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Aim: The COVID‐19 pandemic led to widespread disruption of colorectal cancer services during 2020. Established cancer referral pathways were modified in response to reduced diagnostic availability. The aim of this paper is to assess the impact of COVID‐19 on colorectal cancer referral, presentation and stage. Methods: This was a single centre, retrospective cohort study performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January and December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging. Results: In all, 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender and tumour location (P > 0.05). There was a significant decrease in urgent suspected cancer referrals, diagnostic colonoscopy and radiological imaging performed between March and June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018–2019 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018–2019 (P = 0.03). Conclusion: This study demonstrates that a relatively short‐term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is therefore critical that efforts are made to make this pathway more robust to minimize the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Aim: The coronavirus pandemic has led to significant challenges for healthcare delivery across the globe. Non‐emergency endoscopic activity in the UK has been postponed, raising concerns of increased delays in the diagnosis of colorectal cancer and a surge in demand once services resume. Measures to mitigate this risk must be considered. Method: This paper reviews various investigative modalities for colorectal disease which could be deployed during cessation of colonoscopy services. We focus on colon capsule endoscopy (CCE) due to its relevance during the COVID‐19 pandemic and its ability to triage patients effectively to further endoscopic investigations. Results: CT of the abdomen and pelvis has been suggested as a triage tool while access to colonoscopy is limited. However, CT may lead to the spread of COVID‐19 as patients attend the hospital, and it exposes them to the risks of radiation. Faecal immunochemistry tests have been demonstrated as a good predictor of colonic pathology and could be safely used to risk stratify patients when prioritizing colonoscopy. CCE is a safe and innovative technology for investigating the colon. Procedures can be carried out in the community and can be conducted safely during the coronavirus pandemic. It has been shown to be an accurate detector of colonic neoplasia and can reduce demand for colonoscopy. Conclusion: As colonoscopy services resume, they will probably experience high demand leading to further delays for patients. CCE could be used to reduce the number of patients requiring colonoscopy and triage those requiring further endoscopic investigations appropriately. [ABSTRACT FROM AUTHOR]

Aim: The rapid spread of the COVID‐19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and emergency colorectal surgery, including surgery for colorectal cancer, several questions pertaining to operating room (OR) utilization and techniques needed to be rapidly addressed. Method: This manuscript discusses knowledge related to the critical considerations of patient and caregiver safety relating to personal protective equipment (PPE) and the operating room environment. Results: During the COVID‐19 pandemic, additional personal protective equipment (PPE) may be required contingent upon local availability of COVID‐19 testing and the incidence of known COVID‐19 infection in the respective community. In addition to standard COVID‐19 PPE precautions, a negative‐pressure environment, including an OR, has been recommended, especially for the performance of aerosol‐generating procedures (AGPs). Hospital spaces ranging from patient wards to ORs to endoscopy rooms have been successfully converted from standard positive‐pressure to negative‐pressure spaces. Another important consideration is the method of surgical access; specifically, minimally invasive surgery with pneumoperitoneum is an AGP and thus must be carefully considered. Current debate centres around whether it should be avoided in patients known to be infected with SARS‐CoV‐2 or whether it can be performed under precautions with safety measures in place to minimize exposure to aerosolized virus particles. Several important lessons learned from pressurized intraperitoneal aerosolized chemotherapy procedures are demonstrated to help improve our understanding and management. Conclusion: This paper evaluates the issues surrounding these challenges including the OR environment and AGPs which are germane to surgical practices around the world. Although there is no single universally agreed upon set of answers, we have presented what we think is a balanced cogent description of logical safe approaches to colorectal surgery during the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Aim: The COVID‐19 pandemic has reduced the capacity to diagnose and treat cancer worldwide due to the prioritization of COVID‐19 treatment. The aim of this study was to investigate treatment and outcomes of colon cancer in Sweden before and during the COVID‐19 pandemic. Methods: In an observational study, using the Swedish Colorectal Cancer Registry, we included (i) all Swedish patients diagnosed with colon cancer, and (ii) all patients undergoing surgery for colon cancer, in 2016–2020. Incidence of colon cancer, treatments and outcomes in 2020 were compared with 2019. Results: The number of colon cancer cases in Sweden in April–May 2020 was 27% lower than the previous year, whereas no difference was observed on an annual level (4,589 vs. 4,763 patients [−4%]). Among patients with colon cancer undergoing surgery in 2020, the proportion of resections was 93 vs. 94% in 2019, with no increase in acute resections. Time from diagnosis to elective surgery decreased (29 days vs. 33 days in 2020 vs. 2019). In 2020, more patients underwent a two‐stage procedure with a diverting stoma as first surgery (6.1%) vs. (4.4%) in 2019 (p = 0.0020) and more patients were treated with preoperative chemotherapy (5.1%) vs. (3,5%) 2019 (p = 0.0016). The proportion of patients that underwent laparoscopic surgery increased from 54% to 58% (p = 0.0017) There were no differences in length of stay, surgical complications, reoperation, ICU‐stay or 30‐day mortality between the years. Conclusion: Based on nationwide annual data, we did not observe adverse effects of the COVID‐19 pandemic on colon cancer treatment and short time outcomes in Sweden. [ABSTRACT FROM AUTHOR]

