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

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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. © 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
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Original Article
Timing of surgery following SARS-CoV-2 infection:
an international prospective cohort study
COVIDSurg Collaborative* and GlobalSurg Collaborative*
NIHR Global Health Research Unit on Global Surgery, Birmingham, UK
Summary
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 stratied 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 1.41.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was
increased in patients having surgery within 02 weeks, 34 weeks and 56 weeks of the diagnosis (odds ratio
(95%CI) 4.1 (3.34.8), 3.9 (2.65.1) and 3.6 (2.05.2), 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 (0.92.1)). 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 1.43.4) vs. 1.3% (95%CI 0.62.0), 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 benet from further delay.
.................................................................................................................................................................
Correspondence to: D. Nepogodiev
Email: dnepogodiev@doctors.org.uk
Accepted: 26 February 2021
Keywords: COVID-19; delay; SARS-CoV-2; surgery; timing
This article is accompanied by an editorial by Wijeysundera and Khadaroo, Anaesthesia 2021; 76: 7315.
*Collaborating authors are listed in online Supporting Information Appendix S2.
Twitter: @CovidSurg; @GlobalSurg
Introduction
Patients with peri-operative SARS-CoV-2 infection are at
increased risk of death and pulmonary complications
following surgery [13]. As the cumulative number of
people who have had SARS-CoV-2 infection rises, it will be
increasingly common for patients needing surgery to have
previously had SARS-CoV-2 infection. High-income
countries that are already implementing vaccination
programmes are likely to experience reductions in new
SARS-CoV-2 case infection rates, but these countries
already have tens of millions of SARS-CoV-2 infection
survivors. Most low- and middle-income countries (LMICs)
are likely to have limited access to SARS-CoV-2 vaccines
until at least 2023 [4, 5]. Thus, pre-operative SARS-CoV-2
infection will remain a challenge for the foreseeable future.
Pre-pandemic studies suggest delaying surgery in
patients who have experienced respiratory infection in the
4 weeks preceding surgery [68]. However, there is only
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Anaesthesia 2021, 76, 748758 doi:10.1111/anae.15458
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limited evidence regarding the optimal timing of surgery
following SARS-CoV-2 infection. A prospective cohort study
including 122 patients having surgical for cancer, found that
surgery 4 weeks after a positive SARS-CoV-2 swab result
was associated with a lower risk of postoperative mortality
than earlier surgery [9]. A study in Brazil included 49 patients
whose elective surgery was delayed following the
pre-operative diagnosis of asymptomatic SARS-CoV-2
infection [10]. These patients subsequently underwent
surgery following conrmation of a negative SARS-CoV-2
reverse transcription polymerase chain reaction (RT-PCR)
nasopharyngeal swab result. The postoperative
complication rates were comparable to patients without
SARS-CoV-2 infection. However, the study did not assess the
optimal duration of delay following SARS-CoV-2 diagnosis.
Clinical guidelines support postponing non-emergency
surgery for patients with pre-operative SARS-CoV-2
infection, but specic recommendations are conicting,
recommending delays ranging from 1 to 12 weeks [1115].
More granular data are needed urgently to inform
clinical practice, especially regarding the signicance of
symptomatic vs. asymptomatic pre-operative SARS-CoV-2
infection. The aim of this study was to determine the optimal
timing of surgery following SARS-CoV-2 infection.
Methods
This was an international, multicentre, prospective cohort
study that included patients undergoing any type of
surgery. The study was registered at each participating
hospital in accordance with local and national regulations.
Informed patient consent was taken if required by local or
national regulations. In the UK, this study was registered as
either a clinical audit or service evaluation at each recruiting
institution. Co-investigators were required to conrm that
applicable local and national approvals were in place
before uploading data to the online database. The study
was compliant with guidelines for the reporting of
observational studies [16]. In the conduct of this study, no
changes were made to usual patient care. Routine,
anonymised data were collected using a secure online
database (REDCap, Vanderbilt University, Nashville, TN,USA).
Participating hospitals included consecutive patients
undergoing elective or emergency surgery for any
indication in October 2020. Surgery was dened as any
procedure that is routinely performed in an operating
theatre by a surgeon. A list of excluded procedures was
provided to investigators and is available in online
Supporting Information, Appendix S1. Before commencing
data collection, hospitals dened which surgical specialties
would be participating. Hospitals could choose to collect
data in one or multiple surgical specialties, depending on
local resources. Data could be collected over up to four
blocks of 7 consecutive days (5 October 2020 1 November
2020).
Patients were classied as having pre-operative SARS-
CoV-2 infection based on any one of the following criteria:
(a) positive RT-PCR nasopharyngeal swab taken before
surgery (even if the result became available after surgery);
(b) positive rapid antigen test performed before surgery; (c)
chest computed tomography (CT) scan performed before
surgery showing changes consistent with pneumonitis
secondary to SARS-CoV-2 infection; (d) positive pre-
operative immunoglobulin G or immunoglobulin M
antibody test; or (e) clinical diagnosis made before surgery
(in the absence of negative RT-PCR swab results). Patients
who were diagnosed with SARS-CoV-2 in the period
between postoperative days 0 and 30 were not studied.
