Mid-term Surgery Outcomes in Patients With COVID-19: Results From a Nationwide Analysis

Abstract

Objective: Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery.

Background: COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics.

Methods: We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (-) patients.

Results: Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (-). COVID (+) status was associated with higher postoperative mortality ( P <0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (-). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (-) patients.

Conclusions: This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.

Figure 1.

Flowchart for cohort creation

Figure 2.

Kaplan-Meier plots with 95%-confidence bands for survival among patients who tested positive for COVID-19 any time before surgery vs matched COVID-19 negative patients. Each COVID(+) patient was matched to up to 3 COVID(−) patients based on age, sex, race, ethnicity, BMI, smoking status, CPT code, anesthesia type, ASA class, case urgency, CCI, and cancer history. Outcomes were observed 3/1/20–3/26/21. (A) Survival from all-cause mortality; (B) pulmonary complications are a composite of pneumonia, acute respiratory failure, and acute respiratory distress syndrome; (C) thrombotic complications are a composite of ischemic stroke, myocardial infarction, venous thromboembolism, and arterial thromboembolism; (D) septic complications are a composite of sepsis from an unspecified source, gram-negative sepsis, and post-procedural septic shock.

Figure 3.

Kaplan-Meier plots with 95% confidence bands for survival among patients who tested positive for COVID-19 at 0–4 and ≥5 weeks before surgery vs matched COVID-19 negative patients. Each COVID(+) patient was matched to up to 3 COVID(−) patients based on age, sex, race, ethnicity, BMI, smoking status, CPT code, anesthesia type, ASA class, case urgency, CCI, and cancer history. Outcomes were observed 3/1/20–3/26/21. (A) Survival from all-cause mortality; (B) pulmonary complications are a composite of pneumonia, acute respiratory failure, and acute respiratory distress syndrome; (C) thrombotic complications are a composite of ischemic stroke, myocardial infarction, venous thromboembolism, and arterial thromboembolism; (D) septic complications are a composite of sepsis from an unspecified source, gram-negative sepsis, and post-procedural septic shock.

Figure 4.

Kaplan-Meier plots for survival among patients who tested positive for COVID-19 any time before surgery vs matched COVID-19 negative patients, stratified by case urgency. Each COVID(+) patient was matched to up to 3 COVID(−) patients based on age, sex, race, ethnicity, BMI, smoking status, CPT code, anesthesia type, ASA class, case urgency, CCI, and cancer history. Outcomes were observed 3/1/20–3/26/21. (A) Survival from all-cause mortality; (B) pulmonary complications are a composite of pneumonia, acute respiratory failure, and acute respiratory distress syndrome; (C) thrombotic complications are a composite of ischemic stroke, myocardial infarction, venous thromboembolism, and arterial thromboembolism; (D) septic complications are a composite of sepsis from an unspecified source, gram-negative sepsis, and post-procedural septic shock.