, fewer patients would like to visit ER during lockdown for traffic inconvenience and the fear of contamination. Our study indicated that the COVID-19 has affected ER visits. We confirmed that the mean ER visits reduced by 33.4% in 2 hospitals during the period of lockdown in April, which was more obvious in Children’s hospital (nearly 40%). The ER visits were less decreased in Jiahui hospital (about 30%). Interestingly, the surgery volume got a prominent increase in Jiahui hospital, mainly because the hospital was well managed during the period of lockdown. It is hypothesized that the pathophysiology of acute appendicitis starts with some kind of obstructions, including lymphoid hyperplasia, infection or fecalith, and advances with the increase of intraluminal pressure and ultimate perforation, because the wall had insufficient blood supply and necrosis [ 14 ]. Accordingly, the longer the patients’ duration of symptoms is, the higher the likelihood of perforation is. Early diagnosis of acute appendicitis and consequent appropriate treatment in children is important, as it may prevent complications such as appendix perforation, abscess formation and other postoperative complications. In the pediatric population, complicated appendicitis accounts for the minority of cases (approximately 35%) [ 15 ]. In this study, we found that the duration time in the lockdown group was 2 times longer than the control group. Subsequently, the complicated appendicitis was more, occupying over 70% of the cases in the lockdown group, which is much higher compare with the control group. These findings are similar with the literature reports [ 16 – 18 ]. Furthermore, the inflammation marker CRP and serum bilirubin were significantly higher in the lockdown group, while the WBC and neutrophil percentage of blood tests had no significance between the two groups. The reasons of late visit demonstrated that the main reason was parental ignorance, misdiagnosis or traffic inconvenience that was very similar to the reason in developing countries [ 19 – 21 ]. However, there was no misdiagnosis in the lockdown group: One reason may be that tertiary hospital was the prioritized option for traffic inconvenience during the lockdown period. We also investigated the number of hospital visits to identify whether more hospitals visits led to the delay to the study hospitals. Actually, the results had no differences, which means that hospitals referring is not the reason of delayed presentation during the lockdown period in this study. Oppositely, the number of hospital visits during the lockdown period is mildly fewer than that in the control group. The reasons may be that the symptoms of long duration were much more typical and easier to diagnose or inconvenient alternative hospitals during the quarantine. In the lockdown group, only 1 case who was afraid of contracting COVID-19 in hospitals for late visit was identified. It is much lower than the literature reports, because maybe the sample size was very small or the citizens knew that omicron BA.2 is less virulent [ 6 , 22 , 23 ]. One late visit patient was neglected by his parents, because he had a fever and was mistaken as COVID-19 infection by the family. Antibiotics alone can successfully treat children and adult patients with uncomplicated appendicitis [ 24 – 27 ]. Non-operative management (NOM) for acute appendicitis has been recommended to treat adult acute appendicitis, with satisfactory outcomes during the pandemic [ 9 , 10 ]. However, the changes need further evaluation [ 28 ]. We didn’t find any strong recommendation of NOM for acute appendicitis in children with COVID-19 test negative. There were no differences on NOM between the two groups in the study. The reason of NOM for 4 cases in the lockdown group and 2 cases in the control group was complicated appendicitis with abscess formation, because they missed the timing of surgery, another 2 NOM in the control group were their parents’ determination. Appendectomy is the most common abdominal emergent surgery among pediatric population. Laparoscopy appendectomy has replaced open appendectomy as the preferred surgical technique [ 29 , 30 ]. However, traditional open appendectomy is recommended in case of the aerosol formation in the laparoscopy during the pandemic [ 31 , 32 ]. In this study, only one patient was COVID-19 positive and accepted open appendectomy and the patient was excluded from the lockdown group. Over 80% patients accepted appendectomy in the lockdown group. Fifteen patients were treated with traditional laparoscopic appendectomy and 3 were treated with single-incision laparoscopic appendectomy in the lockdown group. The mean operative time was 20 minutes longer in the lockdown group owing to more complicated appendicitis. Initially, we thought that it might be related to the different procedures, since single-incision needs more time. However, we found that, when the single-incision cases, which were only in the lockdown group, were excluded, the operation time was 25 minutes longer than that in the control group. Single incision procedure decreased operation time, because maybe the single-incision was only performed for uncomplicated appendicitis. There was no conversion to open surgery or unresectable appendix during the operation in the two groups. The current literature reported that the overall incidence of post-appendectomy complications in children is from 5–30%, around 10% in average [ 33 ]. Knaapen reported that the incidence is nearly 25% that is higher in complicated appendicitis (about 38%), especially in tertiary hospitals [ 34 ]. Both the hospitals in our study are tertiary ones, the incidence of post-operative complications in this study is about 13.6% in the lockdown group, which