Data were captured on whether patients had experienced
SARS-CoV-2 symptoms, and if so, whether these symptoms
had resolved by the time of surgery. Both respiratory and
non-respiratory symptoms were considered. These were
classied as follows: asymptomatic; symptomatic but
symptoms now resolved; or symptomatic with ongoing
symptoms. Time from the diagnosis of SARS-CoV-2 infection
to day of surgery was collected as a categorical factor and
pre-determined to be analysed in the following categories:
02 weeks; 34 weeks; 56 weeks; and 7 weeks.
The primary outcome measure was 30-day
postoperative mortality. Patients were followed-up either in-
person or by telephone, as soon after postoperative day 30
as possible. If it was not possible to complete 30-day follow-
up, in-patient mortality status was recorded. The secondary
outcome measure was the incidence of 30-day
postoperative pulmonary complications. This was a
composite of pneumonia, acute respiratory distress
syndrome (ARDS) and/or unexpected postoperative
ventilation. Full denitions are available in online
Supporting Information, Appendix S1.
The following information was collected for each
patient: age; sex; ASA physical status; revised cardiac risk
index (RCRI); presence of respiratory comorbidities;
indication for surgery; grade of surgery (major/minor); and
surgical urgency (elective/emergency). For data protection
purposes, age was collected as a categorical variable.
Consistent with previous analyses, age was categorised as
<70 years or 70 years [1, 2]. American Society of
Anesthesiologists physical status was classied as grades
12 or grades 35. Patients were recorded as having
respiratory comorbidities if they had a diagnosis of asthma
or chronic obstructive pulmonary disease (COPD).
©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 749
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Indications for surgery were classied as: benign disease;
cancer; obstetrics; or trauma. Emergency surgery was
dened as surgery on an unplanned admission, and elective
surgery was dened as surgery on a planned admission. The
RCRI calculation and grade of surgery classication are
available in online Supporting Information, Appendix S1.
National income was recorded for each participating
country, based on the World Banks classication [17].
To ensure consistent denominators, missing data were
included in the descriptive analyses. Imputation for missing
data was not planned as, based on previous studies, a <2%
rate of missing data was anticipated [1, 2]. For categorical
variables, a chi-squared test was used to test for differences
between groups.
To adjust time from SARS-CoV-2 diagnosis to surgery for
confounding factors, logistic regression models were tted
with variables selected a priori. These werevariables that have
previously been identied as independent predictors of
mortality in patients with peri-operative SARS-CoV-2 infection
[1] and included: age; sex; ASA physical status; RCRI;
indication for surgery; grade of surgery; urgency of surgery;
presence of respiratory comorbidities; and national income.
Average marginal effects were used to produce adjusted
mortality estimates stratied by time from SARS-CoV-2
diagnosis to surgery. The main modelincluded all patients.
Since delayed surgery is more likely for elective rather
than emergency cases, a sensitivity analysis was performed
including only elective patients. A further sensitivity analysis
was performed including only patients who either had RT-
PCR nasopharyngeal swab-proven pre-operative SARS-
CoV-2 infection or who were not infected. To address
further possible bias, average marginal effects were used to
produce adjusted mortality rates by time from SARS-CoV-2
diagnosis to surgery, stratied by the following pre-selected
variables: age; ASA physical status; urgency of surgery; and
grade of surgery. In order to explore the association of pre-
operative COVID-19 symptoms, a further logistic regression
model was tted. This included only those patients who had
a pre-operative SARS-CoV-2 diagnosis, since COVID-19
symptom status was not applicable to patients who did not
have pre-operative SARS-CoV-2. These models were tted
with a primary outcome of 30-day postoperative mortality.
Further models were tted for the secondary outcome of
the incidence of 30-day postoperative pulmonary
complications. Analyses were completed in Stata, version
15.1 (StataCorp, College Station, TX, USA).
Results
A total of 140,231 patients were included across 1674
hospitals in 116 countries (see online Supporting
Information, Figure S1). Patient and surgical characteristics
are shown in Table 1. Baseline characteristic data for
patients having elective surgery are available in online
Supporting Information (Table S1). In total, 3127 (2.2%)
patients had a pre-operative SARS-CoV-2 diagnosis. The
time from SARS-CoV-2 diagnosis to surgery was 02 weeks
in 1138 patients (36.4%), 34 weeks in 461 patients
(14.7%), 56 weeks in 326 patients (10.4%) and 7 weeks
in 1202 patients (38.4%) (Table 1). The majority of patients
were asymptomatic at the time of surgery (either having
Table 1 Baseline characteristics and outcomes for patients undergoing surgery stratied by time from diagnosis of SARS-CoV-2
infection. Values are number (proportion).