Aim: The SARS‐CoV‐2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non‐delayed surgery. Methods: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January–April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. Results: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90–1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69–1.27, P = 0.672). Longer delays were not associated with poorer outcomes. Conclusion: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID‐19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long‐term survival attributable to delays is likely to be due to micro‐metastatic disease. [ABSTRACT FROM AUTHOR]

Aim: The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME). Method: A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter‐saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand‐sewn coloanal anastomosis and (D) pull‐through. Intra‐operative and postoperative data were collected and compared. Results: A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3–5] vs. 7 [6–8] group A vs. 6 [5–7] group B, P = 0.000), requiring a hand‐sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5–6 in groups A, B and C, P = 0.026). Conclusion: Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has made a striking impact on healthcare services [1]. Finally, the strict use of personal protective equipment, providing a separate pathway to manage COVID-19 surgical patients as formerly recommended [9], and the use of evidence-based precautions all ensured the protection of the theatre staff and the team taking care of the patient. Fournier's gangrene in a COVID-19 patient with multiple comorbidities: Combatting the triple threat. [Extracted from the article]

Aim: The object of this work was to study how National Health Service hospitals in England and Wales aimed to maintain effective and safe colorectal cancer (CRC) services during the first peak of the COVID‐19 pandemic (April 2020). Method: A national survey was performed among all 148 hospitals providing CRC services. Information was collected about changes in referrals, diagnostic, staging and therapeutic procedures, as well as whether there was access to a 'cold site' (a hospital facility free of COVID‐19). Clinicians in each hospital were also asked to give the 'single most important lesson learned' about keeping services safe and effective. Results: Full responses were received from 123 (83%) hospitals, and information about 'cold sites' was available for 146 (99%). Eighty hospitals (54%) had access to a 'cold site' and this was increased in regions with higher COVID‐19 infection rates (p <0.001). Of the 123 responding hospitals, 105 (85%) indicated that referrals of patients with suspected CRC had dropped by at least 30%, and 69 (56%) indicated that treatment plans were altered in at least 50% of CRC patients. However, 'cold site' availability protected the capacity for diagnostic colonoscopy (p = 0.013) and CRC resection (p = 0.010). Many 'lessons learned' highlighted the importance of adequate structural service organization, often mentioning 'cold sites' and regional coordination as examples, good communication and triage of patients based on clinical urgency. Conclusion: Access to 'cold sites', as well as regional coordination, clear communication and strong leadership, were found to be pivotal in maintaining capacity for diagnosis and treatment of CRC during the COVID‐19 surge. [ABSTRACT FROM AUTHOR]

