Impact of COVID-19 on the presentation and course of acute appendicitis in paediatrics ⋆

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www.analesdepediatria.org

ORIGINAL ARTICLE

Impact of COVID-19 on the presentation and course of acute appendicitis in paediatrics ^⋆

Leire Bonilla

^a

, Carmen Gálvez

^b

, Lara Medrano

^b

, Javier Benito

^a,^∗

aServiciodeUrgenciasdePediatría,HospitalUniversitarioCruces,Barakaldo,Spain

bServiciodeCirugíaInfantil,HospitalUniversitarioCruces,Barakaldo,Spain

Received28October2020;accepted13December2020 Availableonline19February2021

KEYWORDS COVID-19;

Pandemic;

Acuteappendicitis;

Complicated appendicitis;

Perforation;

Postoperative complications

Abstract

Introduction:Acuteappendicitis(AA)isthemostfrequenturgentsurgicalpathologyinpae- diatrics.TheCOVID-19pandemichasledtoadecreaseinemergencydepartment(ED)visits, whichcanleadtoadelayinhealthcareandanincreaseintheseverityofthepathologies.The objectiveistoanalyzetherateofcomplicatedAAduringthepandemic,comparedtothesame periodofthepreviousyear.

Materialsandmethods: Retrospective unicenter observational cohort study that included patientsunder 14years ofage seenintheEDwith adiagnosisofAA duringthemonths of MarchtoMay2019(non-pandemic)and2020(pandemic).

Results:90patientswereincluded(41innon-pandemicand49inpandemic). Nodifference wasfoundbetweenthetwoperiodsinthetimefromthecliniconsetuntilthevisittotheED (37hvs.38h,P=.881),buttherewas adifferenceinthetimefromarrivalattheEDuntil thesurgery(7:00hvs.10:30h,P=.004).Thedifferencewasaccentuatedwhencomparingthe monthofMarchwithApril---May 2020(6hvs.12h;P=.001). Nosignificantdifferenceswere observedintherateofcomplicatedAAinintraoperativediagnosis(35%vs.33%;P=.870)or anatomopathology(35%vs.48%;P=.222),norinthenumberofpostoperativecomplications, lengthofhospitalizationandreadmissions.Anincreaseintheanatomopathologicaldiagnosis ofAAwithperiapendicitiswasobserved(47%vs.81%;P=.001).

Conclusion:Duringthepandemic,adelayfromarrivalattheEDuntilthesurgerywasobserved inchildrendiagnosedwithAA.Thisdelayresultedinanincreaseinthediagnosisofhistologically evolvedAA,butwithoutanincreaseintheclinicalcomplicationsofthedisease.

4.0/).

⋆ Pleasecitethisarticleas:BonillaL,GálvezC,MedranoL,BenitoJ.ImpactodelaCOVID-19enlaformadepresentaciónyevoluciónde laapendicitisagudaenpediatría.AnPediatr(Barc).2021;94:245---251.

∗Correspondingauthor.

E-mailaddress:[email protected](J.Benito).

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PALABRASCLAVE COVID-19;

Pandemia;

Apendicitisaguda;

Apendicitis complicada;

Perforación;

Complicaciones postoperatorias

ImpactodelaCOVID-19enlaformadepresentaciónyevolucióndelaapendicitis agudaenpediatría

Resumen

Introducción: Laapendicitisaguda(AA)eslapatologíaquirúrgica urgentemásfrecuenteen pediatría. Lapandemiaporla COVID-19hageneradoundescenso enlasconsultasaurgen- cias, pudiendo conllevar unretraso en la atención sanitaria y un aumentoen la gravedad delaspatologías.ElobjetivoesanalizarlatasadeAAcomplicadasdurantelapandemia,en comparaciónconelmismoperiododela˜noanterior.

