The COVID-19 pandemic Lockdown caused a significant reduction of the general surgical emergency operations of 42.5% (p = 0.005) in the entire Region 51. This noteworthy reduction of emergencies was reported also from other medical specialties around the globe. Garcia et al. reported about diminished activations of US cardiac catheterization laboratory for STEMI in the COVID-19 era [7]. The Medscape Medical News also announce a 30% decreased rates of major stroke in Chicago [8]. Furthermore, the preliminary data to Stroke care from Shanghai reported a decrease of thrombectomies by 50% in the first month after the Spring Festival (24th to 30th January 2020) [9]. Those specialties discussed the reduction of stress and the deceleration of public live as a potential reason for such a decline of cardiovascular emergencies [7–9].
As the role of negative stress in functional gastrointestinal disorders is well known, the effect of stress on development of abdominal emergencies has not been described so far [11].
The strong decrease of acute appendectomies and acute cholecystectomies of 54% and 39% respectively in the year 2020 in our cohort is striking. Many different deviations of stated therapies, to minimize the risk of COVID-19 cross infection are being reported. Patel et al. described shortly ago an increased consumption of a conservative antibiotic therapy for uncomplicated appendicitis, during the Lockdown in England [12]. This therapy is in the literature stated as a feasible and save option, but with an increased risk for appendicitis recurrence [13, 14]. Patel also reported a deviation from the guidelines and an exclusively use of a conservative therapy as a first line treatment for acute cholecystitis [12, 15].
Based on this knowledge, all centers in Region 51 confirmed no change to the state of the art operative therapy of acute appendicitis and cholecystitis.
The official recommendation of the authorities to the public was to avoid hospitals until a “real” emergency occurs. Furthermore, the patients were encourage to discuss the general practitioners in the first line. According to that, the general practitioners haven´t reported any increase of patients load or change of the therapeutic pathways, including the reporting of all patients suspected of abdominal emergency to a surgical specialist. If the reduction of the case load of emergencies or preferred antibiotic treatment or both are responsible for reduction of acute surgeries in our region stays unknown.
The strict politics of the authorities, with the clear aim of preparing the medical system for a huge number of COVID-19 positive patients, as seen in Italy, caused a dramatic reduction of all elective surgeries of 46% during the Lockdown. We have also observed a faster relocation of the Non-COVID patient’s therapy to the outpatient setting, leading to a shorter median LOS of 3 days (reduction of 25%) in the examined period of 2020. The same trend was reported by Patel et al. in his cohort with a significant reduction of LOS from 3 to 2 days (p = 0.04) [12].
The general avoidance of medical care due to the social distancing or due to the concerns of patients of being infected with COVID-19 in the hospital, remain the most common reasons for the decrease of emergency surgeries in entire Region 51. To underline these facts, we have identified a noticeable decrease in the frequency of 6 of 13 main categories of emergency surgeries in Center 1, which was the only COVID designed Center (“Hot” hospital) in the examined Region 51. Huang et al. already reported this potential perception of personal danger, dramatically reducing the willingness of patients to visit an emergency department of the “Hot” hospital, in 2003, during the last epidemic of SARS from Taipei, Taiwan [16]. The authors reported a reduction of up to 51.6% in daily visits of emergency departments at the peak of the SARS epidemic, which persisted for 3 months after the end of the epidemic. The long-lasting effect of people´s fear of designed SARS centers was reported from the same hospital in Taipei and published in 2008. The results show, that in long-term observation the outpatient department of the general surgery department had still significantly less patients treated at 4 years after SARS epidemic [17].
The further consequences of the COVID-19 pandemic for acute surgical patients, who did not received an appropriate, guidelines conform, therapy remain still unclear and should be further examined. We cannot forget the potentially high mortality of severe intra-abdominal infections, which could reach up to 40% in case of sepsis [3]. The Statistic Austria reported recently the mortality data for Austria during Lockdown (Calendar Week 12 to 16), in comparison to the average for the period in the years 2016–2019. They found a significant growth of the week mortality in the population of 65 Years and older. The highest growth of 252 deaths (16.9%) in the calendar week 12 and growth of 200 deaths (14.9%) in the week 14 was registered again in the group of 65 Years and older. The growth of mortality in State Salzburg was 4% in calendar week 14 and remained low during the whole Lockdown, without a significant change to previous years. Unfortunately, it is not possible to identify the reasons for reported deaths. The increased mortality confirms the frailty of elderly people and reflects the results of studies taking the emergency abdominal surgery in the elderly under the scope. These are showing a higher mortality of 8–16% in this group even being treated [18–20]. Just to reflect the COVID Situation during our examined period, the total number of COVID positive deaths in Austria was 384 and 27 in whole State Salzburg, Austria [21, 22].