Computed tomography-based triage and outcomes of a dedicated COVID-19 Emergency Surgical Team (CEST) for suspected acute abdomen in a Korean COVID-19 base hospital: a retrospective cohort study
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The COVID-19 pandemic significantly disrupted surgical services and necessitated the development of new clinical protocols. National Health Insurance Service Ilsan Hospital in Korea established a COVID-19 Emergency Surgical Team (CEST) to manage surgical cases and optimize medical staff utilization, thereby ensuring timely care during the pandemic. This study describes our experience with the CEST and highlights its potential role in institutional preparedness for future public health crises.
Methods
Between December 19, 2020, and April 4, 2022, this study included patients with laboratory-confirmed COVID-19 who were hospitalized at National Health Insurance Service Ilsan Hospital, a designated COVID-19 treatment center in Korea. Among these patients, those who underwent abdominopelvic computed tomography (APCT) were selected for analysis, and the indications for APCT were categorized. Patients specifically evaluated for suspected surgical abdomen were identified for subgroup analysis.
Results
Among 89 patients who underwent APCT, 32 (36.0%) were evaluated for suspected acute abdomen requiring urgent attention; 25 (28.1%) for persistent fever or elevated inflammatory markers; 15 (16.9%) for acute kidney injury; and 7 (7.9%) for liver enzyme elevation. Compared with the remaining 3,765 patients, the 32 patients with suspected surgical abdomen were significantly older and had longer hospital stays, higher rates of intensive care unit admission, and greater use of high-flow nasal cannula, dexamethasone, and antibiotics. Initial laboratory findings demonstrated higher white blood cell count, ferritin, creatinine, bilirubin, and D-dimer levels in this group. This case series underscores the role of the CEST in managing surgical patients with COVID-19.
Conclusion
We describe our institutional experience with the CEST and emphasize how the lessons learned may inform preparedness for future public health emergencies. This model may serve as a practical framework for managing surgical care during similar crises.
COVID-19, caused by SARS-CoV-2, spread rapidly and became a global health crisis [1]. The pandemic substantially altered workflows within healthcare institutions, particularly in surgical services [2,3]. Surgeons faced unprecedented changes in operative scheduling, preoperative preparation, and postoperative management, largely because of infection-control requirements such as negative pressure isolation for selected patients [4,5]. Accordingly, healthcare systems required carefully structured strategies to expedite patient care while simultaneously protecting healthcare workers from viral exposure.
The National Health Insurance Service Ilsan Hospital (NHISIH) in Korea played a central role during this period [6,7]. As the pandemic intensified, NHISIH rapidly established specialized units to treat patients across the full spectrum of COVID-19 severity, including those requiring critical care. The hospital also formed the COVID-19 Emergency Surgical Team (CEST), composed of surgeons with expertise in trauma and surgical critical care. The CEST managed wards for patients with mild COVID-19 and performed necessary surgical interventions, particularly for abdominal conditions requiring detailed evaluation. This strategy optimized staff allocation and ensured timely and appropriate surgical care for patients with COVID-19 during a period when healthcare resources were severely strained.
During the pandemic, the CEST implemented a dedicated abdominopelvic computed tomography (APCT) protocol for patients with suspected acute abdominal conditions. This protocol was designed to reduce transmission risk among healthcare workers and to streamline diagnostic decision-making within isolation wards. The controlled CT process, supported by infection-control measures and predefined staff pathways, enabled rapid, contact-limited, and comprehensive assessment compared with physical examination or bedside ultrasonography. Because these conventional approaches inherently increased exposure risk, the standardized CT-based strategy aimed to protect frontline staff while maintaining consistent patient evaluation in a high-volume COVID-19 center.
Using this protocol, we analyzed patients who underwent APCT to identify those with surgical abdomen requiring intervention. This approach clarified the role of the CEST in surgical decision-making during the pandemic.
Objectives
This study aims to describe our experience operating the CEST and to provide insights into the evolving role of surgeons and institutional preparedness during future public health emergencies.
METHODS
Ethics statement
The study adhered to ethical guidelines and was approved by the Institutional Review Board of NHISIH (No. 2022-03-021-003). The requirement for informed consent was waived due to the use of deidentified data and the retrospective nature of the study.
Study design and setting
This was a single-center retrospective observational cohort study with a nested case series.
COVID-19 base hospital and COVID-19 dedicated ward
In December 2021, NHISIH was designated as a COVID-19 base hospital. This designation enabled the hospital to respond proactively to the spread of COVID-19 by establishing specialized COVID-19 units. These wards included 155 negative pressure ventilation beds: 12 beds in the disaster intensive care unit (DICU), 19 beds in the moderate-severity wards, 42 beds in the moderate-to-mild severity wards, and 82 beds in the mild-severity wards (Table 1, Fig. 1).