Materialymétodos:Estudioretrospectivoobservacionaldecohortesunicéntricoqueincluyóa pacientesmenoresde14a˜nosatendidosenurgenciascondiagnósticodeAAdurantelosmeses demarzoamayode2019(nopandemia)y2020(pandemia).

Resultados: Seincluyeron90pacientes(41ennopandemiay49enpandemia).Noseencon- traron diferencias eneltiempo desdeel iniciode la clínicahasta la consultaen urgencias entrelosdosperiodos(37hvs.38h,p=0,881),perosíeneltiempodesdelallegadaaurgen- ciashastalaintervenciónquirúrgica(7:00hvs.10:30h;p=0,004).Ladiferenciaseacentuóal compararelmesdemarzoconabril-mayode2020(6hvs.12h;p=0,001).Noseobservaron diferenciassignificativasenlatasadeAAcomplicadaseneldiagnósticointraoperatorio(35%

vs.33%;p=0,870)nianatomopatológico(35%vs.48%;p=0,222),nitampocoenelnúmerode complicacionespostoperatorias,duracióndeingresoyreingresos.Seobjetivóunaumentodel diagnósticoanatomopatológicodeAAconperiapendicitis(47%vs.81%;p=0,001).

Conclusión: Durantelapandemiaseobservóunademoradesdelallegadaaurgenciashastala intervenciónquirúrgicaenni˜nosdiagnosticadosdeAA.Estademorasetradujoenunincremento deldiagnósticodeAAevolucionadashistológicamente,perosinobjetivarseunaumentodelas complicacionesdelaenfermedad.

Introduction

Acuteappendicitis(AA)isthemostfrequentsurgicalemer- gencyinthepaediatricpopulationandistheleadingcause ofsurgicalabdomeninchildrenagedmorethan2years.It mainlyaffectsschool-agedchildrenandadolescents,andit accountsfor8%ofvisitstothepaediatricemergencydepart- ment(PED)associatedwithabdominalpain.¹

Acuteappendicitisisaprogressivedisease.Itstartswith obstruction in theappendiceal lumen, followedby bacte- rialovergrowthandinvasion,inflammation,ischaemiaand gangrene of the wall of the appendix that can eventu- allyprogress toperforationand peritonitis.^2,3 Theclinical presentation is highly variable,⁴ although it usually has onset with epigastric abdominal pain, nausea and vomiting, followed by pain in the right iliac fossa (RIF) and fever.

Treatment consistsof surgicalremovalof theappendix (appendectomy)bylaparoscopyorlaparotomy.Intheearly stages ofdisease,thereis ahigherprobabilityof diagnos- tictestsbeinginconclusiveandofnegativeappendectomy onsurgicalintervention.Ontheotherhand,delayedsurgery increasestheriskofperforatedappendicitiswithperitonitis, whichisassociatedwithasignificantincreaseinmorbidity andmortality.^5,6Thereisampleevidenceprovingthatper- forationisdirectlycorrelatedtothetimeelapsedbetween theonsetofsymptomsandsurgicalintervention.⁷

Coronavirus Disease 2019 (COVID-19), which is caused bysevereacuterespiratorysyndromecoronavirus2(SARS- CoV-2), was declared a pandemic by the World Health Organization(WHO)onMarch11,2020,constitutingaglobal publichealth emergency.On accountofitsrapid progression,inMarch14,2020theSpanishgovernmentdeclareda stateofalert,closingdownschoolsandbusinessesandman- datingtheconfinementofthepopulation whilerestricting travel.

Children accountfor 1%---2% of all cases of COVID-19.⁸ Mostexperiencemild manifestations such asfever, cough andcold symptoms.^9,10 A smaller proportionpresent with gastrointestinalsymptoms,suchasdiarrhoeaorvomiting.