No pre-operative
SARS-CoV-2
infection
(n =137,104)
Pre-operative SARS-CoV-2 infection
(by timing of diagnosis prior to surgery)
02 weeks
(n =1138)
34 weeks
(n =461)
56 weeks
(n =326)
7 weeks
(n =1202)
Age; years
029 31,456 (22.9%) 331 (29.1%) 84 (18.2%) 62 (19.0%) 169 (14.1%)
3049 37,673 (27.5%) 355 (31.2%) 149 (32.3%) 101 (31.0%) 364 (30.3%)
5069 41,649 (30.4%) 265 (23.3%) 162 (35.1%) 109 (33.4%) 471 (39.2%)
7079 17,577 (12.8%) 93 (8.2%) 52 (11.3%) 41 (12.6%) 121 (10.1%)
80 8747 (6.4%) 94 (8.3%) 14 (3.0%) 13 (4.0%) 77 (6.4%)
Missing 2 (0%) ––––
Sex
Female 71,375 (52.1%) 610 (53.6%) 220 (47.7%) 177 (54.3%) 634 (52.7%)
Missing 5 (0.0%) ––––
(continued)
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Table 1 (continued)
No pre-operative
SARS-CoV-2
infection
(n =137,104)
Pre-operative SARS-CoV-2 infection
(by timing of diagnosis prior to surgery)
02 weeks
(n =1138)
34 weeks
(n =461)
56 weeks
(n =326)
7 weeks
(n =1202)
ASA physical status
12 103,503 (75.5%) 779 (68.5%) 316 (68.5%) 227 (69.6%) 805 (67.0%)
35 33,553 (24.5%) 359 (31.5%) 145 (31.5%) 99 (30.4%) 397 (33.0%)
Missing 48 (0.0%) ––––
Revised cardiac risk index
0 61,379 (44.8%) 433 (38.0%) 176 (38.2%) 123 (37.7%) 446 (37.1%)
1 60,722 (44.3%) 512 (45.0%) 211 (45.8%) 145 (44.5%) 564 (46.9%)
2 11,116 (8.1%) 134 (11.8%) 50 (10.8%) 41 (12.6%) 129 (10.7%)
3 3818 (2.8%) 59 (5.2%) 24 (5.2%) 17 (5.2%) 62 (5.2%)
Missing 69 (0.1%) –––1 (0.1%)
Respiratory comorbidities
Yes 12,190 (8.9%) 114 (10.0%) 45 (9.8%) 31 (9.5%) 123 (10.2%)
Missing 111 (0.1%) ––––
Indication for surgery
Benign 86,764 (63.3%) 629 (55.3%) 273 (59.2%) 208 (63.8%) 822 (68.4%)
Cancer 23,612 (17.2%) 100 (8.8%) 117 (25.4%) 73 (22.4%) 234 (19.5%)
Trauma 17,048 (12.4%) 193 (17.0%) 48 (10.4%) 27 (8.3%) 96 (8.0%)
Obstetrics 9673 (7.1%) 216 (19.0%) 23 (5.0%) 18 (5.5%) 50 (4.2%)
Missing 7 (0.0%) ––––
Grade of surgery
Minor 55,301 (40.3%) 400 (35.1%) 131 (28.4%) 122 (37.4%) 462 (38.4%)
Major 81,771 (59.6%) 738 (64.9%) 330 (71.6%) 204 (62.6%) 739 (61.5%)
Missing 32 (0.0%) –––1 (0.1%)
Urgency of surgery
Elective 95,680 (69.8%) 338 (29.7%) 300 (65.1%) 232 (71.2%) 892 (74.2%)
Emergency 41,413 (30.2%) 800 (70.3%) 161 (34.9%) 94 (28.8%) 310 (25.8%)
Missing 11 (0.0%) ––––
COVID-19 symptoms
Asymptomatic 731 (64.2%) 203 (44.0%) 133 (40.8%) 317 (26.4%)
Symptomatic resolved 124 (10.9%) 193 (41.9%) 163 (50.0%) 820 (68.2%)
Symptomatic ongoing 277 (24.3%) 65 (14.1%) 28 (8.6%) 56 (4.7%)
Missing 6 (0.5%) - 2 (0.6%) 9 (0.7%)
Country income
High 90,024 (65.7%) 461 (40.5%) 159 (34.5%) 135 (41.4%) 696 (57.9%)
Low/middle 47,080 (34.3%) 677 (59.5%) 302 (65.5%) 191 (58.6%) 506 (42.1%)
30-day postoperative mortality
Yes 1973 (1.4%) 104 (9.1%) 32 (6.9%) 18 (5.5%) 24 (2.0%)
Missing 92 (0.1%) 0 (0.0%) ––2 (0.2%)
30-day postoperative pulmonary complications
Yes 3654 (2.7%) 149 (13.1%) 60 (13.0%) 33 (10.1%) 42 (3.5%)
Missing 105 (0.1%) –––3 (0.2%)
ASA, American Society of Anaesthesiologists.
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never had symptoms or symptoms having resolved)
(Table 1).
Compared with patients who did not have SARS-CoV-2
infection, patients with pre-operative SARS-CoV-2 infection
were more likely to be ASA physical status 35 (24.5% vs.
32.0%; p <0.001), to undergo major surgery (59.6% vs.
