Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study

Abstract

Objectives: To confirm the incidence of perioperative SARS-CoV-2 infection and associated mortality after surgery. Design and setting: Analysis of routine electronic health record data from National Health Service (NHS) hospitals in England. Methods: We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between 1st January 2020 and 31st October 2020. The exposure was SARS-CoV-2 infection defined by ICD-10 codes. The primary outcome measure was 90-day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson co-morbidity index, index of multiple deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals. Results: We identified 1,972,153 patients undergoing surgery of whom 11,940 (0.6%) had SARS-CoV-2. In total, 19,100 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 2,618/11,940 [21.9%] vs No SARS-CoV-2: 16,482/1,960,213 [0.8%]; OR: 5.8 [5.5-6.1]; p<0.001). Amongst patients undergoing elective surgery 1,030/1,374,985 (0.1%) had SARS-CoV-2 of whom 83/1,030 (8.1%) died, compared with 1,092/1,373,955 (0.1%) patients without SARS-CoV-2 (OR: 29.0 [22.5-37.3]; p<0.001). Amongst patients undergoing emergency surgery 9,742/437,891 (2.2%) patients had SARS-CoV-2, of whom 2,466/9,742 (25.3%) died compared with 14,817/428,149 (3.5%) patients without SARS-CoV-2 (OR: 5.7 [5.4-6.0]; p<0.001). Conclusions: The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study

“…This led to the almost complete cessation of all but the most emergent surgical treatment. The reintroduction of surgery after the first wave of the pandemic was complicated by several factors: first, concerns about the high risk of perioperative mortality amongst surgical patients with concomitant COVID-19 and the postponement of surgery on clinical grounds 18 , 20 ; second, reduced availability of physical and human resources as a result of ongoing care of patients with COVID-19, which limited the capacity of surgical services 21 ; and third, reduced throughput of surgery as a result of new infection control procedures to prevent nosocomial infection and to protect staff members. The consequences of the observed interruption to surgical treatment will be felt by millions of patients for many years to come.…”

“… 25 We have previously demonstrated that ‘green pathway’ operating (in which elective patients are preoperatively screened for COVID-19, isolated in the preoperative period, and kept separate from acute admissions) is safe, with similar perioperative mortality amongst patients on green pathways compared with before the pandemic. 20 Consequently, surgery should not be delayed or prevented if safeguards are put in place. However, this will require significant reorganisation of surgical services and financial commitment from central government.…”

Outcome of surgical patients during the first wave of the COVID-19 pandemic in US hospitals

“…Previous studies have shown worse postoperative outcomes in individual patients with COVID-19 infection 5,6 , even in settings with low overall incidence of perioperative COVID-19 infection 7,8 .…”

Should asymptomatic patients testing positive for SARS-CoV-2 wait for elective surgical procedures?

“…Editor – Recent data suggest that patients with SARS-CoV-2 infection carry a higher risk of postoperative respiratory complications and mortality within 7 weeks of diagnosis, 1 , 2 such that the thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice. 3 The American Society of Anesthesiologists (ASA) recommends that elective surgery be delayed for four weeks even in asymptomatic patients testing positive for SARS-CoV-2.…”