Thepandemichascauseda70%---80%decreaseinthevisits toPEDs and delaysin seekingcare.^11,12 However,despite theconfinementandsocial isolation,children continue to developotherdiseases,someofthemsevereandrequiring urgent medicalcare, suchasbacterial infections, cancer, endocrinedisordersorsurgicaldiseases.Delaysincarecan increasethemorbidityandmortalityassociatedwiththese diseases,asis thecase of AA,a factor thathasnot been takingintoaccountincalculatingtheextentofthedamage causedbythepandemic.¹³

This was the rationale to conduct a study analysing the impact of the pandemic in the clinical presentation, outcomesand complicationsof paediatric patients witha diagnosisofAA.

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Themainobjectiveofthestudywastoanalyzetheinci- dence of complicated AA during the COVID-19 pandemic, comparingit totheincidence duringthesame periodthe yearbefore.

Material and methods

We conducted a retrospective single-centre observational cohort study that included all patients agedless than 14 yearsmanagedinthePEDofatertiarycarehospitalgiven adiagnosisofAAbetweenMarchandMay2020(pandemic), comparingthesecasestodataforthesameperiodtheyear before(nopandemic).

Definitions

• Complicated AA: the surgical diagnosis included per- forated appendicitis, abscess, appendiceal phlegmon requiringsurgeryandperitonitis.^14---16Thehistopathologi- caldiagnosisincludedgangrenousAA,necrotizingAAand AAwithabscessformation.Inthisstudy,wedefinedcom- plicatedAAbasedonthehistopathologicaldiagnosis.

• Periappendicitis: the presence of periappendicitis, or changes in periappendiceal fat and serositis in the histologicalexaminationreflectgreaterhistologicalpro- gressionofAA.

• Stateofalert:exceptionalstatethatisapplicablewhen extraordinary and very dire circumstances (disasters, health care crises, war, etc.) make it impossible to maintainnormallifewiththeordinarypowersofthecom- petentauthorities.Thegovernmentandarmedforcesare givengreaterauthorityandcanrestrictfreetravelofindi- vidualsorvehicles(mandatoryconfinement/lockdown).

• Pandemic: emerging epidemic disease that spreads through a large geographical area, affecting nearly all individualsintheregion.

Diagnosisandtreatmentofacuteappendicitis Thepaediatricemergencyphysicianmadetheinitialdiagno- sisofAAbasedontheclinicalpresentationandsonographic features. Subsequently, the surgeon confirmed the sus- pecteddiagnosisandestablishedtheindicationforsurgery, and antibiotic prophylaxis was administered before the operation. In April and May 2020, with the aim of pre- venting SARS-CoV-2 transmission, the protocol called for performance of a PCR test beforesurgery, except in life- threateningemergencies.

All cases of AA were managed with appendectomy, restricting conservative treatment with antibiotics exclu- sively tocases of suspected appendiceal phlegmon based on clinical and sonographic features. Appendectomy was performed routinely according to standard protocol, in mostcasesthroughlaparoscopy.Duringsurgery,theappen- dicitis wasclassifiedasphlegmonous(inflamed,congested and erythematous appendix with decreased compress- ibility and presence of exudate), gangrenous (appendix with a greyish, purplish or greenish hue and a thin and friablewall)orperforated-complicated(macroscopicperfo- ration,appendicolithorfreefecalith, purulentperitonitis,

para-appendicealabscessor appendicealmass).^14,17,18 The Departmentof Pathology performed routine examinations ofthesurgicalspecimen,classifyingcasesofphlegmonous AAasuncomplicated,casesof phlegmonousAAwithperi- appendicitis as progressing to complicated, and cases of gangrenousAA,necrotizingAAorAAwithabscessformation ascomplicated.

Datacollection

We retrieved information from the electronic health records.Wecollecteddataforthefollowing:demographic characteristics,paediatric assessment triangle(PAT), time elapsed from onset to PED visit, associated symptoms, findings of thephysical examination, diagnostic testsand treatment received. We also analyzed patient outcomes in hospital and after discharge by reviewing hospitaland primary care records and the histopathological report of theexaminationofthesurgicalspecimenthatincludedthe definitivediagnosis.