Patients diagnosed with COVID-19 who were asymptomatic were directed to regional residential treatment centers for quarantine. Patients with severe symptoms or risk factors were promptly transferred to COVID-19 base hospitals. Before hospitalization, infectious disease and pulmonary specialists performed a comprehensive assessment, which was used to classify patients by disease severity. Specifically, patients requiring high-flow nasal cannula (HFNC) or mechanical ventilation were admitted to the DICU; patients with an oxygen requirement or anticipated clinical deterioration were admitted to a moderate-severity ward; patients with more than one risk factor were admitted to a moderate-to-mild severity ward; and patients with one or no risk factors were admitted to a mild-severity ward (Table 1).
Step-up/step-down system
The hospital operated a system to relocate patients and adjust attending responsibility based on changes in disease severity, thereby facilitating efficient patient flow. Depending on clinical progression during hospitalization, patient transfer and the responsible attending physician were determined through coordinated communication among teams. When symptoms worsened after admission, the “step up” process was initiated; conversely, when symptoms improved, the “step down” process was implemented (Fig. 1).
COVID-19 Emergency Surgical Team (CEST)
NHISIH recognized the need for efficient staffing based on in-hospital physician expertise and operated specialized COVID-19 wards accordingly. Respiratory and infectious disease specialists were initially assigned to manage more critically ill patients, whereas other specialists managed patients with less severe disease. In response to the pandemic, we established the CEST, enabling surgical specialists to provide inpatient COVID-19 care and to manage suspected surgical abdomen when needed.
The CEST was staffed by two general surgeons and two trauma and surgical critical care specialists, ensuring 24-hour coverage. The team had three primary roles. First, it provided care for patients with mild COVID-19; if a patient’s condition worsened with respiratory complications beyond the scope of surgical care, the patient was stepped up to a higher level of care. Second, when consultation was required to evaluate suspected surgical abdomen in hospitalized patients with COVID-19, the request was directed to the CEST, which coordinated interventions or surgery with other departments as needed. Third, for patients with COVID-19 who underwent surgery and required postoperative management, the CEST assumed responsibility for postoperative care to ensure comprehensive treatment while maintaining isolation protocols.
When differentiation of surgical abdomen was required in hospitalized patients with COVID-19, based on referral from the Korea Disease Control and Prevention Agency (KDCA) system or the emergency room, the CEST performed an abdominal examination and determined whether APCT was indicated. If surgical abdomen was confirmed based on APCT findings, surgery was arranged in the operating room. A negative pressure stretcher was used to transport the patient to the operating room via a controlled route. After transfer using a designated elevator that directly connected the COVID-19 ward and the surgical recovery area, surgery was performed in a dedicated COVID-19 operating room. The surgical, nursing, and anesthesia teams wore level D personal protective equipment and staffing was minimized to essential personnel. If surgery was expected to last more than 2 hours, the surgical team wore powered air-purifying respirators. Patient movement and staffing were determined through consultation between the hospital staff and the CEST in accordance with guidance from the Korean Surgical Society [4] and the Korean Society of Infectious Diseases [8].
Participants
Between December 19, 2020, and April 4, 2022, we included patients with laboratory-confirmed COVID-19 who were hospitalized at NHISIH, a designated COVID-19 hub hospital in Korea. Patients were admitted through the KDCA referral system or the emergency room (Fig. 2). Patients diagnosed with COVID-19 during hospitalization for other indications and subsequently placed in isolation were also included. Among all hospitalized patients with COVID-19, those who underwent APCT were selected and categorized according to the primary indication for imaging into five groups: acute abdomen evaluation, persistent fever or elevated inflammatory markers, acute kidney injury (AKI) evaluation, liver enzyme elevation, and other indications. In some cases, when direct clinical assessment was limited by infection-control measures, noncontrast APCT was performed in patients with AKI or abrupt liver enzyme elevation to evaluate potential intra-abdominal causes (e.g., obstruction or thrombosis). Indications for APCT were determined by the attending physicians at the time of care and were subsequently reviewed by the authors for consistency. Patients who underwent APCT for acute abdomen evaluation were classified as the “suspected surgical abdomen” group. Clinical characteristics and laboratory findings were compared between this group and all other patients in the cohort. In addition, representative cases illustrating CEST management within the suspected surgical abdomen group were compiled as a case series to describe key management strategies.
Variables
The primary exposure variable was APCT performed in the context of an acute abdominal presentation. Patients who underwent CT imaging for evaluation of acute abdomen were classified as the suspected surgical abdomen group. Outcome variables of interest included ICU admission, hospital length of stay, and the need for respiratory support modalities (including HFNC and mechanical ventilation), as well as subsequent clinical interventions.
Data sources and measurement
We conducted a retrospective review of electronic medical records. COVID-19 infection was confirmed using nasopharyngeal or oropharyngeal swabs, with detection of target genes (RdRp, E, ORF1ab, and N) by real-time reverse transcription polymerase chain reaction (RT-PCR). Indications for APCT were determined by reviewing the progress notes recorded at the time of imaging and the radiology reports (Table 2).