is not statically different from the control group. The complications in our study are not so high: One reason is that we didn’t collect the data of mild complications such as antibiotic related complications, and another reason is that our length of stay was significantly longer than the literature reported, so the post-operative complication of readmission was lower. No readmission was identified till now in our study. However, the complications in our study are a little higher, compared with the literature reports (around 10%). These findings stood in line with previous findings, which suggested that late diagnosis is related to higher incidence of complications [ 35 ]. There are several shortcomings in the article and the authors could identify. The limitations of our study include those inherent to a retrospective review. Another limitation is that the follow-up time for patients treated in the lockdown group is obviously shorter than that in the control group. The postoperative complications in the control group have been collected over 1 or 2 years. The limited sample size and limited time from the two hospitals affected the ability to obtain the accurate estimates on the rate of perforation in the whole city during the whole lockdown period. Conclusion We identified that the lockdown significantly impacted ER visits and led to an overall increase in delayed presentation and complicated appendicitis. The patients with complicated appendicitis had an increased length of stay and longer operative time. How to decrease the pre-hospital time may decrease the incidence of complicated appendicitis. Declarations Funding Information No funding was received for this study. 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Langenbecks Arch Surg 406(1):163–169. https://doi.org/ 10.1007/s00423-020-01976-y Motazedian G, Aryanpoor P, Rahmanian E et al (2021) Incidence of Pediatric Perforated Appendicitis during the COVID-19 Pandemic; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med 10(1):e3. https://doi.org/ 10.22037/aaem.v10i1.1421 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1688805","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":108506070,"identity":"b9d6ec10-b851-4485-ab19-e3ba9d85a7e2","order_by":0,"name":"Hui Li","email":"","orcid":"","institution":"Shanghai Jiahui International Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Li","suffix":""},{"id":108506071,"identity":"8c58d07b-6058-428e-9089-125d5f3722b4","order_by":1,"name":"Weijue Xu","email":"","orcid":"","institution":"Shanghai Children's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weijue","middleName":"","lastName":"Xu","suffix":""},{"id":108506072,"identity":"4d3d9092-e80b-415c-8068-5f79e4225aa3","order_by":2,"name":"Xiong Huang","email":"","orcid":"","institution":"Shanghai Children's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiong","middleName":"","lastName":"Huang","suffix":""},{"id":108506073,"identity":"13e4c6af-51ff-4856-a0a5-6890ba813ae8","order_by":3,"name":"Qingxing Li","email":"","orcid":"","institution":"Shanghai Jiahui International Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qingxing","middleName":"","lastName":"Li","suffix":""},{"id":108506074,"identity":"c448235a-4da7-4480-a83a-74f2ffa23c92","order_by":4,"name":"Yibo Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYDACZh4QKSEnz8x8+MEHAxs7YrVYGBu2s6UZzihISybCGrCWisSG8zwG0jwfDjE2ENJgcJz34GPeNgnGxmYGA2MbgwPMDOyHj27Aq+UwX7IxUAszOzNDwuMcgzt8DDxpaTfwa+Exk85tk2BjbGY4YJxj8IyZQYLHjCgtPAyHGRukLQyAJLFaJBgOMzNIMxCjRRLklz/nJAwMm9nYDHsM0pLZCPmF7/zZgw9nlNXVz+c///nBjz82dvzsh4/h1aJwAF2EDZ9yEJBvIKRiFIyCUTAKRgEAnztE/4tn6+AAAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Children's Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yibo","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2022-05-24 12:59:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1688805/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1688805/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":21927793,"identity":"1d223304-c70b-4f84-9eb1-a22502a69aa7","added_by":"auto","created_at":"2022-05-26 16:07:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50140,"visible":true,"origin":"","legend":"\u003cp\u003eThe reasons of the delayed presentation (\u0026gt;48 h). The main reasons in the lockdown group were parental ignorance and traffic inconvenience, while misdiagnosis and parental ignorance were the main reasons in the control group. There were no significant differences in parental ignorance between the two groups (\u003cem\u003eP\u003c/em\u003e=0.36).\u003c/p\u003e\u003cp\u003eThe frequency of medical visits in the lockdown group was lower than that in the control group, without statistical differences (1.23±0.43 vs1.44±0.58, P=0.1007). Every patient accepted at least once image examination, either ultrasound or CT scan (Fig 2).\u0026nbsp;\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1688805/v1/323fdae2d78f53169a534d3a.png"},{"id":21927794,"identity":"235172ab-96a8-458a-9da4-e7c9fb4bee8c","added_by":"auto","created_at":"2022-05-26 16:07:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225319,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan shows that a 9 years old boy got an acute perforated appendicitis with fecalith. The black arrow indicates the fecalith in the lumen of the appendex. The white arrow indicates that the appendix wall is thick and broken with abscess formation.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1688805/v1/f27bbeab0b27102e94886992.png"},{"id":21927795,"identity":"5242a11d-fec0-42c4-bf33-d6137d2fbb8c","added_by":"auto","created_at":"2022-05-26 16:07:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16838,"visible":true,"origin":"","legend":"\u003cp\u003eComplications of the acute appendicitis shows no significant differences between the two groups.