Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Aug 27, 2021; 13(8): 859-870
Published online Aug 27, 2021. doi: 10.4240/wjgs.v13.i8.859
Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis
Orly Nadell Farber, Giselle I Gomez, Ashley L Titan, Andrea T Fisher, Christopher J Puntasecca, Veronica Toro Arana, Arielle Kempinsky, Clare E Wise, Kovi E Bessoff, Mary T Hawn, James R Korndorffer Jr, Joseph D Forrester, Micaela M Esquivel
Orly Nadell Farber, Giselle I Gomez, Ashley L Titan, Andrea T Fisher, Christopher J Puntasecca, Veronica Toro Arana, Arielle Kempinsky, Clare E Wise, Kovi E Bessoff, Mary T Hawn, James R Korndorffer Jr, Joseph D Forrester, Micaela M Esquivel, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
Author contributions: Esquivel MM, Titan AL, Hawn MT, Bessoff KE, Korndorffer JR Jr, and Forrester JD designed the study; Farber ON, Gomez GI, Fisher AT, Puntasecca CJ, Arana VT, Kempinsky A, Wise CE collected and interpreted the data; Gomez GI and Arana VT performed statistical analyses; Farber ON, Gomez GI, Titan AL, Fisher AT, Puntasecca CJ wrote the manuscript; all authors read and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by the Stanford University Institutional Review Board, No. 56347.
Informed consent statement: This retrospective chart review study is exempt from requiring informed consent.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at mesquive@stanford.edu. No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Micaela M Esquivel, MD, Assistant Professor, Department of Surgery, Stanford University School of Medicine, 900 Blake Wilbur Dr, Palo Alto, CA 94305, United States. mesquive@stanford.edu
Received: April 1, 2021
Peer-review started: April 1, 2021
First decision: May 13, 2021
Revised: May 31, 2021
Accepted: July 9, 2021
Article in press: July 9, 2021
Published online: August 27, 2021

The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.


To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.


A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson’s r correlation coefficient. Variables were compared using the Welch’s t-Test, Chi-squared tests, and Fisher’s exact test as appropriate.


Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].


During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

Keywords: COVID-19, Cholecystitis, Biliary colic, Appendicitis, Acute care surgery

Core Tip: The coronavirus disease 2019 (COVID-19) pandemic has impacted patients with a wide range of diseases due to stay-at-home orders and concerns surrounding the safety and feasibility of accessing care. This study demonstrates that the pandemic resulted in more severe presentations of gallbladder disease and appendicitis, which may be related to delays prior to presentation. Additionally, the pandemic influenced the management of patients with acute surgical conditions, and affected outcomes for patients with acute appendicitis. These findings can inform policy and public messaging surrounding stay-at-home orders and access to care during future COVID-19 surges.