Bias
Selection bias may have occurred because CT imaging was performed based on clinical indications rather than a standardized protocol. As a result, patients who underwent CT may represent a more acutely ill subgroup than those who did not undergo imaging.
Study size
The study included all consecutive hospitalized patients with laboratory-confirmed COVID-19 admitted during the study period. No a priori sample size calculation was performed; instead, the sample size was determined by the total number of eligible admissions and the CT examinations performed during the study timeframe.
Statistical analysis
We used Fisher exact test for categorical variables and the Mann-Whitney test for continuous variables. Statistical significance was defined as P<0.05, with adjustments for multiple comparisons where appropriate. All analyses were performed using IBM SPSS ver. 23 (IBM Corp).
RESULTS
Participants
Among 4,165 hospitalized patients with COVID-19, 368 were excluded because of readmission or missing data (Fig. 3). Consequently, 3,797 unique cases were included in the final analysis. Of these, 89 patients underwent APCT. The most common indication for APCT was evaluation of suspected acute abdomen requiring urgent attention (e.g., suspected bleeding or pneumoperitoneum), accounting for 32 cases (36.0%). The second most common indication was persistent fever or elevated inflammatory markers (n=25, 28.1%). Fifteen patients (16.9%) underwent APCT for AKI, and seven (7.9%) for liver enzyme elevation. In 10 cases (11.2%), APCT was performed for other indications, including suspected cellulitis, thrombocytopenia, or other conditions (Suppl. 1).
Comparison between the 32 patients with suspected surgical abdomen and the remaining 3,765 patients demonstrated that the suspected surgical abdomen group was significantly older, had longer hospital stays, and more frequently required ICU admission, HFNC support, dexamethasone, and antibiotic therapy (Suppl. 2). Initial laboratory findings in this group showed significantly higher white blood cell count, ferritin, creatinine, total bilirubin, and D-dimer levels.
Patients with suspected surgical abdomen
The following cases describe patients in whom surgical abdomen was suspected and for whom the CEST played a central role in evaluation and management. These cases illustrate diverse clinical scenarios, including pneumoperitoneum, acute cholecystitis, appendicitis, and postoperative concerns. Each case highlights the clinical complexity of managing surgical conditions in patients with COVID-19 and underscores the importance of structured consultation pathways and multidisciplinary coordination (Tables 2, 3).
Case 1 (patient 1)
A 73-year-old man with confirmed COVID-19 was admitted to the DICU because of worsening pneumonia and was intubated 3 days after admission. Eight days after intubation, an abdominal radiograph revealed a large volume of air in the right retroperitoneal space. The patient was referred to the CEST for evaluation. Physical examination and APCT demonstrated no evidence of panperitonitis. The pneumoperitoneum was attributed to prolonged mechanical ventilation. The patient was managed conservatively without surgical intervention.
Case 2 (patient 6)
An 81-year-old woman with COVID-19 was transferred to NHISIH because of mental stupor and progressive sepsis during inpatient treatment at another hospital. On hospital day 21 in the DICU, she developed unstable vital signs and elevated inflammatory markers. APCT was performed, and the CEST was consulted to evaluate for acute cholecystitis. The CEST surgeon performed a detailed physical examination and reviewed the imaging findings. Percutaneous transhepatic gallbladder drainage (PTGBD) was initially recommended. However, considering the patient’s advanced age, comorbidities, and subsequent clinical improvement, the team deferred PTGBD and recommended close monitoring. PTGBD was to be reconsidered if inflammatory markers worsened or fever recurred. The patient’s condition improved, and she was subsequently transferred to a lower-level hospital.
Case 3 (patient 7)
A 40-year-old woman undergoing treatment for COVID-19 delivered by cesarean section at 38 weeks and 5 days of gestation. Severe abdominal pain persisted on postoperative day 1. At the request of the primary physician, the CEST evaluated the patient and determined that APCT was indicated for further assessment. Imaging revealed mild fluid collection without active bleeding. Conservative management was pursued, and the patient was discharged in improved condition on postoperative day 13.
Case 4 (patient 9)
An 85-year-old man who had been taking clopidogrel following an acute stroke within the previous 6 months presented to the emergency room with persistent flank pain and ecchymosis over the right lower abdomen. RT-PCR testing confirmed COVID-19 infection, and the patient was referred to the CEST. APCT demonstrated active contrast extravasation into the right transversus abdominis muscle layer. Given the high risk of ongoing hemorrhage, the CEST arranged urgent angioembolization. Embolization of a branch of the right common iliac artery was performed to achieve hemostasis. The patient recovered without complications and was discharged on hospital day 32.