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-1688805/v1/f66fdd559683acd29b7b062f.png"},{"id":21927797,"identity":"436e9f24-5848-4136-9a19-950895f16b9a","added_by":"auto","created_at":"2022-05-26 16:07:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":496522,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1688805/v1/d3d729ff-2c8b-478d-ac73-6436295360bd.pdf"},{"id":21927796,"identity":"651461ab-6219-443b-9289-2575eb1914d1","added_by":"auto","created_at":"2022-05-26 16:07:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":365700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1688805/v1/83bf1898-0760-4337-8d85-39149ab930a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long Duration and Increase in Pediatric Complicated Appendicitis During the Period of Lockdown in April 2022 in Shanghai","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubstantial changes in medical care have occurred worldwide owing to the Corona Virus Disease 2019 (COVID-19) [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Many studies have reported that medical emergencies had been decreased by the pandemic [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is believed that the fear of traveling outside during the pandemic and the fear of contracting the virus in the hospital setting have led to delay in seeking medical care, thus resulting in more complicated presentations of common pediatric pathologies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Acute appendicitis is regarded as one of the most common emergency cases in general surgery in children and the progression is time-sensitive. Delayed diagnosis often lead to more severe diseases, including perforation, intra-abdominal abscess formation and acute peritonitis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Clinical, environmental, and socioeconomic determinants influence the progression of appendicitis in children from simple inflammation to complicated perforation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Since the pandemic has posed additional challenges to emergency surgical care, conservative treatments for acute appendicitis have been established in therapeutic algorithms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It is believed that open appendectomy is a wise option in case of aerosol formation during laparoscopy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is reported that limited access to pediatrician\u0026rsquo;s offices may deter families from obtaining timely assessment in the course of appendicitis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Due to the country\u0026rsquo;s most extensive outbreak of COVID-19 during the spring of 2022, Shanghai was overwhelmed. In response to a dynamic zero-COVID strategy to respond to SARS-CoV-2 variants, the local government had to close schools, factories, and business, and issued the stay-at-home order in April in Pu Xi, Shanghai. Fewer people went out for their normal lives and went to hospitals [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of the current study was to determine whether complicated appendicitis cases in children were influenced by the lockdown in April 2022 in Puxi.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We reviewed the records of all children younger than 16 years old with acute appendicitis in Shanghai Children\u0026rsquo;s Hospital, and Shanghai Jiahui International Hospital, in Puxi region during 2 discrete time periods: a lockdown period between April 1, 2022 and April 30, 2022 as the lockdown group; and a period from April 1, 2020, to April 30, 2021 as the control group. The volume of emergent room (ER) visits or general pediatric surgical ER visits in the 2 hospitals were collected too. The study approval was granted through institutional review board agreements of both hospitals.\u003c/p\u003e \u003cp\u003eAll patients in the two hospitals with the diagnosis of acute appendicitis were included. However, the patients who received the diagnosis of acute appendicitis as inpatients before the first day of the studies or patients with COVID-19 were excluded. Chronic appendicitis or simultaneous appendectomy during abdominal operations were excluded for other diseases. In addition, the patients who were older than the age of 17 were excluded.\u003c/p\u003e \u003cp\u003eThe charts were identified from electronic medical record system of the 2 hospitals via the code \u0026ldquo;K35\u0026rdquo; (acute appendicitis) according to the International Statistical Classification of Diseases (ICD-10). The medical records, including progress notes, lab values, and imaging, were reviewed. Radiographic evidence of acute appendicitis was defined by appendiceal dilatation (\u0026gt;\u0026thinsp;6mm diameter), wall thickening (\u0026gt;\u0026thinsp;3mm), or peri-appendiceal inflammation. All cases were categorized into uncomplicated or complicated grades based on radiographical or intraoperative and histopathological findings. The patients with complicated appendicitis were delineated from those with non-complicated appendicitis based on the identification of gangrenous or perforated appendix, or with a peri-appendicular abscess. The data analysis included demographics, presentation variables, number of hospital visits, preoperative assessments, treatment type, intraoperative findings, appendeceal pathology, and inpatient length of stay. The primary outcome was to observe the rates of complicated appendicitis, which was determined by Radiographic report, attending surgeon documentation, or pathologic report.