Postoperative mortality and complications in patients with and without pre‐operative SARS‐CoV‐2 infection: a service evaluation of 24 million linked records using OpenSAFELY

Abstract

Surgical decision-making after SARS-CoV-2 infection is influenced by the presence of comorbidity, infection severity and whether the surgical problem is time-sensitive. Contemporary surgical policy to delay surgery is informed by highly heterogeneous country-specific guidance. We evaluated surgical provision in England during the COVID-19 pandemic to assess real-world practice and whether deferral remains necessary. Using the OpenSAFELY platform, we adapted the COVIDSurg protocol for a service evaluation of surgical procedures that took place within the English NHS from 17 March 2018 to 17 March 2022. We assessed whether hospitals adhered to guidance not to operate on patients within 7 weeks of an indication of SARS-CoV-2 infection. Additional outcomes were postoperative all-cause mortality (30 days, 6 months) and complications (pulmonary, cardiac, cerebrovascular). The exposure was the interval between the most recent indication of SARS-CoV-2 infection and subsequent surgery. In any 6-month window, < 3% of surgical procedures were conducted within 7 weeks of an indication of SARS-CoV-2 infection. Mortality for surgery conducted within 2 weeks of a positive test in the era since widespread SARS-CoV-2 vaccine availability was 1.1%, declining to 0.3% by 4 weeks. Compared with the COVIDSurg study cohort, outcomes for patients in the English NHS cohort were better during the COVIDSurg data collection period and the pandemic era before vaccines became available. Clinicians within the English NHS followed national guidance by operating on very few patients within 7 weeks of a positive indication of SARS-CoV-2 infection. In England, surgical patients' overall risk following an indication of SARS-CoV-2 infection is lower than previously thought.

Timing of elective surgery and risk assessment after SARS‐CoV‐2 infection: 2023 update

“…Indeed, a blanket ban has never been recommended [4,9], but there are some concerns that previous guidance has been interpreted in this manner. From a population perspective, recent data indicate that the absolute risk of surgery soon after SARS-CoV-2 infection might be lower in the UK than previously reported by COVIDSurg [3,20].…”

“…More recent data have suggested that risks associated with surgery within 7 weeks of infection may be more modest than in previous phases of the pandemic [18,20]. In the Omicron post-vaccination era, a population-based data platform analysis in England showed that surgery 2 weeks, 2-4 weeks, 4-7 weeks and > 7 weeks after SARS-CoV-2 infection was associated with a 30-day mortality rate of 1.1%, 0.5%, 0.3% and 0.2%, respectively [20]. Compared with equivalent data from the first year of the pandemic (i.e.…”

“…Peri-operative infection with SARS-CoV-2 is associated with relative increases in postoperative morbidity and mortality [19,20,22,23], but the absolute increase in risk is determined by pre-existing risk [9,17].…”

“…Data before the era of Omicron and widespread vaccination highlighted that surgery within 7 weeks of SARS-CoV-2 infection was associated with an increased risk of morbidity and mortality [3,23]. More recent data have suggested that risks associated with surgery within 7 weeks of infection may be more modest than in previous phases of the pandemic [18,20]. In the Omicron post-vaccination era, a population-based data platform analysis in England showed that surgery 2 weeks, 2-4 weeks, 4-7 weeks and > 7 weeks after SARS-CoV-2 infection was associated with a 30-day mortality rate of 1.1%, 0.5%, 0.3% and 0.2%, respectively [20].…”

“…The increasing scale of the surgical backlog and implications for population health of delayed access to surgical care have underscored the need for mitigating barriers to surgery [14][15][16], although the overall impact of delayed care due to SARS-CoV-2 guidance is thought to be small [17]. Finally, data have begun to emerge on the impact of peri-operative infection on postoperative outcomes in the Omicron variant and vaccination era [18][19][20].…”