Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy

Abstract

IMPORTANCE There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery. OBJECTIVE To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties. DESIGN, SETTING, AND PARTICIPANTS This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score. EXPOSURES Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase-polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations. MAIN OUTCOMES AND MEASURES The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors. RESULTS Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-ϱ). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications. CONCLUSIONS AND RELEVANCE In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.

Global Prevalence of Perioperative Outcomes of Surgical Patients with COVID-19: A Systematic Review and Meta-Analysis

“…The Meta-Analysis showed that the prevalence of comorbidity among surgical patients was with COVID-19 was 18% (95% CI: 10 to 25) which is in line with the results of included studies (21,23,29,49,90,91,95). The subgroup analysis showed that dementia was the most prevalent comorbidity followed by hypertension and Diabetes Mellitus.…”

“…The Meta-Analysis showed that the pooled mean duration of hospitalization was 10.55 (95% con dence interval (CI): 8.08 to 13.03) which is comparable with the ndings of the included studies (21,29,38,39,52,(89)(90)(91)96).…”

“…Many complications were mentioned in the literature in patients with COVID-19 who underwent surgical procedures (21,29,38,39,52,(89)(90)(91)96). The Meta-Analysis revealed that thromboembolic disease, pulmonary complications, infection, and deep wound infection were the commonest perioperative complications.…”

Surgery triage during the COVID‐19 pandemic

“…46 The risk of perioperative complications associated with COVID-19 could be significant, and profoundly affect postoperative mortality and complication rates. [49][50][51][52] This may influence future considerations regarding preoperative testing, but ideally, if it does not worsen postoperative patient outcomes, the COVID-19 status of surgical patients should be determined before surgery. 53 Where this is not possible, it is key to know which patients pose the highest risk, including those more likely to have been exposed to COVID-19 due to their profession.…”

Screening and testing for COVID‐19 before surgery

“…Infection with the causative virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been associated with considerable postoperative mortality and morbidity for surgical patients. [1][2][3] The global backlog of operations resulting from the temporary suspension of elective surgery could take close to a year to resolve. 4 Although both Australia and New Zealand have experienced a relatively low COVID-19 caseload on an international scale, 5 surgical systems within both countries have still been affected.…”