When to operate after SARS-CoV-2 infection? A review on the recent consensus recommendation of the DGC/BDC and the DGAI/BDA

Abstract

Since the eruption of the worldwide SARS-CoV-2 pandemic in late 2019/early 2020, multiple elective surgical interventions were postponed. Through pandemic measures, elective operation capacities were reduced in favour of intensive care treatment for critically ill SARS-CoV-2 patients. Although intermittent low-incidence infection rates allowed an increase in elective surgery, surgeons have to include long-term pulmonary and extrapulmonary complications of SARS-CoV-2 infections (especially "Long Covid") in their perioperative management considerations and risk assessment procedures. This review summarizes recent consensus statements and recommendations regarding the timepoint for surgical intervention after SARS-CoV-2 infection released by respective German societies and professional representatives including DGC/BDC (Germany Society of Surgery/Professional Association of German Surgeons e.V.) and DGAI/BDA (Germany Society of Anesthesiology and Intensive Care Medicine/Professional Association of German Anesthesiologists e.V.) within the scope of the recent literature. The current literature reveals that patients with pre- and perioperative SARS-CoV-2 infection have a dramatically deteriorated postoperative outcome. Thereby, perioperative mortality is mainly caused by pulmonary and thromboembolic complications. Notably, perioperative mortality decreases to normal values over time depending on the duration of SARS-CoV-2 infection.

Keywords: COVID-19; Operation; Pandemic; Postponement; SARS-CoV-2; Surgery.

Fig. 1

Common immunomodulatory effects of SARS-CoV-2 infection and surgical therapy on postoperative mortality. Both SARS-CoV-2 infection and surgical therapy lead to hyperactivation of macrophages through tissue damage of various causes, which first leads to local hyperinflammation. In the following course, a systemic cytokine storm may occur. In this line, lymphopenia and neutrophilia are induced. These SARS-CoV-2 driven effects on the immune system negatively influence on postoperative immune competence of patients and lead to severe postoperative complications such as ARDS, sepsis and thromboembolism. The question now concerns the impact of perioperative SARS-CoV-2 infection on postoperative mortality. ARDS, acute respiratory distress syndrome; PAMPS, pathogen-associated molecular patterns; DAMPS, damage-associated molecular patterns; IL-6, interleukin-6, TNF-α, tumour necrosis factor-α (modified from [75]; Icons from [76, 77])

Fig. 2

The different diseases phases of SARS-CoV-2 infection in relation to the severity of COVID-19. The initial phase is characterized by mild infection with cough and fever or even presents asymptomatically. Blood examinations might give evidence for lymphopenia and neutrophilia. The prognosis at this stage is very good. In case of progression of the infection, a transition to a pulmonary phase with clinical and morphological development of pneumonia can be found, which makes frequently hospitalization necessary. The prognosis depends on the severity of pulmonary function impairment or respiratory insufficiency and comorbidities of the affected patients. Transition to the 3rd phase results in the development of a systemic extrapulmonary syndrome with a systemic increase in proinflammatory markers. The prognosis is poor due to the development of sepsis with multiple organ failure and/or ARDS (modified from [96])

Fig. 3

The CovidSurg Mortality Score. To estimate postoperative mortality, age, ASA and pulmonary and cardiac comorbidities are considered. Modified from https://covidsurgrisk.app and [140]

Fig. 4

Individual and interdisciplinary factors in elective surgery planning. Summary of individual and interdisciplinary factors influencing the planning of operations in patients with and without perioperative SARS-CoV-2 infection. The SARS-CoV-2 icons by [76]