Theprimaryoutcomewastheproportionofcomplicated appendicitisinpatientsgivenadiagnosisofAAinthepan- demic period, which we compared to the proportion in patientsmanagedtheyearbefore.

Statisticalanalysis

We have expressed qualitative variables as absolute and relativefrequencies.Weanalyzedtheassociationbetween qualitativevariables by means of thechi squaretest. We comparednormallydistributed quantitativevariableswith theStudentt test. Wecompared nonparametricvariables withtheKruskal---WallisandMann---WhitneyUtests.Thesta- tisticalanalysiswasperformedwiththesoftwareSPSS23.0 forWindows(SPSSInc.;Chicago,IL,USA).Wedefinedsta- tisticalsignificanceasaP-valueoflessthan0.05.

Ethicalconsiderations

The study was approved by the Ethics Committee of the hospital.Sincewe collectedall thedatafrom adatabase in which all patient informationwas anonymisedand the inclusionof thesedatain ourregister didnotinvolveany additionalintervention,thestudydidnotrequireobtention ofinformedconsent.

Results

BetweenMarch1andMay31,2019,thePEDmanaged12593 visits,comparedto5775inthesameperiodin2020,which representeda54%reductioninthevolumeofvisits.Fig.1 showsthenumberofvisitstothePEDbrokendownbyweek inbothperiodsunderstudy.

Atotalof90patientsreceivedadiagnosisofAA,41(46%) in the pre-pandemic periodand 49 (54%) during the pandemic,whichamountedto0.3%and0.8%oftotalvisitstothe PEDsineachoftheseperiods,respectively.Themeanage ofthepatientswas9.2years(range,2---13years);73%were maleand27%female,withoutdifferencesinthedistribution betweenstudyperiods.

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Figure1 NumberofvisitstothepaediatricemergencydepartmentoftheHospitalUniversitarioCrucesbyweek,March1---May 31,2020and2021.

Table1 Comparisonofclinicalmanifestations,findingsofphysicalexamination,timeelapsedtoultrasoundandcomplications inthepre-pandemicandpandemicperiods.

Pre-pandemic,n(%;95%CI) Pandemic,n(%;95%CI) P

n=41 n=49

Timeelapsedfromonset(h) 36.73±44.20 38.16±45.82 .893

PaininRIF 36(88%;74---95%) 41(84%;71---91%) .579

Fever 10(24%;14---39%) 12(24%;15---38%) .991

Vomiting 25(61%;46---74%) 34(69%;55---80%) .403

Anorexia 15(37%;24---52%) 32(65%;51---77%) .007

AbnormalPAT 3(7%;3---20%) 2(4%;1---13%) .505

Peritonealirritation 31(76%;61---86%) 41(84%;71---91%) .341

CRP(mg/L) 54.4±67.1 56.4±75.9 .495

WBC(cells/␮L) 15651±5171 15830±4780 .704

Neutrophils(cells/␮L) 12711±5207 13333±4816 .809

TimeelapsedtoUS(h) 1.80±1.84 1.82±1.75 .885

ComplicationsonUS 7(17%;9---31%) 15(31%;20---45%) .137

Quantitativevariablesexpressedasmeanandstandarddeviation.

CI,confidenceinterval;CRP,C-reactiveprotein;PAT,paediatricassessmenttriangle;RIF,rightiliacfossa;US,ultrasound;WBC,white bloodcellcount.

The mean time elapsed from onset of symptoms to surgical interventionwas42.75h(median, 30.50h; range, 9.00---248.00h) in the pre-pandemic period versus 48.42h (median, 40.00h, range,11.00---301.00h)in thepandemic period(P=.936).Table1presentsthedifferencesinthetime elapsedformonsettothePEDvisit,theclinicalmanifesta- tions,findingsofthephysicalexamination,laboratorytest results,timeelapsedfromarrivaltothePEDtoperformance ofultrasoundandthefrequencyofcomplicationsdetected byultrasoundinbothgroups.Weonlyfoundastatistically significant differencein thepresenceof anorexia(37%vs.