64.2%; p <0.001) and to undergo emergency surgery
(30.2% vs. 43.7%; p <0.001). However, there was lower
proportion of patients aged 70 years in the cohort with
SARS-CoV-2 infection (16.1% vs. 19.2%; p <0.001).
The overall 30-day postoperative mortality rate was
1.5% (2151/140,231). When stratied by time from
Table 2 Unadjusted and adjusted model for 30-day postoperative mortality in all patients. Values are odds ratio (OR) (95%CI).
Unadjusted Adjusted
OR (95%CI) p value OR (95%CI) p value
Age; years
069 Reference Reference
70 3.12 (2.863.40) <0.001 1.72 (1.561.90) <0.001
Sex
Female Reference Reference
Male 1.41 (1.291.53) <0.001 1.09 (0.991.19) 0.068
ASA physical status
12 Reference Reference
35 8.96 (8.139.87) <0.001 5.32 (4.755.96) <0.001
Revised cardiac risk index
0 Reference Reference
1 2.33 (2.072.61) <0.001 1.43 (1.261.63) <0.001
2 6.50 (5.697.42) <0.001 1.82 (1.562.13) <0.001
3 12.81 (11.0214.89) <0.001 2.78 (2.323.32) <0.001
Respiratory comorbidities
No Reference Reference
Yes 1.71 (1.511.94) <0.001 1.02 (0.891.16) 0.767
Indication for surgery
Benign Reference Reference
Cancer 1.62 (1.461.80) <0.001 1.98 (1.762.23) <0.001
Trauma 1.60 (1.431.80) <0.001 0.91 (0.791.04) 0.173
Obstetrics 0.27 (0.190.37) <0.001 0.23 (0.160.33) <0.001
Grade of surgery
Minor Reference Reference
Major 3.25 (2.903.63) <0.001 2.37 (2.112.67) <0.001
Urgency of surgery
Elective Reference Reference
Emergency 5.60 (5.106.15) <0.001 6.48 (5.837.21) <0.001
Country income
High Reference Reference
Low/middle 1.76 (1.611.92) <0.001 2.96 (2.693.26) <0.001
Pre-operative SARS-CoV-2 by timing of pre-operative diagnosis
No diagnosis Reference Reference
02 weeks 6.88 (5.608.46) <0.001 3.22 (2.554.07) <0.001
34 weeks 5.11 (3.567.33) <0.001 3.03 (2.034.52) <0.001
56 weeks 4.00 (2.486.45) <0.001 2.78 (1.644.71) <0.001
7 weeks 1.40 (0.932.10) 0.107 1.02 (0.661.56) 0.940
ASA, American Society of Anesthesiologists.
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SARS-CoV-2 diagnosis to surgery, 30-day postoperative
mortality rates were as follows: 9.1% (104/1138) 02 weeks;
6.9% (32/461) 34 weeks; 5.5% (18/326) 56 weeks; and
2.0% (24/1202) at 7 weeks. The 30-day mortality rate in
patients who did not have a pre-operative SARS-CoV-2
infection was 1.4% (1973/137,104).
In the adjusted model, there was a signicantly higher
risk of 30-day mortality in patients with pre-operative SARS-
CoV-2 infection diagnosed 02weeks, 34weeks and 5
6 weeks before surgery compared with patients who did not
have a pre-operative SARS-CoV-2 infection (Table 2).
However, there was no signicant difference in 30-day
postoperative mortality rate in those patients diagnosed with
SARS-CoV-2 infection 7 weeks before surger y (Table 2).
Adjusted 30-day mortality rate in patients who did
not have SARS-CoV-2 infection was 1.5% (95%CI 1.4
1.5). This was increased in patients who had surgery at
02 weeks, 34 weeks and at 56 weeks after SARS-CoV-
2 diagnosis (Fig. 1). In patients who had surgery
7 weeks after SARS-CoV-2 diagnosis, the 30-day
mortality rate was similar to patients who did not have
SARS-CoV-2 infection (Fig. 1).
Sensitivity analyses including only patients having
elective surgery (available in online Supporting
Information, Tables S1S3) and only patients with RT-PCR
nasopharyngeal swab-proven SARS-CoV-2 infection
(available in online Supporting Information, Tables S4S5)
showed that patients having surgery 02 weeks, 34 weeks
and 56 weeks after SARS-CoV-2 diagnosis had
signicantly higher adjusted 30-day postoperative
mortality rates compared with patients who did not have
SARS-CoV-2 infection (Fig. 1). Patients operated 7 weeks
after SARS-CoV-2 infection had a similar mortality as
patients without SARS-CoV-2 infection. These ndings were
also consistent across sub-groups stratied by age, ASA
physical status, and grade and urgency of surgery (Fig. 2).
In the analysis restricted to patients who had
experienced pre-operative SARS-CoV-2 infection, patients
with ongoing COVID-19 symptoms had a higher
adjusted 30-day mortality rate than patients whose
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-2refers 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 S3S4 (elective patients), Tables S5S6 (swab-proven SARS-CoV-2 infection)).
