Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study

Abstract

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Keywords: COVID-19; SARS-CoV-2; delay; surgery; timing.

Figure 1

Overall adjusted 30‐day postoperative mortality from main analysis and sensitivity analyses for patients having elective surgery and those patients with a reverse transcription polymerase chain reaction (RT‐PCR) nasopharyngeal swab positive result for SARS‐CoV‐2. ‘No pre‐operative SARS‐CoV‐2’ refers to patients without a diagnosis of SARS‐CoV‐2 infection. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Sensitivity analysis for RT‐PCR nasopharyngeal swab proven SARS‐CoV‐2 includes patients who either had RT‐PCR nasopharyngeal swab proven SARS‐CoV‐2 or did not have a SARS‐CoV‐2 diagnosis; patients with a SARS‐CoV‐2 diagnosis which was not supported by a RT‐PCR nasopharyngeal swab were not analysed. Full models and results are available in online Supporting Information (Appendix S1, Tables S3–S4 (elective patients), Tables S5–S6 (swab‐proven SARS‐CoV‐2 infection)).

Figure 2

Adjusted 30‐day postoperative mortality rates from main analysis, stratified by pre‐defined sub‐groups. ‘No pre‐operative SARS‐CoV‐2’ refers to patients without a diagnosis of SARS‐CoV‐2 infection. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Full models and results are available in online Supporting Information (Appendix S1, Table S2).

Figure 3

Adjusted 30‐day postoperative mortality rates in patients with pre‐operative SARS‐CoV‐2 infection stratified by COVID‐19 symptoms. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Full models and results are available in online Supporting Information (Appendix S1, Tables S7–S8).

Figure 4

Overall adjusted 30‐day postoperative pulmonary complications (PPC) rate from main analysis and sensitivity analysis for patients having elective surgery. ‘No pre‐operative SARS‐CoV‐2’ refers to patients without a diagnosis of SARS‐CoV‐2 infection. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Full models and results are shown in online Supporting Information (Appendix S1, Tables S9–S10).

Figure 5

Adjusted 30‐day postoperative pulmonary complications (PPC) rate in patients with pre‐operative SARS‐CoV‐2 infection stratified by COVID‐19 symptoms. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Full model and results are available in online Supporting Information (Appendix S1, Tables S13–S14).