Mid-term Surgery Outcomes in Patients With COVID-19

Abstract

Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery. Background: COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics. Methods: We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (−) patients. Results: Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (−). COVID (+) status was associated with higher postoperative mortality (P < 0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (−). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (−) patients. Conclusions: This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.

Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis

“…Lal et al 26 used the Veterans Affairs database and similarly reported increased rates of pulmonary, septic, and ischemic complications but did not find increased 30-day mortality in propensity score–matched patients with SARS-CoV-2 infection. In contrast, a more recent study using the same database but examining midterm surgical outcomes in matched patients with and without SARS-CoV-2 found a significantly higher risk of mortality, pulmonary, thrombotic, and septic complications in patients, particularly during the first 4 weeks following SARS-CoV-2 infection 13 . However, despite the decent sample size and the use of propensity score matching, both studies have limited generalizability because of the inherent patient characteristics specific to the Veterans Affairs population.…”

“…The overall 30-day mortality rate in symptomatic patients with SARS-CoV2 infection was significantly higher than in a matched cohort of patients without SARS-CoV-2 infection (19.1% vs. 11.3%, p = 0.004). Similar to the overall cohort, the preoperative diagnosis of SARS-CoV2 infection, along with the presence of respiratory or radiologic findings of COVID-19 disease, was associated with a longer hospital LOS (median [IQR], 9 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] vs. 8 [3][4][5][6][7][8][9][10][11][12][13][14][15] days; p = 0.035) and higher rates of eight postoperative complications shown in Figure 3A and…”

“…After propensity score matching, patients with SARS-CoV-2 infection had a higher rate of 30-day mortality (12.0% vs. 8.1%, p = 0.012) and longer hospital LOS (median [IQR], 6 [2][3][4][5][6][7][8][9][10][11][12][13][14][15] vs. 5 [1][2][3][4][5][6][7][8][9][10][11][12] days; p = 0.035) compared with patients without SARS-CoV-2 (Fig. 2 and Table 3).…”

“…It remained unclear whether the increased morbidity and mortality in surgical patients with SARS-CoV-2 infection are attributable to the viral disease and its surrounding system challenges or are a selection bias of whom we operated on during the pandemic. To provide careful benchmarking, several recent studies compared risk-adjusted postoperative outcomes between patients with and without SARS-CoV-2 infection during the pandemic and pre-pandemic periods 12–14 . These studies suggested that the presence of SARS-CoV-2 in the perioperative period may be associated with worse surgical outcomes, although the data remains nondefinite.…”

“…To provide careful benchmarking, several recent studies compared risk-adjusted postoperative outcomes between patients with and without SARS-CoV-2 infection during the pandemic and pre-pandemic periods. [12][13][14] These studies suggested that the presence of SARS-CoV-2 in the perioperative period may be associated with worse surgical outcomes, although the data remains nondefinite. Despite the current guidelines regarding the timing of elective surgery following SARS-CoV-2 infection, 15 many surgeons worldwide continue to face the challenging dilemma of whether to pursue surgery or opt for often less effective but potentially safer nonoperative alternatives in emergency surgery patients with SARS-CoV-2 and to balance safety and negative impact of delayed elective surgery.…”