Introduction

Acute appendicitis is the most frequent surgical pathology in our environment, being the main cause of acute surgical abdomen [1]. This pathology is defined as inflammation of the cecal result as a consequence of infectious, obstructive, including immunosuppressive processes [2, 3]. Despite being a high-frequency pathology, it continues to pose a diagnostic challenge, taking into account the differential diagnoses that should be desired [4]. Including gynecologic-obstetric, neoplastic, and even pulmonary inflammatory processes [5—7].

Among the complications that we find most frequently we have necrosis, perforation, abscess formation, among others. Given the seriousness of its complications, the need for a longer hospital stay could be generated [8]. Hospital stay is a hospital indicator defined as the number of days in which the patient remains hospitalized, counting from the day of admission until 1 day before discharge, and can also be associated with multiple factors [9, 11, 13], among which epidemiological variables stand out. such as age and sex, taking into account the background reported in the literature, asserting a higher prevalence of acute appendicitis among men aged 34 on average [23—26]. Regarding the time of illness, it was developed that the patients who had a prolonged hospital stay were those who attended after a time interval of 24—48 hours from the onset of symptoms [23, 33]. Regarding hospital variables such as pre-surgical hospital time and time of day in which the surgery was performed, the study conducted by Cerpa Paredes, 2020 [12] concludes that a preoperative time greater than 15 hours was associated with a prolonged hospital stay in 62% of cases; On the other hand, the one conducted by Marie Crandall et al, determines that the study of the day in which the surgery is performed is an important factor that influences the length of hospital stay, concluding that the patients operated during the night shift had a hospital stay 50% shorter than those operated during the day [14] medical increases the risk of complications of the disease [10, 27, 28].

It is in this context that the COVID-19 pandemic that we are currently going through becomes important. Which is caused by a new variant of coronavirus identified in China as SARS-COV-2 at the end of 2019, which is characterized by its high virulence and pathogenicity, especially in vulnerable populations, generating the largest health and social crisis of the last century. consequence of the restrictions that have had to be taken to prevent its spread [15—17].

Since its identification to date, the clinical spectrum of SARS-COV-2 infection has not been concretely defined, given that it usually manifests with rather non-specific signs and symptoms, which predominantly include: headache, sore throat, cough, fever, respiratory distress, malaise, gastrointestinal symptoms, among others [18, 19].

For all these reasons, acute infection by SARS-CoV-2 could not only make the diagnosis of acute appendicitis difficult, by generating a delay in the admission of the patient to the hospital, but also produce an impact on the length of hospital stay in patients once once the surgical intervention has been performed and thus postpone discharge [20—22].

At this point, it is worth mentioning the background taken for the approach of this project, such as that of María Burgard, et al, Freiburg 2021, which establishes the effect of the COVID-19 pandemic on the incidence of complicated appendicitis, concluding that in 63% of the cases taken during the pandemic, the hospital stay was longer than 2 days, while in the group of patients taken prior to it, this occurred only in 32% of the cases [23]. Likewise, in the study conducted by María Velayos et al, Madrid 2020, reports that from a sample of 66 pediatric patients, the average hospital stay was longer in the group made up of patients after the declaration of the state of emergency due to COVID-19 (5.6 days) while in the pre-COVID-19 group it was lower (3.3 days) [24]. However, in the study carried out by Oreoluwa Bajomo et al, Liverpool 2021, it is evident that a shorter hospital stay (2.6 days) was observed in the cohort of patients taken during the pandemic compared to the cohort taken prior to it (3 days) [25)] Finally, in the study by Heather C.M.Pringle, et al, England 2021, it was reported that the average length of hospital stay during 2019, prior to the pandemic, was 4 days, while during the pandemic it was shortened to 3 days [26].

Due to the above, it is important to know the impact generated by the SARS-COV-2 infection in a third world country such as the one in which the present study was developed, and in this way, provide quality care to patients with said diagnosis, In addition, the result of said investigation allows taking into account from the administrative point of view that a patient with prolonged hospitalization produces a decrease in the capacity of the hospital to receive fewer patients, especially in the context of a pandemic like the one we are going through.

Material and methods

Study area

A review of 420 medical records of post-operative patients for acute appendicitis at the Trujillo Regional Teaching Hospital was carried out from March 2019 to March 2020 and April 2020 to April 2021.