Case 5 (patient 18)
A 37-year-old woman with COVID-19 developed abdominal pain, nausea, vomiting, and diarrhea during treatment at a local medical center. APCT demonstrated acute appendicitis. The CEST was consulted, and the patient was transferred to NHISIH for surgical management. The CEST coordinated with the on-call surgeon to perform surgery in a designated isolation operating room. Following emergency appendectomy, the patient received postoperative care and continued COVID-19 treatment. She experienced no postoperative complications and was discharged on hospital day 8.
Case 6 (patient 30)
An 82-year-old woman was admitted for ileostomy repair following prior left hemicolectomy with loop ileostomy performed at another hospital for sigmoid colon perforation of unknown etiology. On postoperative day 5, she developed fever and tested positive for COVID-19, necessitating isolation. During isolation, she experienced abdominal pain and elevated inflammatory markers, prompting consultation with the CEST to evaluate for postoperative complications such as panperitonitis. APCT and physical examination demonstrated no intra-abdominal complications. The CEST assumed postoperative management during isolation. Her respiratory symptoms were treated with supportive care, and she was discharged on hospital day 13.
DISCUSSION
Key results
Among 4,165 hospitalized patients with COVID-19, 368 were excluded, resulting in a final sample of 3,797 admissions. Eighty-nine patients (2.3%) underwent APCT; among these, evaluation for acute abdomen accounted for 32 of 89 cases (36.0%), defining the suspected surgical abdomen group. The next most common indication was persistent fever or elevated inflammatory markers, accounting for 25 of 89 cases (28.1%). Compared with the remaining 3,765 patients, the suspected surgical abdomen group was older, had longer hospital stays, and more frequently required ICU admission, HFNC therapy, dexamethasone, and antibiotic treatment. In addition, this group had higher levels of white blood cell count, ferritin, creatinine, bilirubin, and D-dimer.
Interpretation
Patients with suspected surgical abdomen
In this study, patients who required differential diagnosis of acute abdomen were older and had a high rate of ICU admission (Suppl. 2). There were no deaths in this group; however, these patients appeared more clinically vulnerable than those in the comparison group. COVID-19 can present with abdominal pain and should be considered in the differential diagnosis of acute abdomen [9]. Prior studies have suggested that COVID-19 may lead to gastrointestinal complications, including bowel ischemia [10,11]. Consistent with these reports, our findings suggest that patients with suspected surgical abdomen and COVID-19 may experience more severe clinical courses and could have adverse outcomes without timely and appropriate management. Hospitals should establish structured communication pathways between attending physicians and consulting surgeons.
COVID-19 Emergency Surgical Team (CEST)
In the context of COVID-19, limited access to diverse specialty expertise for patients under isolation highlighted the need for structured surgical support, particularly for acute abdominal presentations requiring timely evaluation. The CEST, comprising trauma and surgical critical care specialists with supporting surgeons, was established in response to this need. Although initially intended to support overburdened infectious disease and pulmonary teams, the CEST evolved to contribute substantially to surgical assessment and the management of emergency surgical and trauma cases.
This initiative was particularly effective in hospitals such as NHISIH, which treated patients across a broad spectrum of COVID-19 severity and fostered close collaboration among clinical teams. Involving surgeons familiar with inpatient COVID-19 care facilitated more nuanced decision-making regarding the necessity and appropriateness of interventions. Beyond direct patient care, the CEST contributed to developing clinicians experienced in pandemic conditions and familiar with hospital operational systems. This expertise became a valuable institutional resource, including for training surgeons with first-hand experience in pandemic-era care. In addition, through the central role of the CEST, the hospital benefited from coordinated planning to optimize patient transport routes and to develop early operational strategies, including implementation of initial isolation facilities. These collaborative efforts likely reduced unnecessary exposure within the hospital and strengthened safety protocols. They also supported the later development of an acute care surgery team integrating hospitalists, rapid response teams, critical care, and trauma surgery in the postpandemic era [12,13].
Comparison with previous studies
COVID-19 can present with diverse symptoms, including abdominal pain, which may obscure recognition of surgical abdomen [14]. Abdominal imaging findings in patients with COVID-19 may include bowel abnormalities and gallbladder bile stasis, and some patients have demonstrated ischemic changes at laparotomy, potentially related to small-vessel thrombosis [15]. Given these complexities, specialized surgical teams dedicated to patients with COVID-19 may be beneficial for optimizing care and outcomes. During the COVID-19 pandemic, several studies described surgeons actively providing care for patients with COVID-19, underscoring evolving clinical roles and operational challenges. For example, Kim and Youn [16] described trauma surgeon–led interventions during the COVID-19 pandemic. de Lesquen et al. [17] emphasized recalibration of military medical planning to support the COVID-19 crisis and described the Golden Hour Offset Surgical Team (GHOST) concept for damage-control surgery in austere environments. Di Lella et al. [18] discussed otolaryngology teams managing patients with COVID-19–associated acute respiratory distress syndrome requiring tracheostomy in ICUs, emphasizing organizational planning and resource allocation during pandemic surges. Mallari et al. [19] evaluated the impact of enhanced patient education, recovery room assessment to support non-ICU admission, and post-discharge communication for patients undergoing brain tumor surgery during the pandemic, highlighting the value of streamlining perioperative care.