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symptoms had resolved or who had been asymptomatic
(Fig. 3). Following a 7-week delay between SARS-CoV-2
infection and surgery, patients with ongoing COVID-19
symptoms had a higher mortality rate than patients whose
symptoms had resolved or who had been asymptomatic
(Fig. 3).
Overall, 2.8% (3938/140,231) of patients developed a
postoperative pulmonary complication within 30 days,
including 1.7% (2387/140,231) who developed pneumonia,
0.8% (1100/140,231) who developed ARDS, and 0.8%
(1137/140,231) who had an unexpected requirement for
mechanical ventilation. In both the overall analysis and the
sensitivity analysis for elective surgery, patients who had
surgery 02 weeks, 34 weeks and 56 weeks after SARS-
CoV-2 diagnosis had signicantly higher adjusted 30-day
postoperative pulmonary complication rates compared
with patients who did not have SARS-CoV-2 infection.
However, patients who had surgery 7 weeks after
SARS-CoV-2 infection had similar rates of postoperative
pulmonary complications as patients without SARS-CoV-2
infection (Fig. 4). Among patients operated 7 following
SARS-CoV-2 diagnosis, those with ongoing COVID-19
symptoms were at greatest risk of 30-day postoperative
pulmonary complications (Fig. 5).
Discussion
This study found that patients operated within 6 weeks of
SARS-CoV-2 diagnosis were at an increased risk of 30-day
postoperative mortality and 30-day postoperative
pulmonary complications. These risks decreased to
baseline in patients who underwent surgery 7 weeks after
SARS-CoV-2 diagnosis. These ndings were consistent
across both low-risk (age <70 years, ASA physical status
12, minor surgery) and high-risk (age 70 years, ASA
physical status 35, major surgery) sub-groups. Therefore,
surgery should be delayed for at least 7 weeks following
SARS-CoV-2 infection to reduce the risk of postoperative
mortality and pulmonary complications. In addition, we have
shown that patients who are still symptomatic 7 weeks after
SARS-CoV-2 infection and undergo surgery also have an
increased mortality rate. As such, these patients may benet
from a further delay until their symptoms resolve.
Our ndings that pre-operative SARS-CoV-2 infection
increases the risk of postoperative mortality and pulmonary
Figure 2 Adjusted 30-day postoperative mortality rates from main analysis, stratied by pre-dened sub-groups. No pre-
operative SARS-CoV-2refers 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).
754 ©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
Anaesthesia 2021, 76, 748758 COVIDSurgCollaborative and GlobalSurg Collaborative | Timing of surgery following SARS-CoV-2 infection
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Figure 3 Adjusted 30-day postoperative mortality rates in patients with pre-operative SARS-CoV-2 infection stratied 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 S7S8).
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-2refers 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 S9S10).
©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 755
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complications is line with previous work [13]. However, this
is the rst study to provide robust data regarding the
optimal timing for surgery following SARS-CoV-2 infection.
The greater granularity in this analysis compared with
previous studies [9, 10] has enabled 7 weeks to be
determined as the optimal cut-off. Whilst cut-offs beyond
7 weeks were not formally tested, they are unlikely to offer a
signicant advantage, since adjusted mortality rates for
delay intervals 7 weeks were broadly stable (see online
Supporting Information, Appendix S1). Moreover, overall
mortality following a delay of 7 weeks was similar to
mortality in patients who did not have pre-operative SARS-
CoV-2 infection.
There is a backlog of tens of millions of elective
operations that were cancelled during the early phase of the
COVID-19 pandemic [18]. This study offers evidence to
support the safe restarting of surgery in the context of a
rapidly increasing number of people who have survived
SARS-CoV-2. This studysndings should support informed
shared decision-making by anaesthetists, surgeons and
patients. Decisions should be tailored for each patient, since
the possible advantages of delaying surgery for at least
7 weeks following SARS-CoV-2 diagnosis must be balanced
against the potential risks of delay. For some urgent surgical
procedures, such as resection of advanced tumours [19, 20],
surgeons and patients may decide that the risks of delay are
not justied.
This study has some limitations. Firstly, ascertainment of
SARS-CoV-2 status was based on routine pre-operative
tests. Therefore, it is possible that some patients who had
previously experienced SARS-CoV-2 infection may have
been misclassied as never having been infected. This
Figure 5 Adjusted 30-day postoperative pulmonary complications (PPC) rate in patients with pre-operative SARS-CoV-2
infection stratied 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 S13S14).
756 ©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
Anaesthesia 2021, 76, 748758 COVIDSurgCollaborative and GlobalSurg Collaborative | Timing of surgery following SARS-CoV-2 infection
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could be particularly likely for patients with asymptomatic
infection who may be less likely to get tested. However, it is
re-assuring that a high proportion of patients in this cohort
were recorded as having had asymptomatic infection,
suggesting that many such cases were detected. Secondly,
this study was based on time from SARS-CoV-2 diagnosis to
surgery, but it is possible that diagnosis was delayed in
some patients, underestimating the true delay from when
patients were infected to the date of surgery. This was
addressed by a sensitivity analysis restricting SARS-CoV-2
diagnosis to those patients who had positive RT-PCR
nasopharyngeal swab results, since swab-based diagnosis
is likely to give the best approximation of date of infection.