Population

The type of study was retrospective, analytical, of cohorts, using a simple random sampling according to the antecedents found, in which post-operative patients for acute appendicitis were included in the already established period of time. Target population: post-operative patients for acute appendicitis at the Trujillo Regional Teaching Hospital. Accessible population: The target population that meets the inclusion criteria will be studied.

Definitions-Measurements

Postoperative patients for acute appendicitis were divided into an exposed cohort, infected by SARS-COV-2 and an unexposed cohort, without SARS-CoV-2 infection. Regarding prolonged hospital stay, it is an indicator defined as the number of days in which the patient he remains hospitalized from the day of admission until 1 day before discharge, being considered prolonged when it is >3 days.

Within the intervening variables, age was considered as the chronological measure of the time elapsed from birth to the present. It was divided into 5 groups: children, 6—11 years; adolescents, 12—17 years; youth, 18—29 years; adults, 30—59 years and older adults, 60—65 years. Sex defined as a biological and physiological condition: female and male. The epidemiological history considered as the existence of an epidemiological risk factor for developing SARS-CoV-2, either by direct contact or a risky work environment, was classified as the absence or presence of said variable. Illness time was defined as the time interval elapsed from the onset of symptoms suggestive of appendicitis and was classified as early admission <24 hours and late admission >24 hours. Preoperative hospital time was defined as the time elapsed from the patient’s admission to the moment surgery is performed and was classified as short preoperative hospital time <12 hours and long preoperative hospital time >12 hours. Regarding the place of origin, it was defined as the place of residence declared in the medical history and patients within the province of Trujillo or patients residing in any of the provinces of La Libertad were taken into account. Self-medication was considered as the prior consumption of drugs by the patient, without a medical prescription, including also drugs advertised as curative treatment for SARS-CoV-2, azithromycin, ivermectin, among others. The time of day when the surgery was performed is defined as the shift in which the surgical intervention was carried out, either during the day shift or the night shift. Finally, the postoperative diagnosis of acute appendicitis mentions the diagnosis resulting from the macroscopic analysis of the cecal appendix during the surgical act, which can be classified as uncomplicated acute appendicitis (appendix with a normal or inflamed appearance with the presence or absence of pericolic fluid) or complicated (appendix necrotic, with plastron or abscess and/or perforated).

Procedure

The following project was presented to request the permission and approval of the Academic Department of the Antenor Orrego University. Subsequently, the project was presented to the Trujillo Regional Teaching Hospital, to request the respective permission to access the database and clinical records of postoperative patients for acute appendicitis in the periods from March 2019 to March 2020 and April 2020 to April 2021, who meet the corresponding inclusion criteria.

Once the project was approved, the virtual database of the Surgery Service was requested, from which data regarding the independent and dependent variables were obtained, as well as 4 of the intervening variables; the information regarding the remaining intervening variables was obtained from the physical clinical histories, a simple random sampling was carried out on the patients belonging to each study group, for the exposed cohort their diagnosis of SARS-CoV-2 infection was taken into account; In the same way, the required information from the clinical histories of the selected patients was recorded in the data collection sheet (Annex 1) until completing the sample sizes of both cohorts.

The information was recorded in an Excel format database, using rows for collected data and columns with codes assigned to each patient. Two different Excel sheets were created, one for the unexposed cohort and the other for the exposed cohort, being classified as postoperative acute appendicitis patients without SARS-COV-2 infection and postoperative acute appendicitis patients without concomitant infection.

Finally, the statistical analysis of the results was carried out, quantifying the relative risk (RR) and carrying out the analysis of the intervening variables through the use of Pearson’s Chi Square, in order to obtain the levels of association between said variables and the dependent variable.

Ethical aspects

Approval of the project was requested by the committee of research projects and bioethics of the School of Medicine of the Antenor Orrego Private University.

Data analysis plan

The statistical software SPSS-26 was used to carry out the corresponding analysis. Relative risk was calculated. In addition, Pearson’s Chi Square test was performed for qualitative variables. The associations between intervening variables were considered significant if the possibility of error was less than 5% (p<0.05).