65%,P=.007).

The mean time elapsed from arrival of the patient to thePEDtosurgicalinterventionwas7.00h(median,6.30h;

range,2.00---17.00h)inthepre-pandemicperiod,compared to10.30h(median,9.30h;range,3.00---28.00h)inthepan- demic period (P=.004). Every patient received antibiotic prophylaxisbeforesurgery,administeredeitheratthePED orthesurgicalanteroom.Administrationofantibiotherapy atthePEDbeforesurgerywassignificantlymorefrequentin thepandemicperiod(83%)comparedtothepre-pandemic period (58%) (P=.008). Two patients with a sonographic

diagnosis of appendiceal phlegmon, one in each period, received conservative treatment with antibiotherapy and didnotundergo surgery,in adherence totheprotocol for managementofphlegmon.

Table2presentsthedifferencesinthefrequencyofcom- plicatedAA,postoperativecomplications,lengthofstayand readmissionrateinpatientsthatunderwentsurgicalinter- vention in each period. The proportion of patients with periappendicitis,changesinperiappendicealfatorserositis wasgreaterinthepandemicperiod(19%vs.39%;P=.001).

Of the 49 patients in the pandemic period, 13 (27%) were managed in March and the remaining 36 (73%) in April and May.In the latter subset, patients underwenta SARS-CoV-2PCRtestbeforesurgery,whichturnedoutneg- ative in all. The mean time elapsed between onset and seeking care in the PED was 45.69h in March (median, 24.00h; range,8.00---288.00h) versus 35.44h in April---May (median, 36.00h; range, 5.00---168.00h) (P=.072). Fig. 2 showsthetimeelapsedfromtheonsetofsymptomstothe PEDvisit, andFig.3 thetimeelapsed fromarrivaltothe PEDtosurgical intervention in the3 periodsunder study.

Thedifferenceinthetimeelapsedtosurgicalintervention

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Table2 ComparisonofproportionofcomplicatedAA,incidenceofpostoperativecomplications,lengthofstayandreadmission rate.

Pre-pandemic,n(%;95%CI) Pandemic,n(%;95%CI) P

n=40^a n=48^a

Intraoperativediagnosis

Phlegmonous 16(40%;26---55%) 14(29%;18---43%) .286

Gangrenous 9(22%;12---35%) 17(35%;23---50%) .186

Complicated 14(35%;22---50%) 16(33%;22---47%) .870

Histologicaldiagnosis

Periappendicitis 19(47%;33---62%) 39(81%;68---90%) .001

Complicated 14(35%;22---50%) 23(48%;34---62%) .222

Postoperativecomplications 7(17%;9---32%) 8(17%;9---30%%) .918

Lengthofstay(days) 4.2±4.3 5.3±6.7 .098

Readmission 4(10%;4---23%) 4(8%;3---20%) .787

Quantitativevariablesexpressedasmeanandstandarddeviation.

AA,acuteappendicitis;CI,confidenceinterval.

a Exclusionof1patientwithadiagnosisofphlegmonthatdidnotundergosurgery.

Figure2 Hourselapsedfromonsetofsymptomstoseeking care at the paediatric emergency department of the Hospi- tal Universitario Crucesin March---May 2019, March 2020and April---May2020.

Figure3 Hourselapsedfromarrivaltothepaediatricemer- gency department of the Hospital Universitario Cruces to surgical intervention in March---May 2019, March 2020 and April---May2020.

between March2020 and April---May2020 wasstatistically significant(6vs.12h;P=.001).Wedidnotfindstatistically significantdifferencesintheproportionofcomplicatedAA diagnosed intraoperatively (31% vs. 34%; P=.818) or his- tologically (46% vs. 49%; P=.882) or in the frequency of postoperativecomplications(23%vs.14%;P=.468).