&
Consistent with prior reports, the CEST applied surgical expertise to the care of patients with COVID-19 who required surgical intervention. The CEST also provided consultation and facilitated transfer planning for hospitals that lacked surgical capability within COVID-19–dedicated settings. Unlike many previously described models, the CEST also assumed responsibility for COVID-19 ward care irrespective of immediate surgical needs, helping to mitigate staffing shortages. The CEST additionally contributed to the development of the hospital’s early response system, as illustrated in Figs. 1 and 2.
Limitations
This study has several limitations. First, it was a small-scale, single-center retrospective study, which may limit generalizability to other institutions or populations. Second, the retrospective design may introduce data reliability concerns and selection bias. Third, the data primarily reflect conditions early in the COVID-19 pandemic and may not capture the impact of later variants such as Delta or Omicron. However, the CEST provided COVID-19 care for patients across a wide range of disease severity in a specialized hospital setting. This model may offer an efficient approach to staffing by integrating surgical expertise into pandemic inpatient care. In addition, the surgical community may improve hospital care quality by developing clinicians experienced in COVID-19 management and by addressing challenges in managing complex infectious diseases.
Conclusions
At our designated COVID-19 referral hospital, a surgeon-led CEST developed and implemented a standardized APCT imaging protocol to evaluate acute abdominal symptoms in patients under isolation precautions. Although computed tomography was performed in only 2.3% of all admissions, approximately one-third of these scans were obtained for suspected surgical abdomen. These examinations identified patients with greater disease severity and higher utilization of healthcare resources. This integrated care model facilitated timely diagnostic assessment, enhanced protection of healthcare workers, and strengthened institutional preparedness for managing surgical emergencies during future infectious disease outbreaks.
ARTICLE INFORMATION
Author contributions
Conceptualization: JYJ, JHK, SL; Data curation: JHK, KP, DHJ, IJ, HY; Funding acquisition: JYJ; Investigation: JHK, JYJ; Methodology: KP, KYL, JYJ; Supervision: JYJ, SL, KP, KYL; Visualization: DHJ, IJ, HY; Writing–original draft: JHK, JYJ; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
This study was supported by a National Health Insurance Service Ilsan Hospital grant (No. NHIMC-2022-CR-039).
Acknowledgements
The authors gratefully acknowledge the dedication of healthcare professionals involved in the COVID-19 response and also thank Ms. Rin Heo (Department of Nursing Education Support, National Health Insurance Service Ilsan Hospital) for her assistance in image creation.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
Classification algorithm for COVID-19 specialized units. ER, emergency room; DICU, disaster intensive care unit.
Fig. 2.
Flowchart of the COVID-19 Emergency Surgical Team (CEST) activation. KDCA, Korea Disease Control and Prevention Agency; ER, emergency room; NHISIH, National Health Insurance Service Ilsan Hospital.
Fig. 3.
Flowchart of the study population. APCT, abdominopelvic computed tomography.
Table 1.
In-hospital severity classification for COVID-19 specialized units
Classification
Description
DICU
HFNC or higher oxygen therapy
Moderate ward
An oxygen demand or expected worse progress
Moderate-mild ward
More than one risk factor
Mild ward
One or less risk factor
Risk factors are as follows: (1) age >65 years; (2) initial room air saturation <90%; (3) chronic comorbidity (chronic kidney disease, chronic liver disease, chronic lung disease, cardiovascular disease, solid cancer patients undergoing chemotherapy, hematologic cancer patients, and immunocompromised individuals); and (4) severe obesity or smoking history.
DICU, disaster intensive care unit; HFNC, high-flow nasal cannula.
Table 2.
Clinical characteristics and treatments for patients with suspected surgical abdomen
Laboratory results and medical/surgical interventions for patients with suspected surgical abdomen
Patient No.