Results

In this study, 420 patients from the General Surgery area of the Trujillo Regional Teaching Hospital were included. In the unexposed cohort of patients made up of 336 patients, 50 (14.88%) had a prolonged hospital stay while the remaining 286 (85.12%) did not. Regarding the intervening variables: age, 54 (16.07%) patients are in the range of 6-11 years, 71 (21.13%) patients in the range of 12 to 17 years, 81 (24.10%) patients in the range of 18—29 years, 126 (37.5%) in the range of 30—59 years, 4 (1.2%) patients in the range of 60—65 years; sex, 194 (57.54%) patients are male and 142 (42.26%) females. Regarding the origin, 215 (63.98%) patients reside in Trujillo and 121 (36.02%) reside in neighboring provinces. With respect to illness time, 84 (25%) patients had illness time of less than 24 hours, while the remaining 252 (75%) exceeded said time; 259 (77.09%) patients presented a pre-surgical hospital time of less than 12 hours, on the other hand, the remaining 77 (22.91%) exceeded 12 hours; 87 (25.83%) patients reported self-medication, while the remaining 249 (74.17%) did not; Regarding the assessment of the time of day that the surgery was performed, 144 (42.91%) patients underwent surgery during the night shift and 192 (57.09%) during the day shift. Finally, 225 (67.08%) patients were diagnosed as complicated acute appendicitis, in turn 111 (32.9%) as uncomplicated acute appendicitis.

In the exposed cohort of patients made up of 84 patients, the following results were obtained: 22 (26.19%) had a prolonged hospital stay, while the remaining 62 (73.81%) did not. Regarding the intervening variables: age, 15 (17.85%) patients are in the range of 6—11 years, 19 (22.61%) patients in the range of 12—17 years, 19 (22.61%) patients in the range of 18—29 years, 30 (35.71%) in the range of 30—59, 1 (1.22%) patients in the range of 60—65 years; Regarding sex, 41 (48.80%) patients are male and 43 (51.20%) are female. Regarding the epidemiological history, 76 (90%) patients claimed to have it while 8 denied it (10%). Regarding the origin, 53 (63.10%) patients reside in Trujillo and 31 (36.90%) reside in neighboring provinces. Regarding illness time, 23 (27.59%) patients had illness time of less than 24 hours, while the remaining 61 (72.41%) exceeded said time; 68 (81.04%) patients presented a pre-surgical hospital time of less than 12 hours, on the other hand, the remaining 16 (18.96%) exceeded 12 hours; 17 (20.68%) patients reported self-medication, while the remaining 67 (79.32%) did not. When evaluating the moment in which the surgery was performed, 41 (48.27%) patients were operated on on night shift and 43 (51.73%) on day shift. Finally, 65 (77.58%) patients were diagnosed as complicated acute appendicitis, in contrast to the 19 (22.42%) patients who had uncomplicated acute appendicitis as a postoperative diagnosis.

Table 1. Intervening variables in the incidence of prolonged hospital stay in post-operative patients for acute appendicitis

Table 2. Association of SARS-COV 2 infection and prolonged hospital stay in patients undergoing surgery for acute appendicitis

There is sufficient evidence at the 5% level (p<0.05) to affirm that there is an association between infection with SARS-CoV-2 and prolonged hospital stay. A relative risk of 1.76 (1.13 2.73) means that post-operative patients for acute appendicitis with SARS-CoV-2 infection are 1.76 times more likely to have a prolonged hospital stay compared to non-coinfected patients. with SARS-CoV-2. Likewise, as the lower and upper limit of the 95% confidence interval of the RR is greater than 1, it can be affirmed that coinfection by SARS-CoV-2 is a risk factor.

Of the proposed intervening variables, those associated with prolonged hospital stay are the time of day the surgery was performed and the postoperative diagnosis, given that after performing the statistical analysis using Pearson’s Chi-square test, all of them have value — p<0.05/

Discussion

SARS-CoV-2 infection is an important health problem globally and especially in our country where the mortality rate has been identified as one of the highest in the world, it is known that this pathology is characterized by a respiratory infection. mild that can lead to atypical pneumonia and in certain cases to systemic complications. Obviously, this implies a greater demand for health services, especially intensive care units and hospitalization. This reality is aggravated in the cases of patients with underlying pathologies, including surgical ones, in which SARS-CoV-2 coinfection leads to medical and logistical complications, including the need for a prolonged hospital stay [10, 24, 26].