\u003c/p\u003e \u003cp\u003eAll data were collected and transferred to a database. They were imported to IBM SPSS Statistics, Version 25 (IBMCorp. Released 2017. Armonk, NY), for statistical analysis. According to the data distribution, the statistical tests were applied using the t test for continuous variables and the chi-squared test or Fisher exact testing for categorical variables. Continuous variables are presented as mean (S.D.) and categorical variables as number with percentages. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were regarded to be statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the first month of lockdown, the number of general pediatric surgical ER visit in Shanghai Children\u0026rsquo;s Hospital decreased by 38.4% and the number of ER visit in Shanghai Jiahui International Hospital decreased by 29.2%, with 33.4% of decrease on average, compared with the cohort period of the last 2 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, the volume of surgery in Shanghai Jiahui Hospital increased by 79.6% (413 vs 230) during the period of lockdown, compared with the control period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of ER visits or pediatric general surgical ER visits in 2 hospitals in the two periods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Period (Mean of 2 years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLockdown Period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDecrease percentage%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShanghai Children\u0026rsquo;s*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJia Hui**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e612\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e741\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Pediatric general surgical ER visits\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e**ER visits\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eWe identified 22 acute appendicitis, excluding 1 chronic appendicitis and 1acute appendicitis with SARS-CoV-2 PCR positive in the lockdown group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), as well as 48 cases, excluding 1 chronic appendicitis in the control group.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of appendicitis in children during the lockdown period versus the control period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Period (N\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLockdown Period (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.91\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, m:f\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27:21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8:14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom duration, h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.9 (2-192)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.2 (7-264)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of late presentation cases (\u0026gt;\u0026thinsp;48 h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(22.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (42.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1479\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of hospitals visited\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission WBC 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.95\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutrophil %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.94\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.58\u0026thinsp;\u0026plusmn;\u0026thinsp;8.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP, mg/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.43\u0026thinsp;\u0026plusmn;\u0026thinsp;28.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.82\u0026thinsp;\u0026plusmn;\u0026thinsp;49.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum bilirubin, \u003cem\u003eu\u003c/em\u003emol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.74\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.07\u0026thinsp;\u0026plusmn;\u0026thinsp;11.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplicated appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(43.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(72.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervals between diagnosis and operation (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.82\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendectomy performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(91.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(81.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.25\u0026thinsp;\u0026plusmn;\u0026thinsp;34.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.50\u0026thinsp;\u0026plusmn;\u0026thinsp;35.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay, d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(13.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(13.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.946\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA descriptive analysis of the variables of interest was performed in both groups, and the results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mean duration of symptoms before treatment in the lockdown group was nearly 2 times longer than that in the control group (67.2\u0026thinsp;\u0026plusmn;\u0026thinsp;77.6 vs 31.9\u0026thinsp;\u0026plusmn;\u0026thinsp;34.7 h, P\u0026thinsp;=\u0026thinsp;0.01). However, the number of delayed presentation (༞ 48h) had no statistical significances between the two groups, (42.86% vs 22.92%, P\u0026thinsp;=\u0026thinsp;0.1479). The reasons for late presentation in the lockdown group included parental ignorance, traffic inconvenience, and the fear of contracting the virus. One main reason for delayed presentation in the control group was misdiagnosis (5 cases were misdiagnosed as gastroenteritis and 3 were misdiagnosed as adenomesenteritis), and another reason was parental ignorance that was observed in 3 cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There were no statistical differences in parental ignorance between the two groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe frequency of medical visits in the lockdown group was lower than that in the control group, without statistical differences (1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43 vs1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58, P\u0026thinsp;=\u0026thinsp;0.1007). Every patient accepted at least once image examination, either ultrasound or CT scan (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe blood test of WBC and neutrophil percentage at admission had no statistical significances in the two group. However, the serum level of C-reactive protein (CRP) at admission in the lockdown group was greatly higher, compared with the control group, (61.82\u0026thinsp;\u0026plusmn;\u0026thinsp;49.75 vs 23.43\u0026thinsp;\u0026plusmn;\u0026thinsp;28.19, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Meanwhile, the serum bilirubin level was significantly higher in the lockdown group, compared with the control group (19.07\u0026thinsp;\u0026plusmn;\u0026thinsp;11.07 vs 10.74\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37 umol/L, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The percentage of complicated appendicitis rose to 72.73% in the lockdown group, but 43.75% in the control group (P\u0026thinsp;=\u0026thinsp;0.037). Eleven (68.75%) complicated appendicitis were diagnosed in the first half of stay-at-home period in the lockdown group. Most patients accepted surgery without differences, with 18 (81.82%) in the lockdown group and 44 (91.67%) in the control group. Totally, 8 cases, with 4 cases in each group, were treated with conservative antibiotics. Six patients had complicated appendicitis with abscess formation and 2 patients in the control group had non-complicated appendicitis whose parents chose the conservative treatment. The interval between diagnosis and operation was 5.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94 hours in the lockdown group and 3.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11 hours in the control group, without statistical differences (P\u0026thinsp;=\u0026thinsp;0.076). The operation time in the lockdown group was longer than that in the control group, (92.50\u0026thinsp;\u0026plusmn;\u0026thinsp;35.46 vs 71.25\u0026thinsp;\u0026plusmn;\u0026thinsp;34.44, P\u0026thinsp;=\u0026thinsp;0.03). The operation time was significantly longer in the lockdown group when the patients who accepted single-incision laparoscopic appendectomy were excluded, (96.53\u0026thinsp;\u0026plusmn;\u0026thinsp;37.24 vs 71.25\u0026thinsp;\u0026plusmn;\u0026thinsp;34.44, P\u0026thinsp;=\u0026thinsp;0.01). The mean length of stay was 10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37 d in the lockdown group and 7.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.74 d in the control group, with statistical significances (P\u0026thinsp;=\u0026thinsp;0.0072). There were no differences in the risks of complications and mortality in the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Every patent in the lockdown group obtained a SARS-CoV-2 PCR test, and only 1 had a positive result and it was excluded for the different treatment strategy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA wave of SARS-CoV-2 infection rapidly appeared in the last two months in Shanghai, China. Nearly 0.6\u0026nbsp;million cases, including 537,726 asymptomatic carriers, have been identified as of April 30, 2022 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Shanghai has issued the stay-at-home order in Puxi region in order to restrict the pandemic from April 1, 2022. The local citizens suffered from daily inconveniences during lockdown [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Many hospitals had to close medical service temporarily, due to the hospitalized COVID-19 positive patients. COVID-19 has greatly changed medical care worldwide too. It has reported that the ER visits reduced nearly 50%-60%, especially in younger children below the age of 10 years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Overall, fewer patients would like to visit ER during lockdown for traffic inconvenience and the fear of contamination. Our study indicated that the COVID-19 has affected ER visits. We confirmed that the mean ER visits reduced by 33.4% in 2 hospitals during the period of lockdown in April, which was more obvious in Children\u0026rsquo;s hospital (nearly 40%). The ER visits were less decreased in Jiahui hospital (about 30%). Interestingly, the surgery volume got a prominent increase in Jiahui hospital, mainly because the hospital was well managed during the period of lockdown.