Segment (%)
CRP (mg/dL)
Ferritin (ng/mL)
LDH (IU/L)
Cr (mg/dL)
BUN (mg/dL)
Lactate (mmol/L)
PCT (ng/mL)
D-dimer (mg/L FEU)
AST (IU/L)
ALT (IU/L)
APCT/CEST consult cause
Medical and surgical intervention
1
71.3
1.96
100.5
165
0.80
17.5
1.6
<0.06
0.25
19
14
Pneumoperitoneum
Subcutaneous emphysema due to mechanical ventilator, conservative management
2
78.9
7.07
1,041.4
332
1.25
17.8
1.7
<0.06
2.85
60
49
Acute hematoma of left psoas muscle
Hold antiplatelet therapy and close monitoring
3
71.8
3.27
1,112.6
278
1.04
14.4
2.0
0.08
0.28
73
85
Nausea, abdominal discomfort
Conservative management
4
57.6
0.70
49.8
242
1.64
41.2
1.5
<0.06
0.22
27
14
Nausea, abdominal discomfort
Conservative management
5
63.8
3.29
594.8
369
0.59
14.8
1.7
-
0.45
52
33
Nausea, abdominal discomfort
Conservative management
6
82.2
0.90
414.4
186
0.47
9.7
2.7
<0.05
0.75
19
31
Acute cholecystitis
Conservative management
7
82.0
0.48
6.6
202
0.60
9.7
2.2
<0.06
2.45
21
10
Acute severe pain, following repeat cesarean section for second pregnancy
Conservative management
8
47.9
0.30
58.3
221
1.11
7.7
1.3
<0.06
0.36
27
21
Left flank pain
Conservative management
9
67.3
0.07
365.4
393
1.30
20.8
1.2
0.06
0.86
111
69
Right flank pain, bruise
Angioembolization for hemostasis, hold antiplatelet due to active contrast extravasation into the right transverse abdominal muscle layer
10
81.0
1.90
312.7
174
1.23
15.0
4.1
0.06
0.50
33
22
Nausea, vomiting
Conservative management
11
77.2
4.61
647.2
328
1.12
19.6
2.5
<0.05
13.36
56
24
Abdominal pain with desaturation
Conservative management
12
35.6
0.12
177.6
124
0.63
9.7
1.5
<0.05
0.20
21
29
RUQ tenderness
Conservative management
13
53.9
0.50
218.1
163
0.83
11.9
1.2
0.05
0.51
28
34
Transfer due to supraumbilical pain
Conservative management
14
75.0
11.46
1,314.2
426
0.75
8.4
1.5
<0.05
0.81
180
314
Transfer due to abdominal pain
Conservative management
15
58.1
1.11
303.9
251
0.75
39.8
1.1
-
2.61
43
25
Transfer due to low hemoglobin
Conservative management
16
79.2
0.40
89.5
201
1.32
22.4
1.5
0.08
9.27
22
13
Melena
Duodenal diverticulitis, close monitoring
17
88.6
0.34
383.8
233
1.01
15.7
2.2
<0.06
0.48
60
118
Transfer due to RLQ pain
Hydration and conservative management due to ureter stone
18
94.3
7.18
48.0
146
0.54
7.6
1.3
<0.05
2.34
26
19
Transfer due to appendicitis
Laparoscopic appendectomy
19
63.4
3.71
176.0
160
0.67
16.2
1.3
<0.06
0.75
29
17
Abdominal pain with diarrhea
Conservative management
20
67.6
0.98
384.9
377
0.70
15.1
2.2
<0.06
1.31
41
23
Acute cholecystitis
Patient refused treatment
21
68.9
3.86
458.3
436
0.86
21.9
1.8
0.11
1.50
31
11
Nausea, vomiting
Conservative management
22
50.5
0.71
84.4
109
0.72
13.0
-
-
0.59
28
27
ER visit due to RLQ pain
Laparoscopic appendectomy
23
47.4
0.19
168.3
207
0.78
18.7
1.1
-
-
39
28
Left flank pain
Conservative management
24
86.0
12.88
359.1
198
0.71
10.3
2.5
0.27
3.33
23
14
Diverticulitis
Patient refused treatment
25
75.3
1.00
142.2
176
0.80
10.1
-
-
5.17
34
13
Vomiting
Consult to neurologist due to stroke
26
75.0
3.82
213.5
161
0.72
7.8
-
0.07
0.33
24
34
Transfer due to appendicitis
Laparoscopic appendectomy
27
56.8
1.45
773.0
210
1.32
28.2
1.5
-
0.32
33
22
Right flank pain
Conservative management
28
75.2
0.16
14.9
135
0.78
58.1
-
-
0.34
16
11
Ruled out melena
Black stool due to iron medication
29
82.0
0.67
165.1
169
1.08
19.0
-
-
0.56
27
30
ER visit due to RLQ pain
Laparoscopic appendectomy
30
60.4
0.14
180.5
177
0.62
10.0
2.1
<0.06
2.56
21
10
Postoperative fever, abdominal pain, following ileostomy repair
Conservative management
31
82.4
11.37
399.1
184
0.72
11.6
1.5
0.32
1.06
51
43
Both flank pain
Consult to nephrologist due to acute pyelonephritis
32
70.1
15.67
588.7
299
0.83
13.0
0.8
0.15
1.99
37
33
Hematochezia
Consult to gastroenterologist
For cases involving ER visits or transfers, patients were referred to the CEST either upon hospital arrival or before admission. Conservative management indicates cases in which no specific findings were observed on computed tomography or in which symptoms improved with conservative treatment. Some cases with simple symptoms (e.g., nausea) were not referred to the CEST.
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Computed tomography-based triage and outcomes of a dedicated COVID-19 Emergency Surgical Team (CEST) for suspected acute abdomen in a Korean COVID-19 base hospital: a retrospective cohort study
Fig. 1. Classification algorithm for COVID-19 specialized units. ER, emergency room; DICU, disaster intensive care unit.
