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Introduction
The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, generated notable changes in all human activities1,2. Therefore, medical and surgical practice also had great modifications2. The pandemic transformed the functioning of general surgery services worldwide3; while elective surgeries were suspended, emergency surgeries had to continue4.
In other countries, most researchers have noticed diverse changes in the features of cases that warrant emergency surgery during the 2020 COVID-19 pandemic5. In Mexico, there is no information about this issue. The study was carried out to evaluate the features of the Mexican Government's workers who required emergency surgery in the general surgery service at a General Hospital administered by the Institute of Social Security and Services for State Workers Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) during the 2020 COVID-19 pandemic compared to a non-exposed group in 2019.
Methods
It was a retrospective cohort study. This investigation was approved by the institutional Research and Education Division. All procedures performed and studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. We analyzed the medical records of Mexican Government's workers, or their relatives, undergoing emergency surgery during the periods from March-August 2019 and from March-August 2020 (COVID-19 pandemic), at the Hospital General Tacuba. From March-2020, our institution was adapted in a COVID-19 hospital. Patients undergoing surgery outside the hospital were excluded, and cases with insufficient information or lost records were eliminated.
Initially, at the emergency department, all cases were assessed with a full clinical history and a thorough physical examination. Their evaluation included complete blood count, glucose, urea, creatinine, and activated partial thromboplastin time. Besides, abdominal, or pelvic ultrasound, and chest X-rays were done. According to individual clinical data, the evaluation was extended to thoracic, or abdominopelvic computed tomography (CT scan). With the diagnosis of an abdominal emergency, the staff of the general surgery department evaluated the patients, determining the diagnosis, and the surgical management.
From all medical files, the following variables were analyzed: demography (age, gender), anthropometry (weight, height, and body mass index), biochemical (hemoglobin, hematocrit, leukocytes, platelets, glucose, urea, and creatinine), and comorbidity (diabetes, metabolic syndrome, arterial hypertension, obesity, and so on) that were registered upon admission to the emergency service. In addition, post-operative diagnoses (acute appendicitis, acute calculous cholecystitis, intestinal occlusion, and etcetera), days of stay in the emergency room before surgery, days from the onset of symptoms until emergency surgery, post-surgery stay, and post-surgical complications were examined.
Continuous variables were expressed as absolute values or their mean with standard deviation. The categorical variables were presented in numbers with their percentage. The analysis of the continuous variables, with normal distribution, was performed with the two-tailed student's t-test for independent samples. The categorical variables' analysis was carried out with the “X2” test, or Fisher's exact test; the latter, if any of the values in the 2 × 2 table were ≤ 5. For all assessments, the statistic program OpenEpi version 3 (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open-Source Epidemiologic Statistics for Public Health, Versión. www.OpenEpi.com. USA) was used. All values of p < 0.05 were considered statistically significant.
Results
Two hundred and fourteen patients undergoing emergency surgery were identified; however, 21 cases were excluded from the study. Finally, 193 patients were analyzed: 106 from 2019 and 87 from 2020 (Table 1). This represented a decrease of 18% in surgical emergencies. Both groups were similar (Table 1).
Table 1 Demography, anthropometry, comorbidities, and pre-post-operative information
| Characteristic | 2019 (n = 106) | 2020 (n = 87) | p |
|---|---|---|---|
| Age | 47.5 ± 19.7 | 51.4 ± 18.2 | 0.15# |
| Women, n (%) | 53 (50) | 87 (60) | 0.11$ |
| Body mass index | 27.2 ± 5 | 28.3 ± 5.6 | 0.15# |
| Patients without comorbidity, n (%) | 55 (51.8) | 42 (48.2) | 0.97$ |
| Days of stay in the emergency room | 1.5 ± 0.6 | 1.3 ± 0.6 | 0.02# |
| Days from the onset of symptoms to surgery | 7.6 ± 4.6 | 14 ± 6.7 | < 0.0001# |
| Days of post-operative stay | 5.2 ± 8.6 | 5.2 ± 5.4 | > 0.99# |
#Statistical test used: Two-tailed student's t-test for independent samples,
$The χ"2" test,
&Fisher's exact test
In the pandemic, the days elapsed between the onset of symptoms, and the emergency surgery increased (Table 1). Meanwhile, the days spent in the emergency room were reduced. In addition, the number of cases of appendicitis decreased 29.6% (Table 2). While an increased by 97.8% occurred for the surgeries for acute calculous cholecystitis (Table 2). Only five patients had an emergency surgery and simultaneously COVID-19 infection (two acute appendicitis and three acute calculous cholecystitis); no one died. From the 87 cases attended in the pandemic, just six had a pre-operative COVID-19 test, all done outside the hospital.