\u003c/p\u003e \u003cp\u003eIt is hypothesized that the pathophysiology of acute appendicitis starts with some kind of obstructions, including lymphoid hyperplasia, infection or fecalith, and advances with the increase of intraluminal pressure and ultimate perforation, because the wall had insufficient blood supply and necrosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Accordingly, the longer the patients\u0026rsquo; duration of symptoms is, the higher the likelihood of perforation is. Early diagnosis of acute appendicitis and consequent appropriate treatment in children is important, as it may prevent complications such as appendix perforation, abscess formation and other postoperative complications. In the pediatric population, complicated appendicitis accounts for the minority of cases (approximately 35%) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this study, we found that the duration time in the lockdown group was 2 times longer than the control group. Subsequently, the complicated appendicitis was more, occupying over 70% of the cases in the lockdown group, which is much higher compare with the control group. These findings are similar with the literature reports [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, the inflammation marker CRP and serum bilirubin were significantly higher in the lockdown group, while the WBC and neutrophil percentage of blood tests had no significance between the two groups. The reasons of late visit demonstrated that the main reason was parental ignorance, misdiagnosis or traffic inconvenience that was very similar to the reason in developing countries [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, there was no misdiagnosis in the lockdown group: One reason may be that tertiary hospital was the prioritized option for traffic inconvenience during the lockdown period. We also investigated the number of hospital visits to identify whether more hospitals visits led to the delay to the study hospitals. Actually, the results had no differences, which means that hospitals referring is not the reason of delayed presentation during the lockdown period in this study. Oppositely, the number of hospital visits during the lockdown period is mildly fewer than that in the control group. The reasons may be that the symptoms of long duration were much more typical and easier to diagnose or inconvenient alternative hospitals during the quarantine. In the lockdown group, only 1 case who was afraid of contracting COVID-19 in hospitals for late visit was identified. It is much lower than the literature reports, because maybe the sample size was very small or the citizens knew that omicron BA.2 is less virulent [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. One late visit patient was neglected by his parents, because he had a fever and was mistaken as COVID-19 infection by the family.\u003c/p\u003e \u003cp\u003eAntibiotics alone can successfully treat children and adult patients with uncomplicated appendicitis [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Non-operative management (NOM) for acute appendicitis has been recommended to treat adult acute appendicitis, with satisfactory outcomes during the pandemic [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the changes need further evaluation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. We didn\u0026rsquo;t find any strong recommendation of NOM for acute appendicitis in children with COVID-19 test negative. There were no differences on NOM between the two groups in the study. The reason of NOM for 4 cases in the lockdown group and 2 cases in the control group was complicated appendicitis with abscess formation, because they missed the timing of surgery, another 2 NOM in the control group were their parents\u0026rsquo; determination. Appendectomy is the most common abdominal emergent surgery among pediatric population. Laparoscopy appendectomy has replaced open appendectomy as the preferred surgical technique [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, traditional open appendectomy is recommended in case of the aerosol formation in the laparoscopy during the pandemic [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In this study, only one patient was COVID-19 positive and accepted open appendectomy and the patient was excluded from the lockdown group. Over 80% patients accepted appendectomy in the lockdown group. Fifteen patients were treated with traditional laparoscopic appendectomy and 3 were treated with single-incision laparoscopic appendectomy in the lockdown group. The mean operative time was 20 minutes longer in the lockdown group owing to more complicated appendicitis. Initially, we thought that it might be related to the different procedures, since single-incision needs more time. However, we found that, when the single-incision cases, which were only in the lockdown group, were excluded, the operation time was 25 minutes longer than that in the control group. Single incision procedure decreased operation time, because maybe the single-incision was only performed for uncomplicated appendicitis. There was no conversion to open surgery or unresectable appendix during the operation in the two groups.\u003c/p\u003e \u003cp\u003eThe current literature reported that the overall incidence of post-appendectomy complications in children is from 5\u0026ndash;30%, around 10% in average [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Knaapen reported that the incidence is nearly 25% that is higher in complicated appendicitis (about 38%), especially in tertiary hospitals [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Both the hospitals in our study are tertiary ones, the incidence of post-operative complications in this study is about 13.6% in the lockdown group, which is not statically different from the control group. The complications in our study are not so high: One reason is that we didn\u0026rsquo;t collect the data of mild complications such as antibiotic related complications, and another reason is that our length of stay was significantly longer than the literature reported, so the post-operative complication of readmission was lower. No readmission was identified till now in our study. However, the complications in our study are a little higher, compared with the literature reports (around 10%). These findings stood in line with previous findings, which suggested that late diagnosis is related to higher incidence of complications [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several shortcomings in the article and the authors could identify. The limitations of our study include those inherent to a retrospective review. Another limitation is that the follow-up time for patients treated in the lockdown group is obviously shorter than that in the control group. The postoperative complications in the control group have been collected over 1 or 2 years. The limited sample size and limited time from the two hospitals affected the ability to obtain the accurate estimates on the rate of perforation in the whole city during the whole lockdown period.