Aim: The dramatic curtailment of endoscopy and CT colonography capacity during the coronavirus pandemic has adversely impacted timely diagnosis of colorectal cancer (CRC). We describe a rapidly implemented COVID‐adapted diagnostic pathway to mitigate risk and maximize cancer diagnosis in patients referred with symptoms of suspected CRC. Method: The 'COVID‐adapted pathway' integrated multiple quantitative faecal immunochemical tests (qFIT) to enrich for significant colorectal disease with judicious use of CT with oral contrast to detect gross pathology. Patients reporting 'high‐risk' symptoms were triaged to qFIT+CT and the remainder underwent an initial qFIT to inform subsequent investigation. Demographic and clinical data were prospectively collected. Outcomes comprised cancer detection frequency. Results: Overall, 422 patients (median age 64 years, 220 women) were triaged using this pathway. Most (84.6%) were referred as 'urgent suspicious of cancer'. Of the 422 patients, 202 (47.9%) were triaged to CT and qFIT, 211 (50.0%) to qFIT only, eight (1.9%) to outpatient clinic and one to colonoscopy. Fifteen (3.6%) declined investigation and seven (1.7%) were deemed unfit. We detected 13 cancers (3.1%), similar to the mean cancer detection rate from all referrals in 2017–2019 (3.3%). Compared with the period 1 April–31 May in 2017–2019, we observed a 43% reduction in all primary care referrals (1071 referrals expected reducing to 609). Conclusion: This COVID‐adapted pathway mitigated the adverse effects on diagnostic capacity and detected cancer at the expected rate within those referred. However, the overall reduction in the number of referrals was substantial. The described risk‐mitigating measures could be a useful adjunct whilst standard diagnostic services remain constrained due to the ongoing pandemic. [ABSTRACT FROM AUTHOR]

Aim: The COVID‐19 pandemic has resulted in the near‐complete loss of routine endoscopy services. We describe a major reorganization of service at a regional referral centre (Royal Surrey NHS Foundation Trust) to manage the crisis. Faecal immunochemical testing (FIT) was implemented for triage to make optimum use of limited diagnostic resources. Consultations were switched from face‐to‐face to telephone. Our aim was to evaluate the impact FIT had on resource allocation and patient diagnoses in the first 3 months of use. Method: All colorectal 2‐week‐wait patient referrals were posted a pack requesting FIT and notification of telephone consultation. A prepaid envelope was included for return of the samples. At consultation, FIT was incorporated with the presenting symptoms to guide the choice of investigation and triage urgency. FIT ≥10 μg/g was interpreted as positive. Outcome data were collected prospectively and compared with retrospective audit data from prepandemic levels across 3 months. Results: From 26 March 2020 to 2 July 381 patients were referred who were invited to provide FIT samples and underwent telephone consultations. Three hundred and fifty eight FIT samples were returned (94%). Onward referral for colonoscopy reduced from 62% to 34% (P < 0.001). There were 14 colorectal cancers (CRC) (3.7%) diagnosed, which was not statistically different from the prepandemic level of 3.9% (P = 0.995). Twelve of the 14 patients with a CRC diagnosis had provided samples; all 12 had FIT ≥10 μg/g and were offered fast‐track investigations. Conclusions: The incorporation of FIT optimized the allocation of limited resources to triage those who required urgent colonic investigation for detecting CRC. [ABSTRACT FROM AUTHOR]

Aim: The COVID‐19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID‐19 infection. Methods: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end‐to‐end stapled anastomosis and extraction of the specimen through mini‐laparotomy in the ideal location. Results: We present preliminary results of 17 patients with left‐sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120–280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3–12 days). There was one case of anastomotic leak managed with conservative treatment. Conclusion: Intracorporeal resection and end‐to‐end anastomosis with the possibility of extraction of the specimen by a mini‐laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID‐19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis. [ABSTRACT FROM AUTHOR]