Discussion

Ourstudyshowsthatduringthefirst3monthsoftheCOVID- 19 pandemic, there wasan increase in the time elapsed between arrival to the PED and surgical intervention in patientswithadiagnosisof AA.Thisdelay wasassociated withthe presence of moreadvanced stages of AA at the timeofhistologicaldiagnosis,whichdidnotresultinahigher frequencyofpreoperativeorpostoperativecomplications.

Manystudieshaveevincedadecreaseinthetotalnum- berofvisitstoPEDs,atrendthatstartedbecomingevident inFebruary 2020 andthat becamemore markedwiththe mandatory lockdowns established in different countries and the first peak of cases in the first wave of the pandemic in late March. Consistent with studies performed in Italy,11,12,19,20 the UnitedKingdom²¹ or Ireland,²² whose authorsreporteda70%---80%decreaseinPEDvisitscompared to2018and2019,ourstudyfoundamuchlower-than-normal frequencyofPEDvisitsbetweenMarchandMay2020.Dur- ingthepandemic,thenumberofvisitstoourPEDdecreased by54%, and the decreasewasmost marked in theweeks that followedthe declaration of thestate of alert,when thenumberdroppedto25%oftheexpectedvolume.

Thisdecreaseinmedicalvisitscanbeexplainedinpart by the reduction in the transmission of infections and in traumaticinjuriesresultingfromconfinement.^19,20However, fear of the hospital setting, advertising campaigns that encourage staying at home and guidance by health care staffobtained through the telephonemay also have con- tributedtodelaysinseeingcare.^12,23Thesedelayshaveled todelayeddiagnosis ofdiseasessuchasdiabetesmellitus, sepsis,differentformsofcancerorAA.²⁴

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Despite the decrease in the total number of visits, we found a similar frequency in the diagnosis of AA, whichsuggeststhat patientswithseverediseasehave not stopped seekingmedical advice. In ourhospital, cases of AA amounted to 0.3% of all visits to the PED in the pre- pandemic period and 0.8% of the total in the pandemic period. This supports previous findings in the literature describing adecrease invisits for mild complaintsandan increase in the proportion of diagnosticcodes considered urgentintriage.^11,20

A similarstudy publishedrecently²⁵ found an increase in the time elapsed between the onset of symptoms and thediagnosis of AAduringthepandemic comparedtothe pre-pandemic period. Our study did not identify statistically significant differences in the duration of symptoms at thetimeof careseekingbetweenthe2 periods(37vs.

38h).However,whenwefocusedspecificallyonthemonth ofMarch,whichcorrespondedtothebeginningofthepan- demic,theexponentialincreaseinthenumberofCOVID-19 cases andthe declarationof thestate of alert,we found a delayin seekingcare at thePED thatwasgreater com- paredtothemonthsthatfollowed(46vs.35h),whichmay beexplainedbyagreaterfearofcontagioninthehospital settingatthebeginningofthepandemic.

Our study found an increase in the time elapsed from arrivaltothePEDtosurgicalinterventioninthepandemic period compared to the pre-pandemic period (10.30 vs.

7.00h), adelaythatincreasedinthelast2monthsofthe pandemicperiod(12vs.6h).Thisincreasewasduetothe turnaroundtimeoftheSARS-CoV-2PCRtest,asinthefirst monthofthepandemicperiod,whenthistestwasnotper- formed before surgery, the time elapsed to surgery was similartothetimeelapsedinthepre-pandemicperiod(6.00 vs.7.00h).

There is controversy regarding the clinical impact of delayed consultation at the PED. Some articles have reported an increase in mortality associated with the delayed diagnosis of diseases such as sepsis and malignancies.²⁴However,otherauthorshavereportedthat the proportion of patients that delay seeking care that requireadmission tothe hospitalor thePICU isnot signi- ficantlyhighercomparedtopatientsthatdonotdelay,²³so itdoesnotseemasifthesedelaysincreasethefrequency ofcomplications.