Table 2 The most frequent surgical pathologies
| Characteristic | 2019 (n = 106), n (%) | 2020 (n = 87), n (%) | p |
|---|---|---|---|
| Acute appendicitis | 64 (60.3) | 37 (42.5) | 0.007$ |
| Acute calculous cholecystitis | 13 (12.2) | 21 (24.14) | 0.02$ |
| Complicated abdominal wall hernias | 13 (12.2) | 9 (10.3) | 0.34$ |
| Bowel occlusion due to adhesions | 3 (2.8) | 3 (3.4) | > 0.99& |
| Intestinal volvulus | 3 (2.8) | 1 (1.1) | 0.47& |
| Mesenteric thrombosis | 1 (0.9) | 1 (1.1) | > 0.99& |
#Statistical test used: Two-tailed student's t-test for independent samples,
$The χ"2"test,
&Fisher's exact test. All values of p <0.05 were considered statistically significant.
In cases of appendicitis, during the pandemic, the days elapsed between the onset of symptoms, and the surgery increased (Table 3). Just six cases were managed with laparoscopic appendectomy. In the cases of acute calculous cholecystitis, during the pandemic, the patients age, and the days of stay in the emergency room decreased (Table 4). However, the body mass index, the days elapsed between the onsets of symptoms until the surgery, leukocytes and cases with gangrenous cholecystitis increased (Table 4). Just six cases were managed with laparoscopic cholecystectomy.
Table 3 Acute appendicitis cases
| Characteristic | 2019 (n = 64) | 2020 (n = 37) | p |
|---|---|---|---|
| Age | 39.1 ± 17.5 | 44.7 ± 17.7 | 0.12# |
| Patients without comorbidity, n (%) | 41 (64) | 19 (51.3) | 0.69$ |
| Body mass index | 24.6 ± 9.3 | 24 ± 9.6 | 0.76# |
| Initial leukocytes | 15.8 ± 4.7 | 15.1 ± 6 | 0.54# |
| Days of stay at the emergency room | 1.4 ± 0.5 | 1.3 ± 0.5 | 0.33# |
| Days of symptom onset to surgery | 2.6 ± 1.4 | 3.5 ± 1.4 | 0.002# |
| Days of post-operative stay | 3 ± 1.3 | 2.9 ± 1.2 | 0.7# |
| Grade IV appendicitis, n (%) | 16 (25) | 11 (29.7) | 0.30$ |
#Statistical test used: Two-tailed student's t-test for independent samples,
$The χ"2" test,
&Fisher's exact test
Table 4 Acute calculous cholecystitis cases
| Characteristic | 2019 (n = 13) | 2020 (n = 21) | p |
|---|---|---|---|
| Age | 61.9 ± 14.1 | 48.9 ± 15.1 | 0.01# |
| Patients without comorbidity, n (%) | 4 (30.7) | 9 (42.8) | 0.51& |
| Body mass index | 26.2 ± 3.5 | 29 ± 2.5 | 0.01# |
| Initial leukocytes | 9.6 ± 3.6 | 13.6 ± 6.1 | 0.02# |
| Days of stay at the emergency room | 1.8 ± 0.5 | 1.3 ± 0.6 | 0.001# |
| Days of symptom onset to surgery | 17.5 ± 5.3 | 35.5.1 ± 8.9 | < 0.0001# |
| Patients with gangrenous cholecystitis, n (%) | 1 (7.6) | 9 (42.8) | 0.03& |
#Statistical test used: Two-tailed student's t-test for independent samples,
$The "χ2" test,
&Fisher's exact test. All values of p <0.05 were considered statistically significant.
Discussion
In this investigation, notable changes were identified in emergency surgeries during the 2020 COVID-19 pandemic at a general hospital that insured workers of the Mexican Government: these surgeries decreased. In other parts of the world, the behavior of these operations was heterogeneous. While, in few countries these surgeries were maintained with the same frequency5-8, in most reports, a reduction was described3,9-16. This diverse conduct was due to the heterogeneous manner of the pandemic in the different countries7.
In this research, it was identified that the number of days between surgery, and the onset of the surgical disease increased. This finding is like the reports from other regions of the World9,15,17. Authors agree that this circumstance was by several factors, including the “stay at home” recommendation from authorities or the patients' fear of going to hospitals, delaying their timely management3,9-16.
Herein, a decrease in the number of cases of acute appendicitis was found. In other parts of the world, the behavior of this disease was also heterogeneous. A few medical units identified an increase in these cases16,18,19; however, most hospitals recognized a reduction20-23. This diverse conduct was also due to the heterogeneous behavior of the pandemic in the World7.
In a singular way, in our work an increase in cases of acute calculous cholecystitis was identified. Meanwhile, few authors did not detect changes in the frequency of this disease5,20; most centers noticed a decline in cases of cholecystitis9,10,21,22. In our cholecystitis cases, a significant increase in their body mass index, initial leukocytes, cases with gangrenous cholecystitis, as well as in the number of days between the onset of symptoms and cholecystectomy were identified. This was consistent with what happened with appendicitis, where patients did not go to hospitals in a timely manner due to the “stay at home” recommendation from authorities or the patients' fear of contracting COVID-193,9-16.
Alike all studies this one has limitations. This work is the result of a single urban hospital population. Our patients were exclusively workers of the Mexican Government or their relatives. In addition, retrospective cohort studies have intrinsic limitations due to their design. Notwithstanding the former data, our findings are consistent with other surveys.
