Updated December 8, 2020
These guidelines are meant to provide advice for surgeons and to serve the best interests of patients based on estimates of risk for average patients (in terms of clinical condition, patient health, hospital resource availability) and are meant to be considered for patients presenting with general surgical emergencies during this pandemic. For patients who are known to be COVID-19 positive or at high clinical suspicion for COVID infection, non-operative management is preferred, if feasible and safe for the patient. If operation is required in these patients then appropriate PPE should be utilized and precautions taken to protect the health care team.
Most acute hemorrhoidal conditions can be managed non-operatively based on the judgment of the surgeon. Where possible, management under local anesthesia in an outpatient setting may be appropriate. Emergency surgical procedures should generally be reserved for significant bleeding and severe disease or disease unresponsive to non-operative measures.
Perianal abscesses that are superficial and localized may be managed with incision and drainage with local anesthesia based on the surgeon’s usual indications. Incision and drainage of larger perirectal abscesses in the operating room should not be delayed in order to ensure adequate initial drainage, prevent extension of the disease to an invasive infection and shorten hospital stay. If the operating room is not available percutaneous drainage should be considered as an alternative and temporizing measure.
Superficial and localized abscesses may be managed with incision and drainage with local anesthesia. Incision and drainage in the operating room of larger abscesses or those with an intra-muscular component is preferred to ensure adequate initial drainage and shorten hospital stay. Patients with concern for necrotizing soft tissue infections should proceed with emergent debridement.
Antimicrobial therapy should be used if infected necrosis is confirmed. The “step up” approach is recommended which includes: percutaneous drainage, endoscopic debridement or by interventional radiologic techniques (note that I/R techniques may be preferred in COVID positive patients due to risk of aerosolization with endoscopy), followed by laparoscopic or open operative drainage if no other option available.
Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010:362-1491-1502. https://www.nejm.org/doi/full/10.1056/nejmoa0908821
Patients presenting with suspected bowel perforation, intestinal ischemia, closed loop obstruction, or obstruction secondary to incarcerated hernia should proceed with emergent surgery. Non-operative management of small bowel obstruction secondary to adhesions should follow usual practice.
There is high-quality evidence that most patients with appendicitis can be managed with antibiotics instead of appendectomy (69 percent overall avoid appendectomy by 90 days, 75 percent of those without appendicolith, and 59 percent of those with appendicolith). Based on the surgeon’s judgment, patient preferences, and local resources (e.g., hospital staff, bed, and PPE supply availability) antibiotics are an acceptable first-line treatment, with appendectomy offered for those with worsening or recurrent symptoms. Length of time in the hospital setting was similar between treatments, but nearly half of patients receiving antibiotics were not admitted to the hospital. Antibiotics resulted in more 90-day emergency room visits and hospitalizations. Antibiotics were associated with a higher risk of complications in those with an appendicolith.
CODA Collaborative, Flum DR, Davidson GH, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020;383(20):1907-1919. doi:10.1056/NEJMoa2014320
Frazee RC, Abernathy SW, Davis M, Hendricks JC, Isbell TV, Regner JL, Smith RW. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis. J Trauma Acute Care Surg. 2014 Jan;76(1):79-83. doi: 10.1097/TA.0b013e3182ab0d42
Mahida JB, Lodwick DL, Macion KM, et al. High failure rate of nonoperative management of acute appendicitis with an appendicolith in children. J Pediatr Surg. 2016;51(6):908-911. https://doi.org/10.1016/j.jpedsurg.2016.02.056.
Complicated appendicitis can be managed per usual practice. In brief, all patients should receive IV antibiotics until clinically improving, followed by transition to PO antibiotics. Patients with a defined abscess should undergo percutaneous drainage. Patients with evidence of perforation may be managed with percutaneous drainage or operation based on patient condition. Patients who fail non-operative management should proceed to surgery expeditiously
Patients with symptomatic cholelithiasis and chronic cholecystitis should have their pain managed. If this is feasible, surgery should be delayed and performed electively. For patients with crescendo symptoms, and for those with pain refractory to medical management, consider laparoscopic cholecystectomy.
Patients with choledocholithiasis without signs of cholangitis may be managed expectantly. For those with larger stones, and those who fail to spontaneously pass their stone, an ERCP with sphincterotomy, followed by elective cholecystectomy in a delayed fashion is appropriate. Note that appropriate precautions should be taken for ERCP in patients with COVID-19 infection as it should be considered an aerosolizing procedure.
Healthy patients with acute cholecystitis should undergo laparoscopic cholecystectomy to minimize hospital stay. If the patient is too high risk for surgery or an operating room is not available then consider IV antibiotics. Patients who fail to clinically improve on antibiotics, and those with signs of sepsis should undergo percutaneous cholecystostomy in addition to the administration of IV antibiotics
Patients with ascending cholangitis often respond to broad spectrum antibiotics and appropriate resuscitation. For patients that fail to clinically improve and those with sepsis, ERCP and sphincterotomy are indicated. If there is a concern for concomitant cholecystitis, percutaneous cholecystostomy may be appropriate. Note that appropriate precautions should be taken for ERCP in patients with COVID-19 infection as it should be considered an aerosolizing procedure. Cholecystectomy should be performed in a delayed fashion.
Uncomplicated diverticulitis can be managed with usual care which includes IV antibiotics with transition to PO antibiotics. Patients who present with purulent or feculent peritonitis with diffuse pneumoperitoneum should undergo surgery. Hinchey class 1 and 2 diverticulitis should be managed with percutaneous drainage in addition to antimicrobial therapy. Patients with phlegmon may be successfully managed with antibiotics, with percutaneous drainage reserved for subsequent abscess development. Patients who fail non-operative management should proceed to surgery expeditiously