The results of this sensitivity analysis were consistent with
the main analyses. Thirdly, it was not possible to conduct
procedure-specic analyses, although exploration of results
stratied by grade (minor vs. major) and urgency of surgery
(elective vs. urgency) demonstrates that the overall ndings
were consistent across these groups. Finally, whilst both
subgroup analyses by age, ASA physical status, urgency
and grade of surgery, and sensitivity analyses for elective
surgery were all consistent with the main analysis, there is a
possibility of residual bias.
In conclusion, we performed an international, multicentre,
prospective cohort study of 140,231 patients undergoing
surgery in 116 countries, in order to determine the optimal
timing of surgery after SARS-CoV-2 infection. We found that
risks of postoperative morbidity and mortality are greatest if
patients are operated within 6 weeks of diagnosis of SARS-
CoV-2 infection. Our results suggest that, where possible,
surgery should be delayed for at least 7 weeks following
SARS-CoV-2 infection. Patients with ongoing symptoms at
7 weeks from diagnosis may benetfromfurtherdelay.
Acknowledgements
Trial registration at clinicaltrials.gov (NCT04509986). The
authors would like to thank the RCS Covid Research Group
for their support. Funding was provided by: the National
Institute for Health Research (NIHR) Global Health Research
Unit; Association of Coloproctology of Great Britain and
Ireland; Bowel and Cancer Research; Bowel Disease
Research Foundation; Association of Upper Gastrointestinal
Surgeons; British Association of Surgical Oncology; British
Gynaecological Cancer Society; European Society of
Coloproctology; Medtronic; NIHR Academy; Sarcoma UK;
the Urology Foundation; Vascular Society for Great Britain
and Ireland; and Yorkshire Cancer Research. The views
expressed are those of the authors and not necessarily those
of the funding partners. No other competing interests.
References
1. COVIDSurg Collaborative. Mortality and pulmonary complica-
tions in patients undergoing surgery with perioperative SARS-
CoV-2 infection: an international cohort study. Lancet 2020; 396:
2738.
2. Glasbey JC, Nepogodiev D, Simoes JFF, et al. Elective cancer
surgery in COVID-19-free surgical pathways during the SARS-
CoV-2 pandemic: an international, multicenter, comparative
cohort study. Journal of Clinical Oncology 2021; 39:6678.
3. Jonker PKC, van der Plas WY, Steinkamp PJ, et al. Perioperative
SARS-CoV-2 infections increase mortality, pulmonary
complications, and thromboembolic events: a Dutch,
multicenter, matched-cohort clinical study. Surgery 2021; 169:
26474.
4. Economist Intelligence Unit. Coronavirus vaccines: expect delays.
Q1 global forecast 2021. 2021. https://www.eiu.com/n/campa
igns/q1-global-forecast-2021/ (accessed 01/02/2021).
5. Wouters OJ, Shadlen KC, Salcher-Konrad M, et al.
Challenges in ensuring global access to COVID-19 vaccines:
production, affordability, allocation, and deployment. Lancet
2021. Epub 12 February. https://doi.org/10.1016/S0140-
6736(21)00306-8.
6. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative
pulmonary complications in a population-based surgical
cohort. Anesthesiology 2010; 113: 133850.
7. Canet J, Sabate S, Mazo V, et al. Development and validation of
a score to predict postoperative respiratory failure in a
multicentre European cohort: a prospective, observational
study. European Journal of Anaesthesiology 2015; 32: 45870.
8. Mazo V, Sabate S, Canet J, et al. Prospective external validation
of a predictive score for postoperative pulmonary
complications. Anesthesiology 2014; 121: 21931.
9. COVIDSurg Collaborative. Delaying surgery for patients with a
previous SARS-CoV-2 infection. British Journal of Surgery 2020;
107: e6012.
10. Baiocchi G, Aguiar S Jr, Duprat JP, et al. Early postoperative
outcomes among patients with delayed surgeries after
preoperative positive test for SARS-CoV-2: a case-control study
from a single institution. Journal of Surgical Oncology 2021;
123: 82333
11. Arnal Velasco S, Morales-Conde S. Recomendaciones para la
programaci
on de cirug
ıa en condiciones de seguridad durante
la pandemia COVID-19. 2020. https://www.aecirujanos.es/le
s/noticias/165/documentos/COVID19_Cirugia_electiva(1).pdf
(accessed 03/02/2021) .
12. Andrea A, Stefano A, Francesco C, et al. Gestione della Fase Pre-
Operatoria. 2020. https://www.sicm.it/storage-le/covid19/
0525-LG-Pre-Op-Covid-SICM_PDF.pdf (accessed 05/02/2021).
