Operative vs Non-Operative Management of Acute Appendicitis and Acute Cholecystitis in COVID-19 Positive Patients

Study Results

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Basic Information

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Recruitment Status

TERMINATED

Clinical Phase

NA

Total Enrollment

2 participants

Study Classification

INTERVENTIONAL

Study Start Date

2020-12-28

Study Completion Date

2021-04-06

Brief Summary

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This study evaluates operative and non-operative management of acute appendicitis (infection or inflammation of the appendix) and acute cholecystitis (inflammation/infection of the gallbladder) in patients with active mild to moderate COVID-19 infection. The hypothesis is that COVID+ patients with uncomplicated acute appendicitis or acute cholecystitis amendable to a laparoscopic procedure can have safe operative outcomes compared to those managed non-operatively.

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Detailed Description

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As the novel coronavirus disease 2019 (COVID-19) disseminates across the United States, more routine preoperative testing is going to expose infected patients with no or mild pneumonia symptoms. Currently, little is known regarding the true consequences of general anesthesia in COVID-positive (COVID+) patients. Surgeons are going to face challenging decisions regarding whether or not to operate for non-elective cases requiring general anesthesia when non-operative treatment options exist. Patients with acute appendicitis are usually treated with an operation to remove the appendix, but they can also be initially treated with antibiotics and have an operation at a later date. Similarly, patients with acute cholecystitis are usually treated with an operation to remove the gallbladder, but they can be treated with antibiotics and a percutaneous cholecystostomy tube (a tube that going through the skin to drain the gallbladder) and have an operation at a later date. However, patients managed without a definitive operation may require more resource utilization, PPE consumption, interactions with hospital personnel, and could experience treatment failures that exacerbate their viral illness. This is a pilot study comparing the safety of operative versus non-operative management of COVID+ patients with mild to moderate symptoms.

Conditions

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Covid19 Appendicitis Cholecystitis, Acute Cholecystitis; Gallstone Cholecystitis

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

This will be a prospective, non-blinded, pilot randomized controlled trial comparing operative to non-operative management of acute appendicitis and acute cholecystitis in patients with mild to moderate COVID-19 infection. This will be a two-arm trial with intervention 1: intervention 2 allocation ratio of 1:1.

Primary Study Purpose

TREATMENT

Blinding Strategy

NONE

Participants will be informed regarding the treatment they receive at the time of randomization.

Study Groups

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Operative management

Treatment with surgery

Group Type ACTIVE_COMPARATOR

Operative management

Intervention Type PROCEDURE

Patients will undergo surgical removal of the affected organ. The initial approach will be in a minimally invasive, laparoscopic fashion. If necessary, conversion to an open operation may be performed. These patients will be treated preoperatively and postoperatively with similar antibiotic regimens, however the duration of antibiotic therapies will be dependent on factors such as intraoperative findings, resolution of laboratory abnormalities, and tolerance of oral medications.

Non-operative management

Treatment with antibiotics

Group Type ACTIVE_COMPARATOR

Non-operative management

Intervention Type PROCEDURE

Patients will be treated with 3 days of intravenous antibiotics followed by 7 days of oral antibiotics, as described below:

Non-penicillin allergic patients

* piperacillin/tazobactam 3.375g IV every 6 hours for 3 days
* amoxicillin/clavulanate 875/125mg by mouth every 12 hours for 7 days

Penicillin allergic patients

* ertapenem 1g IV every 24 hours for 3 days
* ciprofloxacin 500mg every 12 hours AND metronidazole 500mg every 8 hours for 7 days

Patients may be considered to have failed non-operative management (e.g. treatment failure) if they experience absence of clinical improvement, worsening abdominal pain and/or localized/diffuse peritonitis in the judgment of the treating surgeon at any point within the study window. If this occurs, then surgeons may proceed with rescue appendectomy or percutaneous drainage in the setting of appendicitis, or with placement of a percutaneous cholecystostomy tube in the setting of acute cholecystitis.

Interventions

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Operative management

Patients will undergo surgical removal of the affected organ. The initial approach will be in a minimally invasive, laparoscopic fashion. If necessary, conversion to an open operation may be performed. These patients will be treated preoperatively and postoperatively with similar antibiotic regimens, however the duration of antibiotic therapies will be dependent on factors such as intraoperative findings, resolution of laboratory abnormalities, and tolerance of oral medications.

Intervention Type PROCEDURE

Non-operative management

Patients will be treated with 3 days of intravenous antibiotics followed by 7 days of oral antibiotics, as described below:

Non-penicillin allergic patients

* piperacillin/tazobactam 3.375g IV every 6 hours for 3 days
* amoxicillin/clavulanate 875/125mg by mouth every 12 hours for 7 days

Penicillin allergic patients

* ertapenem 1g IV every 24 hours for 3 days
* ciprofloxacin 500mg every 12 hours AND metronidazole 500mg every 8 hours for 7 days

Patients may be considered to have failed non-operative management (e.g. treatment failure) if they experience absence of clinical improvement, worsening abdominal pain and/or localized/diffuse peritonitis in the judgment of the treating surgeon at any point within the study window. If this occurs, then surgeons may proceed with rescue appendectomy or percutaneous drainage in the setting of appendicitis, or with placement of a percutaneous cholecystostomy tube in the setting of acute cholecystitis.

Intervention Type PROCEDURE

Eligibility Criteria

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Inclusion Criteria

* COVID-19 confirmed positive by a microbiologic test.
* Mild COVID-19 - no or mild pneumonia
* EITHER

1. Uncomplicated acute appendicitis without a fecalith OR
2. Acute cholecystitis - by TG18/TG13 diagnostic criteria where definite diagnosis requires one item in A + one item in B + C A. Local signs of inflammation etc.



1. Murphy's sign
2. RUQ mass/pain/tenderness B. Systemic signs of inflammation etc.



1. Fever
2. elevated CRP
3. elevated WBC count C. Imaging findings characteristic of acute cholecystitis

Exclusion Criteria

* Active pregnancy
* COVID-19 severe disease that would be a contraindication to operative intervention at the discretion of the attending surgeon supported by the following, none of which are individually required or are a strict exclusion criterion as some of these could be attributed or exacerbated by the underlying surgical problem:

1. Persistent dyspnea
2. Persistent respiratory frequency \>30/min
3. Persistent blood oxygen saturation \<93%
4. Partial pressure of arterial oxygen to fraction of inspired oxygen ratio \<300
5. Lung infiltrates \>50%
* COVID-19 critical disease - respiratory failure, shock, or multiorgan dysfunction
* The surgeon expects increased operative complexity - high risk of conversion to open or prolonged procedure
* Unable or unwilling to consent or fulfill study procedures - need to complete 90 day follow-up by telephone

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No