Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

Abstract

Purpose: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway.

Patients and methods: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation).

Results: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76).

Conclusion: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

Trial registration: ClinicalTrials.gov NCT04384926.

FIG 1.

Differences between hospitals with a coronavirus disease 2019 (COVID-19)–free surgical pathway and hospitals with no defined pathway. COVID-19–free surgical pathways: complete segregation of operating room, critical care, and inpatient ward areas for elective cancer surgery away from patients being treated for COVID-19. No defined pathways: hospitals where there was mixing of patients who were undergoing treatment for COVID-19 and elective surgical patients in any operating room, critical care, or inpatient ward area. ICU, intensive care unit.

FIG 2.

Factors associated with postoperative pulmonary complications after elective cancer surgery, including data from 8,971 patients with complete data. See Data Supplement for the full model, details around missing data, and full definitions. ASA, American Society of Anesthesiologists; BMI, body mass index; COVID-19, coronavirus disease 2019; ECOG, Eastern Cooperative Oncology Group; OR, odds ratio; RCRI, Revised Cardiac Risk Index; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

FIG 3.

Rates of pulmonary complications, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and death in hospitals with coronavirus disease 2019 (COVID-19)–free surgical pathways v those with no defined pathway. Pulmonary complications were defined as pneumonia, acute respiratory distress syndrome, and/or unexpected postoperative ventilation.