13. Frydenberg M, Maddern G, Collinson T, et al. Delaying surgery
for patients recovering from COVID-19: a rapid review
commissioned by RACS. 2021. https://www.surgeons.org/-/
media/Project/RACS/surgeons-org/les/news/covid19-informa
tion-hub/2021-01-11-RACS-Post-covid-delay-to-surgery-report.
pdf (accessed 04/02/2021).
14. American Society of Anesthesiologists. ASA and APSF Joint
Statement on Elective Surgery and Anesthesia for Patients after
COVID-19 Infection. 2020. https://www.asahq.org/about-asa/
newsroom/news-releases/2020/12/asa-and-apsf-joint-stateme
nt-on-elective-surgery-and-anesthesia-for-patients-after-covid-
19-infection (accessed 04/02/2021).
15. European Association for Endoscopic Surgery and other
Interventional Techniques. Preoperative testing and screening
for elective surgery during the pandemic COVID-19 to re-start
surgery. 2021. https://eaes.eu/covid-19-statements/preopera
tive-testing-and-screening-for-elective-surgery-during-the-pa
ndemic-covid-19-to-re-start-surgery/ (accessed 04/02/2021).
©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 757
COVIDSurg Collaborative and GlobalSurg Collaborative | Timing of surgery following SARS-CoV-2 infection Anaesthesia 2021, 76, 748758
13652044, 2021, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15458 by INASP - GHANA, Wiley Online Library on [07/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
16. von Elm E, Altman DG, Egger M, et al. The strengthening the
reporting of observational studies in epidemiology (STROBE)
statement: guidelines for reporting observational studies.
Lancet 2007; 370: 14537.
17. World Bank. World Bank Country and Lending Groups. 2021.
https://datahelpdesk.worldbank.org/knowledgebase/articles/
906519-world-bank-country-and-lending-groups (accessed
04/01/2021).
18. COVIDSurg Collaborative. Elective surgery cancellations due
to the COVID-19 pandemic: global predictive modelling to
inform surgical recovery plans. British Journal of Surgery 2020;
107: 14409.
19. Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer
treatment delay: systematic review and meta-analysis. British
Medical Journal 2020; 371: m4087.
20. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-
19 pandemic on cancer deaths due to delays in diagnosis in
England, UK: a national, population-based, modelling study.
Lancet Oncology 2020; 21: 102334.
Supporting Information
Additional supporting information may be found online via
the journal website.
Appendix S1. Supporting information.
Table S1. Baseline characteristics and outcomes in
elective patients.
Table S2. Unadjusted and adjusted 30-day
postoperative mortality (95%CI) in key sub-groups from
main analysis.
Table S3. Sensitivity analysis for elective patients with
unadjusted and adjusted models for 30-day postoperative
mortality.
Table S4. Sensitivity analysis for elective patients with
unadjusted and adjusted 30-day postoperative mortality
(95%CI) in key sub-groups.
Table S5. Sensitivity analysis for RT-PCR nasopharyngeal
swab proven SARS-CoV-2 infection, with unadjusted and
adjusted models for 30-day postoperative mortality.
Table S6. Sensitivity analysis for RT-PCR
nasopharyngeal swab proven SARS-CoV-2 infection with
unadjusted and adjusted 30-day postoperative mortality in
key sub-groups.
Table S7. Unadjusted and adjusted models for 30-day
postoperative mortality in patients with pre-operative SARS-
CoV-2 infection.
Table S8. Unadjusted and adjusted 30-day
postoperative mortality in patients with pre-operative SARS-
CoV-2 infection in key sub-groups.
Table S9. Unadjusted and adjusted model for 30-day
postoperative pulmonary complications in all patients.
Table S10. Unadjusted and adjusted 30-day
postoperative pulmonary complications in key sub-groups
from main analysis.
Table S11. Sensitivity analysis for elective patients with
unadjusted and adjusted model for 30-day postoperative
pulmonary complications.
Table S12. Sensitivity analysis for elective patients with
unadjusted and adjusted 30-day postoperative pulmonary
complications in key sub-groups.
Table S13. Unadjusted and adjusted models for 30-
day postoperative pulmonary complications in patients with
pre-operative SARS-CoV-2 infection.
Table S14. Unadjusted and adjusted 30-day
postoperative pulmonary complications in patients with
pre-operative SARS-CoV-2 infection in key sub-groups.
Table S15. List of excluded procedures.
Table S16. 30-day postoperative mortality and
postoperative pulmonary complication rates stratied by
timing of surgery after SARS-CoV-2 diagnosis.
Table S17. 30-day postoperative mortality and
postoperative pulmonary complication rates in patients
operated 3 weeks after SARS-CoV-2 diagnosis, stratied by
results of most recentrepeat RT-PCR nasopharyngeal swab.
Figure S1. Study owchart.
Figure S2. Adjusted 30-day postoperative mortality
rates from sensitivity analysis for elective patients, stratied
by pre-dened sub-groups.
Appendix S2. COVIDSurg Collaborative and
GlobalSurg Collaborative authors (all PubMed indexed co-
authors).