Aim: There is not sufficient evidence about whether stool DNA methylation tests allow prioritizing patients to colonoscopy. Due to the COVID‐19 pandemic, there will be a wait‐list for rescheduling colonoscopies once the mitigation is lifted. The aim of this meta‐analysis was to evaluate the accuracy of stool DNA methylation tests in detecting colorectal cancer. Methods: The PubMed, Cochrane Library and MEDLINE via Ovid were searched. Studies reporting the accuracy (Sackett phase 2 or 3) of stool DNA methylation tests to detect sporadic colorectal cancer were included. The DerSimonian–Laird method with random‐effects model was utilized for meta‐analysis. Results: Forty‐six studies totaling 16 149 patients were included in the meta‐analysis. The pooled sensitivity and specificity of all single genes and combinations was 62.7% (57.7%, 67.4%) and 91% (89.5%, 92.2%), respectively. Combinations of genes provided higher sensitivity compared to single genes (80.8% [75.1%, 85.4%] vs. 57.8% [52.3%, 63.1%]) with no significant decrease in specificity (87.8% [84.1%, 90.7%] vs. 92.1% [90.4%, 93.5%]). The most accurate single gene was found to be SDC2 with a sensitivity of 83.1% (72.6%, 90.2%) and a specificity of 91.2% (88.6%, 93.2%). Conclusions: Stool DNA methylation tests have high specificity (92%) with relatively lower sensitivity (81%). Combining genes increases sensitivity compared to single gene tests. The single most accurate gene is SDC2, which should be considered for further research. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to describe the change in surgical practice and the impact of SARS‐CoV‐2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS‐CoV‐2 pandemic. Method: This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS‐CoV‐2. Centres entered data from their first recorded case of COVID‐19 until 19 April 2020. The primary outcome was 30‐day mortality. Secondary outcomes included anastomotic leak, postoperative SARS‐CoV‐2 and a comparison with prepandemic European Society of Coloproctology cohort data. Results: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty‐day mortality was 1.8% (38/2073), the incidence of postoperative SARS‐CoV‐2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS‐CoV‐2 (14/1601, 0.9%) and highest in patients with both a leak and SARS‐CoV‐2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58–14.06), postoperative SARS‐CoV‐2 (16.90, 7.86–36.38), male sex (2.46, 1.01–5.93), age >70 years (2.87, 1.32–6.20) and advanced cancer stage (3.43, 1.16–10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%). Conclusion: Surgeons need to further mitigate against both SARS‐CoV‐2 and anastomotic leak when offering surgery during current and future COVID‐19 waves based on patient, operative and organizational risks. [ABSTRACT FROM AUTHOR]

Aim: Proctology is one of the surgical specialties that has suffered the most during COVID‐19 pandemic. Using a cross‐sectional non‐incentivised World Wide Web survey, we aimed to snapshot the current status of proctological practice in six world regions. Method: Surgeons affiliated to renowned scientific societies with an interest in coloproctology were invited to join the survey. Members of the ProctoLock Working Group enhanced recruitment by direct invitation. The predictive power of respondents' and hospitals' demographics on the change of status of surgical and outpatient activities was calculated. Results: Respondents (n = 1050) were mostly men (79%), with a mean age of 46.9 years, at consultant level (79%), practising in academic hospitals (53%) offering a dedicated proctology service (68%). A total of 119 (11%) tested positive for SARS‐CoV‐2. The majority (54%) came from Europe. Participants from Asia reported a higher proportion of unaltered practice (17%), while those from Europe had the highest proportion of fully stopped practice (20%). The likelihood of ongoing surgical practice was higher in men (OR 1.54, 95% CI 1.13–2.09; P = 0.006), in those reporting readily availability of personal protective equipment (PPE) (OR 1.40, 1.08–1.42; P = 0.012) and in centres that were partially or not at all involved in COVID‐19 care (OR 2.95, 2.14–4.09; P < 0.001). This chance decreased by 2% per year of respondent's age (P = 0.001). Conclusion: Several factors including different screening policies and resource capacity affected the current status of proctological practice. This information may help health authorities to formulate effective preventive strategies to limit curtailment of care of these patients during the pandemic. [ABSTRACT FROM AUTHOR]

This European Society of Coloproctology guidance focuses on a proposed conceptual framework to resume standard service in colorectal surgery. The proposed conceptual framework is a schematic and stepwise approach including: in‐depth assessment of damage to non‐COVID‐19‐related colorectal service; the return of service (integration with the COVID‐19‐specific service and the existing operational continuity planning); safety arrangements in parallel with minimizing downtime; the required support for staff and patients; the aftermath of the pandemic and continued strategic planning. This will be dynamic guidance with ongoing updates using critical appraisal of emerging evidence. We will welcome input from all stakeholders (statutory organizations, healthcare professionals, public and patients). Any new questions, new data and discussion are welcome via https://www.escp.eu.com/guidelines. [ABSTRACT FROM AUTHOR]