Considering this situation and the lack of national studies, it is important to carry out our research together with research outside our environment, proposing the hypothesis that SARS-COV-2 infection is associated with prolonged hospital stay. For this reason, our study included 420 patients, of whom 336 belonged to the unexposed cohort taken before the start of the pandemic and 84 patients who underwent surgery during the pandemic, belonged to the exposed cohort. Obtaining a statistically significant association having obtained the results of the statistical analysis that report a risk ratio of 1.76 (p=0.014). which means that patients in the exposed cohort have a 1.76 times higher probability of prolonged hospital stay compared to those in the unexposed cohort.

In the study by María Burgard, et al, Freiburg, 2021, in which it is reported that 63% of the patients taken during the pandemic had a stay of more than 2 days, while in the cohort of patients prior to the pandemic this it occurred in only 32% [10]. Likewise, in the study conducted by María Velayos et al, Madrid 2020, reported that the group infected with COVID-19, made up of 25 pediatric patients aged 9.3±3.1 years, presented a mean hospital stay of 5.6±5.9 days, while In the unexposed cohort made up of 41 patients, the mean hospital stay was 3.2±4.1 days [13, 32]. Regarding the study carried out by Oreoluwa Bajomo et al, Liverpool 2021, patients taken during the SARS-CoV-2 pandemic had an average hospital stay of 2.6 days in contrast to patients in the unexposed cohort who were hospitalized for an average of 3 days [14]. Finally, in the study by Heather C.M Pringle, et al, in Exeter 2021, it was reported that the length of hospital stay in the 2019 cohort (pre-COVID) was 4 days, while in the 2020 cohort (during the pandemic). it was 3 days [15]. Regarding the previous studies, 2 of them support our results, however two of them are in contrast with them, this was the reason why the development of this research was considered important to help clarify this association.

On the other hand, the significant intervening variables that demonstrated an association with prolonged hospital stay, in the multivariate analysis, were the time of day the surgery was performed and postoperative diagnosis, given that a p value <0.05 was found. Regarding the first, the study conducted by Marie Crandall et.al determined that patients operated on during the night shift had a 50% shorter prolonged hospital stay than those operated on during the day shift. Regarding the second, the study by Mateo Lozano, 2019, reports a statistically significant association between prolonged hospital stay and histological type (complicated or uncomplicated) (OR: 12.18; 95% CI: 5.10—29.06, p=0.00) (30.12) Thus, Table 3 shows that both infection with SARS-CoV-2 (RRa: 1.83, 95% CI: 1.02—3.29) and postoperative diagnosis as complicated appendicitis (RRa: 2.94, 95% CI: 1.44—5.98) are independent risk factors for prolonged hospital stay in postoperative patients for acute appendicitis.

Table 3. Multivariate analysis of risk factors for prolonged hospital stay after surgery for acute appendicitis

Note. Adjusted relative risk, according to the logistic regression model built with the variables infection with SARS-CoV-2 (yes), postoperative diagnosis (complicated appendicitis) and time of day the surgery was performed (during night shift). Source: file service of the Trujillo Regional Teaching Hospital.

Among the limitations that we must recognize in the development of this work, it is worth noting those that depend exclusively on the data collection system used in public hospitals, such as the Trujillo Regional Teaching Hospital, in which there are various shortcomings and errors in the writing, storage, interpretation and access to the data recorded in the medical records; which inevitably meant successive delays to complete the collection and processing of the data that we are presenting, with an information bias due to the retrospective nature of the study. A selection bias could also occur since the selection of the patients that formed the cohort was at the discretion of the research team.

Conclusions

Based on the results presented, it is concluded that there is an association between SARS-CoV-2 infection and prolonged hospital stay in postoperative patients for acute appendicitis. The incidence of prolonged hospital stay among postoperative patients for acute appendicitis coinfected with SARS-CoV-2 was 26%. The incidence of prolonged hospital stay among postoperative patients for acute appendicitis without SARS-CoV-2 infection was 15%. The relative risk of prolonged hospital stay in postoperative patients for acute appendicitis coinfected by SARS-CoV-2 compared to those not infected was 1.76. Which means that the former are 1.76 more likely to have a prolonged hospital stay than the latter. Based on the statistical analysis of the data, the variables time of day the surgery was performed and postoperative diagnosis are those associated with prolonged hospital stay according to the p value <0.05.

Ethical responsibilities

Protection of people and animals.

The authors declare that no experiments on humans or animals have been performed in this manuscript.

Data confidentiality.

The authors declare that no patient data appears in this article.

Financing: None.

Conflicts of interest: None.