Fig. 2. Flowchart of the COVID-19 Emergency Surgical Team (CEST) activation. KDCA, Korea Disease Control and Prevention Agency; ER, emergency room; NHISIH, National Health Insurance Service Ilsan Hospital.
Fig. 3. Flowchart of the study population. APCT, abdominopelvic computed tomography.
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Graphical abstract
Computed tomography-based triage and outcomes of a dedicated COVID-19 Emergency Surgical Team (CEST) for suspected acute abdomen in a Korean COVID-19 base hospital: a retrospective cohort study
Classification
Description
DICU
HFNC or higher oxygen therapy
Moderate ward
An oxygen demand or expected worse progress
Moderate-mild ward
More than one risk factor
Mild ward
One or less risk factor
Patient No.
Sex
Age (yr)
Comorbidity
ICU
Application
MV
Treatment
O2
HFNC
Regdanvimab
Dexamethasone
Remdesivir
Antibiotics
1
Male
73
-
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
2
Male
82
HTN, DM, CVA
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
3
Male
68
-
Yes
Yes
Yes
No
No
Yes
Yes
Yes
4
Female
85
-
No
Yes
Yes
No
No
Yes
Yes
Yes
5
Female
69
-
No
Yes
Yes
No
No
Yes
Yes
Yes
6
Female
81
HTN, dementia
No
Yes
Yes
No
No
Yes
Yes
Yes
7
Female
40
-
No
Yes
No
No
No
Yes
Yes
Yes
8
Male
47
HTN
No
No
No
No
No
No
No
No
9
Male
85
CVA, CKD
Yes
No
No
No
No
Yes
Yes
Yes
10
Male
65
-
No
Yes
No
No
No
Yes
Yes
Yes
11
Female
87
HTN
No
Yes
No
No
No
Yes
Yes
Yes
12
Female
45
-
No
No
No
No
No
No
No
Yes
13
Male
27
-
No
No
No
No
Yes
No
No
Yes
14
Male
46
-
No
Yes
No
No
No
Yes
No
Yes
15
Female
80
HTN
Yes
No
No
No
No
Yes
No
Yes
16
Male
79
-
No
No
No
No
No
No
No
No
17
Male
46
-
No
No
No
No
No
No
No
Yes
18
Female
37
-
No
No
No
No
No
No
No
Yes
19
Female
78
-
No
No
No
No
Yes
No
No
Yes
20
Male
58
-
No
No
No
No
No
No
No
Yes
21
Female
79
-
No
Yes
No
No
No
Yes
Yes
Yes
22
Female
53
-
No
No
No
No
No
No
No
Yes
23
Female
77
HTN, CVA
No
No
No
No
No
No
Yes
Yes
24
Male
58
Cancer
No
No
No
No
No
No
No
Yes
25
Male
22
-
No
No
No
No
No
No
No
No
26
Male
18
-
No
No
No
No
No
No
No
Yes
27
Female
91
HTN
No
Yes
No
No
No
Yes
No
Yes
28
Female
81
-
No
No
No
No
No
No
Yes
Yes
29
Male
43
-
No
No
No
No
No
No
No
Yes
30
Female
82
HTN
No
Yes
No
No
No
No
No
Yes
31
Female
63
-
No
No
No
No
No
No
No
Yes
32
Female
75
HTN, CKD, cancer
No
No
No
No
No
No
Yes
Yes
Patient No.