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe identified that the lockdown significantly impacted ER visits and led to an overall increase in delayed presentation and complicated appendicitis. The patients with complicated appendicitis had an increased length of stay and longer operative time. How to decrease the pre-hospital time may decrease the incidence of complicated appendicitis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e(WHO) WHO (2020) WHO director general\u0026acute;s opening remarks at the media briefing on COVID 19 11march 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-atthe-media-briefing-on-covid-19%2D%2D-11-march-2020\u003c/span\u003e\u003cspan address=\"https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-atthe-media-briefing-on-covid-19%2D%2D-11-march-2020\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Saverio S, Pata F, Gallo G et al (2020) Coronavirus pandemic and colorectal surgery: practical advice based on the Italian experience. 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Langenbecks Arch Surg 406(1):163\u0026ndash;169. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s00423-020-01976-y\u003c/span\u003e\u003cspan address=\" 10.1007/s00423-020-01976-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMotazedian G, Aryanpoor P, Rahmanian E et al (2021) Incidence of Pediatric Perforated Appendicitis during the COVID-19 Pandemic; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med 10(1):e3.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.22037/aaem.v10i1.1421\u003c/span\u003e\u003cspan address=\" 10.22037/aaem.v10i1.1421\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Appendicitis, Pediatric, Complicated appendicitis, Corona Virus Disease 2019 (COVID-19), Lockdown","lastPublishedDoi":"10.21203/rs.3.rs-1688805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1688805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e The Corona Virus Disease 2019 (COVID-19) has tremendously transformed medical care worldwide, and elective surgery has been affected. The aim of the current study was to determine whether complicated appendicitis rates in children were influenced by the lockdown in April 2022 in Puxi region of Shanghai due to COVID-19.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe progression of acute appendicitis from simple to complicated is affected by the presentation timeliness. In the context of city-mandated control, the influences of lockdown in Puxi April on children suffering from acute appendicitis will be investigated in this study. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe medical records of all children presenting in 2 hospitals with acute appendicitis between April 1 and April 30, 2022 (The first lockdown month in Puxi region) were reviewed and analyzed as the lockdown group. Moreover, the medical records of the latest 2 years of acute appendicitis in the same period were reviewed and analyzed as the control group. In addition, the clinical and laboratory parameters, treatment ways, intraoperative and pathological findings, and postoperative outcomes were analyzed.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 22 children were diagnosed with acute appendicitis in the first month of the lockdown period in 2 hospitals. Compared with a 2-year control cohort of acute appendicitis, we observed a longer mean duration of symptoms (67.2±77.6 vs 31.9±34.7 h, P=0.01) and higher rate (72.73% vs 43.75%, P=0.038) in children with complicated appendicitis and a long operation time (92.5±35.46 vs 71.25±34.44 min, P=0.03), as well as a higher CRP (61.82±49.75 vs 23.43±28.19 mg/dL, P\u0026lt;0.001) and serum bilirubin (19.07±11.07 vs 10.74±4.37 umol/L, P\u0026lt;0.0001).\u0026nbsp;The mean length of stay was longer in the lockdown group than that in the control group (10.77±5.37 vs 7.70±3.74 d, P=0.0072). The admission WBC and neutrophil percentage had no significant differences, the mean number of hospital or clinic visits had no differences, and the interval between diagnosis and operation has no statistical differences (5.28±2.94 vs 3.73±3.11 h, P=0.076). However, the overall conservative treatment cases, postoperative morbidity and mortality did not change.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe lockdown affected the symptoms’ duration time of pediatric acute appendicitis. The children in the lockdown period demonstrated higher complicated appendicitis compared with the historical controls, as well as longer mean length of hospital stay.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Long Duration and Increase in Pediatric Complicated Appendicitis During the Period of Lockdown in April 2022 in Shanghai","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-26 16:07:22","doi":"10.21203/rs.3.rs-1688805/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff768169-c9dd-40dc-a298-046ebf528025","owner":[],"postedDate":"May 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-05-26T16:07:23+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-26 16:07:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1688805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1688805","identity":"rs-1688805","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}