Aim: The aim of this work was to investigate the sensitivity and utility of CT of the chest in diagnosing active SARS‐Cov‐2 (COVID‐19) infection, and its potential application to the surgical setting. Method: A literature review was conducted using Google Scholar® and MEDLINE®/PubMed® to identify current available evidence regarding the sensitivity of CT chest compared with RT‐PCR for the diagnosis of COVID‐19‐positive patients. GRADE criteria and the QUADAS 2 tool were used to assess the level of evidence. Results: A total of 20 articles were identified that addressed the question of sensitivity of CT for diagnosis of symptomatic and asymptomatic COVID‐19‐positive patients. Overall sensitivity of CT scan ranged from 57%–100% for symptomatic and 46%–100% for asymptomatic COVID‐19 patients, while that of RT‐PCR ranged from 39%–89%. CT chest was a better diagnostic modality and capable of detecting active infection earlier in the time course of infection than RT‐PCR in symptomatic patients. In asymptomatic patients, disease prevalence seems to play a role in the positive predictive value. Minimal evidence exists regarding the sensitivity of CT in patients who are asymptomatic. Conclusions: In surgical patients, CT chest should be considered as an important adjunct for detection of COVID‐19 infection in patients who are symptomatic with negative RT‐PCR prior to any operation. For surgical patients who are asymptomatic, there is insufficient evidence to recommend routine preoperative CT chest for COVID‐19 screening. [ABSTRACT FROM AUTHOR]

Aim: The current COVID‐19 pandemic is challenging healthcare systems at a global level. We provide a practical strategy to reorganize pathways of emergency and elective colorectal surgery during the COVID‐19 pandemic. Method: The authors, all from areas affected by the COVID‐19 emergency, brainstormed remotely to define the key‐points to be discussed. Tasks were assigned, concerning specific aspects of colorectal surgery during the pandemic, including the administrative management of the crisis in Italy. The recommendations (based on experience and on the limited evidence available) were collated and summarized. Results: Little is known about the transmission of COVID‐19, but it has shown a rapid spread. It is prudent to stop non‐cancer procedures and prioritize urgent cancer treatment. Endoscopy and proctological procedures should be performed highly selectively. When dealing with colorectal emergencies, a conservative approach is advised. Specific procedures should be followed when operating on COVID‐19‐patients, using dedicated personal protective equipment and adhering to specific rules. Some policies are described, including minimally‐invasive surgery. These policies outline the strict regulation of entry/ exit into theatres and operating building as well as advice on performing procedures safely to reduce risk of spreading the virus. It is likely that a reorganization of health system is required, both at central and local levels. A description of the strategy adopted in Italy is provided. Conclusion: Evidence on the management of patients needing surgery for colorectal conditions during the COVID‐19 pandemic is currently lacking. Lessons learnt from healthcare professionals that have managed high volumes of surgical patients during the pandemic could be useful to mitigate some risks and reduce exposure to other patients, public and healthcare staff. [ABSTRACT FROM AUTHOR]

Although the Covid pandemic I per se i is not a Black Swan, colorectal surgeons now face one related to it, namely vaccine induced thrombosis & thrombocytopenia syndrome. Those colorectal surgeons who have to provide an emergency general surgery/acute care service will undoubtedly see patients with abdominal pain and thrombocytopaenia within 5-28 days of COVID-19 vaccination over the coming months as vaccine programmes disseminate. The COVID-19 pandemic continues to cause significant disruption to our everyday lives and the services that we strive to provide for our patients. [Extracted from the article]

I Dear Editor i , COVID-19 (SARS-CoV-2) has caused major disruption to healthcare practices globally. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Amoxicillin plus clavulanic acid versus appendectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomized controlled trial. [Extracted from the article]