Segment (%)
CRP (mg/dL)
Ferritin (ng/mL)
LDH (IU/L)
Cr (mg/dL)
BUN (mg/dL)
Lactate (mmol/L)
PCT (ng/mL)
D-dimer (mg/L FEU)
AST (IU/L)
ALT (IU/L)
APCT/CEST consult cause
Medical and surgical intervention
1
71.3
1.96
100.5
165
0.80
17.5
1.6
<0.06
0.25
19
14
Pneumoperitoneum
Subcutaneous emphysema due to mechanical ventilator, conservative management
2
78.9
7.07
1,041.4
332
1.25
17.8
1.7
<0.06
2.85
60
49
Acute hematoma of left psoas muscle
Hold antiplatelet therapy and close monitoring
3
71.8
3.27
1,112.6
278
1.04
14.4
2.0
0.08
0.28
73
85
Nausea, abdominal discomfort
Conservative management
4
57.6
0.70
49.8
242
1.64
41.2
1.5
<0.06
0.22
27
14
Nausea, abdominal discomfort
Conservative management
5
63.8
3.29
594.8
369
0.59
14.8
1.7
-
0.45
52
33
Nausea, abdominal discomfort
Conservative management
6
82.2
0.90
414.4
186
0.47
9.7
2.7
<0.05
0.75
19
31
Acute cholecystitis
Conservative management
7
82.0
0.48
6.6
202
0.60
9.7
2.2
<0.06
2.45
21
10
Acute severe pain, following repeat cesarean section for second pregnancy
Conservative management
8
47.9
0.30
58.3
221
1.11
7.7
1.3
<0.06
0.36
27
21
Left flank pain
Conservative management
9
67.3
0.07
365.4
393
1.30
20.8
1.2
0.06
0.86
111
69
Right flank pain, bruise
Angioembolization for hemostasis, hold antiplatelet due to active contrast extravasation into the right transverse abdominal muscle layer
10
81.0
1.90
312.7
174
1.23
15.0
4.1
0.06
0.50
33
22
Nausea, vomiting
Conservative management
11
77.2
4.61
647.2
328
1.12
19.6
2.5
<0.05
13.36
56
24
Abdominal pain with desaturation
Conservative management
12
35.6
0.12
177.6
124
0.63
9.7
1.5
<0.05
0.20
21
29
RUQ tenderness
Conservative management
13
53.9
0.50
218.1
163
0.83
11.9
1.2
0.05
0.51
28
34
Transfer due to supraumbilical pain
Conservative management
14
75.0
11.46
1,314.2
426
0.75
8.4
1.5
<0.05
0.81
180
314
Transfer due to abdominal pain
Conservative management
15
58.1
1.11
303.9
251
0.75
39.8
1.1
-
2.61
43
25
Transfer due to low hemoglobin
Conservative management
16
79.2
0.40
89.5
201
1.32
22.4
1.5
0.08
9.27
22
13
Melena
Duodenal diverticulitis, close monitoring
17
88.6
0.34
383.8
233
1.01
15.7
2.2
<0.06
0.48
60
118
Transfer due to RLQ pain
Hydration and conservative management due to ureter stone
18
94.3
7.18
48.0
146
0.54
7.6
1.3
<0.05
2.34
26
19
Transfer due to appendicitis
Laparoscopic appendectomy
19
63.4
3.71
176.0
160
0.67
16.2
1.3
<0.06
0.75
29
17
Abdominal pain with diarrhea
Conservative management
20
67.6
0.98
384.9
377
0.70
15.1
2.2
<0.06
1.31
41
23
Acute cholecystitis
Patient refused treatment
21
68.9
3.86
458.3
436
0.86
21.9
1.8
0.11
1.50
31
11
Nausea, vomiting
Conservative management
22
50.5
0.71
84.4
109
0.72
13.0
-
-
0.59
28
27
ER visit due to RLQ pain
Laparoscopic appendectomy
23
47.4
0.19
168.3
207
0.78
18.7
1.1
-
-
39
28
Left flank pain
Conservative management
24
86.0
12.88
359.1
198
0.71
10.3
2.5
0.27
3.33
23
14
Diverticulitis
Patient refused treatment
25
75.3
1.00
142.2
176
0.80
10.1
-
-
5.17
34
13
Vomiting
Consult to neurologist due to stroke
26
75.0
3.82
213.5
161
0.72
7.8
-
0.07
0.33
24
34
Transfer due to appendicitis
Laparoscopic appendectomy
27
56.8
1.45
773.0
210
1.32
28.2
1.5
-
0.32
33
22
Right flank pain
Conservative management
28
75.2
0.16
14.9
135
0.78
58.1
-
-
0.34
16
11
Ruled out melena
Black stool due to iron medication
29
82.0
0.67
165.1
169
1.08
19.0
-
-
0.56
27
30
ER visit due to RLQ pain
Laparoscopic appendectomy
30
60.4
0.14
180.5
177
0.62
10.0
2.1
<0.06
2.56
21
10
Postoperative fever, abdominal pain, following ileostomy repair
Conservative management
31
82.4
11.37
399.1
184
0.72
11.6
1.5
0.32
1.06
51
43
Both flank pain
Consult to nephrologist due to acute pyelonephritis
32
70.1
15.67
588.7
299
0.83
13.0
0.8
0.15
1.99
37
33
Hematochezia
Consult to gastroenterologist
Table 1. In-hospital severity classification for COVID-19 specialized units
Risk factors are as follows: (1) age >65 years; (2) initial room air saturation <90%; (3) chronic comorbidity (chronic kidney disease, chronic liver disease, chronic lung disease, cardiovascular disease, solid cancer patients undergoing chemotherapy, hematologic cancer patients, and immunocompromised individuals); and (4) severe obesity or smoking history.
DICU, disaster intensive care unit; HFNC, high-flow nasal cannula.
Table 2. Clinical characteristics and treatments for patients with suspected surgical abdomen
Table 3. Laboratory results and medical/surgical interventions for patients with suspected surgical abdomen
For cases involving ER visits or transfers, patients were referred to the CEST either upon hospital arrival or before admission. Conservative management indicates cases in which no specific findings were observed on computed tomography or in which symptoms improved with conservative treatment. Some cases with simple symptoms (e.g., nausea) were not referred to the CEST.
, Sungho Lee1
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