When it comestoAA, arecent study byVelayos etal.

foundthatduringthepandemic,therewasanincreaseinthe proportionofcomplicatedAAwithperitonitis(32%vs.7.3%) andofcomplicationsingeneral(20%vs.9.8%)comparedto beforethepandemic,withoutsignificantdifferencesinthe timeelapsedfromonsettodiagnosis(46vs.30h).Thisdif- fersfromourfindings,asinourstudy,despitean increase in thetimeelapsed formonsettosurgical intervention in the pandemic period, theincidence of complications was similartothe incidencetheyear prior. Differencesin the criteriausedtodefine complicatedAAor in thedelays in surgerymayexplainthisdiscrepancy.Infact,theproportion ofcomplicatedAAcasesinourserieswashighercompared totheproportionreportedinthestudybyVelayosetal.in bothperiodsunderstudy.Weoughttohighlight thatwhile we did not find an increase in the proportion of complicated AA, the increaseddelay in surgery observed in our studywasassociatedwithasignificantincreaseinthedetec-

tionofAAwithperiappendicitisonhistologicalexamination, whichsuggestsagreaterprogressionofAAatthehistological level.

Whether gangrenous AA should be classified as complicated or uncomplicated based on the intraoperative findings continues to be the subject of debate.^14---16 This is a macroscopic, visual diagnosis that can be subject to interratervariability.In ourstudy,although thefrequency of phlegmonous and complicated cases of AA remained stable, we found an increase in the proportion of gan- grenousAAcasesduringthepandemic (22%vs. 35%).This highlights the usefulness of histological criteria, which not only are more objective but were able to demon- strate a greater progression of the inflammatory process at the periappendiceal level that was statistically significant. Thus, our findings suggest that delays in surgical intervention favour progression of the inflammatory pro- cessof AAat thehistologicallevel,althoughtheobserved delayswerenotlargeenoughtoresultinclinicallysignificant complications.

In patients with AA receive early antibiotherapy and undergo surgery within 24h of onset, the incidence of complications is lower.^26---28 In our series, while we found morecasesofgangrenousAAandmoreadvancedhistological progression,we didnotfindahigherincidenceofcompli- catedAAorintraoperativeorpostoperativecomplications, although it must be taken intoaccount that the delay in surgicalinterventionneverexceeded28h.

Thereareseverallimitationstothisstudy.First,itwas conductedinasinglecentreandarelativelysmallsample, which increases the probability of biases associated with thecharacteristicsofcaredeliveryinourPED.However,we believethattheresultscanbeextrapolatedtootherPEDs servingpopulationsofsimilarsociodemographiccharacteris- tics.Ontheotherhand,therearethelimitationsintrinsicto itsretrospectivedesignandobtainingdatafrompasthealth records. In this regard, the fact that the documentation wasproduced byqualified staffandtheuseof prewritten notesguaranteedthequalityofthehealth recordsforthe purposesof our study.In addition,the comparisonof the surgicaldiagnosis,withaknowninterratervariability,and thehistopathologicaldiagnosis,improvedtheobjectivityof thefindings.

In conclusion, we observed an increase in the number of cases of AA withhistological progression, although we foundnoevidencethatthiswasassociatedwithanincrease in the incidence of postoperative complications or in the lengthofstay.TheincreaseincasesofAApresentingatmore advancedstages seemstobeassociatedwiththedelay in surgicalinterventionfromthetimeofonset,resultingfrom boththeinitialdelayinseekingemergencycareand,later on,thedelayinawaitingtheresultsoftheSARS-CoV-2PCR test.Consideringthatthesituationcausedbythepandemic willcontinueinupcomingmonths,weneedtoensureahigh qualityand safety of care in PEDs to inspiretrust in the communityand allowthepromptdiagnosis andtreatment ofAA,avoidingunnecessarydelays.

Conflicts of interest

Theauthorshavenoconflictsofinteresttodeclare.

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