Incidence of Perforated Appendicitis during the COVID-19 Pandemic: Lessons to Be Considered in the Second Wave


Acute appendicitis is the most frequent disease requiring emergency surgery and has an estimated lifetime risk of 6.7 to 8.6%.1 Perforated appendicitis has a mortality rate of up to 5%.2,3

The COVID-19-pandemic has impacted many lives and affects healthcare systems globally. To provide sufficient capacity for SARS-CoV-2 patients, elective surgery cases have been postponed in Germany from March 16, 2020, to May 2020.

An increasing number of perforated appendicitis cases since March 16, 2020, prompted the question whether this increase can be ascribed to delayed initial medical contact after the onset of symptoms as a result of fear of contracting COVID-19 or whether there was a patient shift in our catchment area.

Material and Methods

This is a retrospective, single-center study, approved by the local ethic committee with analysis of all patients treated for acute appendicitis in a 10-week period from March 16 to May 31 in 2018, 2019, and 2020 were considered for the study. Informed consent was obtained from all participants.

Data are available in SPSS v. (IBM, Armonk, NY, USA) and were presented as means ± SD.


In total, 143 patients (73 male, 70 female, mean age 38.36 years) were operated for acute appendicitis. Table 1 shows the patients’ characteristics. In 2018, 12 (22.22%) of 54 patients and in 2019, 13 (30.23%) of 43 patients with acute appendicitis suffered a perforation. In 2020, during 10 weeks of the first wave of COVID-19-pandemic, 21 (44.68%) of 46 patients with acute appendicitis perforations were found (p = 0.039). Treatment-related characteristics are listed in Table 2.

Table 1 Patient characteristics according to year of treatment
Table 2 Treatment characteristics of acute appendicitis according to year of treatment


Our clinical impression of seeing more complicated events of different entities, especially perforated appendicitis, was proven by this analysis. No relation between SARS-CoV-2 infections and appendicitis has been described so far.

We found a statistically significant increase in perforations during the recent period (p = 0.039).

Lessons to be considered in the second wave: Especially in the actual situation of increasing number of SARS-CoV-2 infections surgeons and institutions need to be prepared for advanced intraoperative findings, more intensive monitoring, more complications, and longer hospital stay in patients with acute appendicitis.


  1. 1.

    Baird DLH, Simillis C, Kontovounisios C et al. (2017) Acute appendicitis. BMJ 357:j1703

    Article  Google Scholar 

  2. 2.

    Flum DR (2015) Clinical practice. Acute appendicitis--appendectomy or the "antibiotics first" strategy. N Engl J Med 372:1937-1943

    Article  Google Scholar 

  3. 3.

    Papandria D, Lardaro T, Rhee D et al. (2013) Risk factors for conversion from laparoscopic to open surgery: analysis of 2138 converted operations in the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 79:914-921

    Article  Google Scholar 

Download references


Dörte Wichmann = D.W.1

Daniel Wulff = D.W.2

D.W.1, U.S., and D.W.2 were involved in study design, interpretation of data, and drafting of the article. H.T. and C.B. were involved in data acquisition and drafting of the article. R.A. and A.K. were involved in data analysis and drafting of the article. D.W.1, U.S., D.W.2, C.B., K.T., A.K., and R.A. were involved in data acquisition and critical revision of the article.


Open Access funding enabled and organized by Projekt DEAL.

Author information



Corresponding author

Correspondence to Dörte Wichmann.

Ethics declarations

Conflict of Interest

The authors declare having no conflict of interests.

Ethics Approval

This study was approved by the Ethics Committee of Tübingen University Hospital, Germany (No.: 324/2020BO2), and it is registered by (NCT04472052).

Informed Consent

Informed consent obtained from all individual participants included in the study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wichmann, D., Schweizer, U., Wulff, D. et al. Incidence of Perforated Appendicitis during the COVID-19 Pandemic: Lessons to Be Considered in the Second Wave. J Gastrointest Surg (2021).

Download citation


  • COVID-19
  • Perforated acute appendicitis