758 ©2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
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... G lobal surgical and perioperative impacts should be considered as part of the enormous toll exacted by the COVID-19 pandemic. Early reports illustrated a high mortality rate of up to 24% in surgical patients with a perioperative COVID-19 infection, [1][2][3][4][5][6][7] and ongoing research continues to indicate an elevated risk of COVID-19-associated perioperative morbidity and mortality. [8][9][10][11][12] The majority of previous research did not differentiate elective care from urgent surgery. ...
... Previous studies have attempted to define the perioperative mortality of patients infected with COVID-19. [1][2][3]7,9,10,24,25 Many of these studies encompass international surveys and the experience of countries with a different patient demographic than the United States. Most United States studies are limited to isolated surgical populations or do not investigate mortality. ...
... The risks of surgery after COVID-19 infection must be balanced against the risks of delaying surgery; these data will help to guide the shared decision-making and discussions that should occur among the patient, the surgeon, and the anesthesiologist. In contrast to previous work indicating that the risk of mortality is significant up to 7 weeks, 3 we observed that this risk tapered off after 2 weeks. Another study demonstrated that a composite risk of complications and death declined with time after infection. ...
Article
Background Surgical procedures performed on patients with recent exposure to COVID-19 infection have been associated with increased mortality risk in prior studies. Accordingly, elective surgery is often delayed after infection. We aimed to compare 30-day hospital mortality and postoperative complications (acute kidney injury, pulmonary complications) of surgical patients with a prior COVID-19 infection, to a matched cohort of patients without known prior COVID-19. We hypothesized that COVID-19 exposure would be associated with an increased mortality risk. Methods In this retrospective observational cohort study, patients presenting for elective inpatient surgery across a multicenter cohort of academic and community hospitals from April 2020 to April 2021 who had previously tested positive for COVID-19 were compared to controls who had received at least one prior COVID-19 test but without a known prior COVID-19 positive test. We matched cases based on anthropometric data, institution, and comorbidities. Further, we analyzed outcomes stratified by timing of a positive test result in relation to surgery. Results 30-day mortality occurred in 229/4951 (4.6%) of COVID-19 exposed patients and 122/4951 (2.5%) controls. Acute kidney injury was observed in 172/1814 (9.5%) of exposed patients and 156/1814 (8.6%) controls. Pulmonary complications were observed in 237/1637 (14%) of exposed patients and 164/1637 (10%) controls. COVID-19 exposure was associated with an increased 30-day mortality risk (adjusted odds ratio 1.63, 95% CI 1.38-1.91), an increased risk of pulmonary complications (1.60, 1.36-1.88), but not associated with an increased risk of acute kidney injury (1.03, 0.87-1.22). Surgery within 2 weeks of infection was associated with a significantly increased risk of mortality and pulmonary complications, but that effect was non-significant after 2 weeks. Conclusion Patients with a positive test for COVID-19 prior to elective surgery early in the pandemic have an elevated risk of perioperative mortality and pulmonary complications, but not acute kidney injury as compared to matched controls. The span of time from positive test to time of surgery affected the mortality and pulmonary risk, which subsided after 2 weeks.
... Second, the prognosis may not be good if surgery is performed, while the disease has not firmly improved. Reportedly, patients with cancer have a higher risk of severe events of SARS-CoV-2 [23] and perioperative SARS-CoV-2 infections, which are known to lead to high mortality rates [7,8,24,25]. Nepogodiev et al. conducted an observational cohort study on patients with SARS-CoV-2 infection who underwent surgery at 235 hospitals in 24 countries and reported that 30-day mortality was 21.1% (62 of 294) in patients who were confirmed with SARS-CoV-2 infection 7 days before the operation [24]. ...
... Reportedly, perioperative SARS-CoV-2 infection is associated with an increased risk of postoperative complications and mortality [7,8,24,25]; however, the association has not yet been fully identified. Therefore, the timing for surgery remains under discussion. ...
... Consequently, we needed careful observation when the test results remained positive 8 weeks after the onset of COVID-19. However, a prospective cohort study of 140,231 patients in 116 countries showed that the risks of 30-day postoperative mortality and 30-day postoperative pulmonary complications decreased to baseline in patients who underwent surgery ≥ 7 weeks after SARS-CoV-2 diagnosis [25]. Ct values of the test results for this patient remained above 30; therefore, the risks of mortality and complications related to both surgery and COVID-19 itself were supposed to be relatively low. ...
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Background The perioperative mortality rate is high in patients with coronavirus disease 2019 (COVID-19), and infection control measures for medical care providers must be considered. Therefore, the timing for surgery in patients recovering from COVID-19 is difficult. Case presentation A 65-year-old man was admitted to a hospital with a diagnosis of moderate COVID-19. He was transferred to our hospital because of risk factors, including heavy smoking history, type 2 diabetes mellitus, and obesity (BMI 34). Vital signs on admission were a temperature of 36.1 °C, oxygen saturation > 95% at rest, and 94% on exertion with 3 L/min of oxygen. Chest computed tomography (CT) showed bilateral ground-glass opacities, predominantly in the lower lungs. Contrast-enhanced abdominal CT incidentally revealed a liver tumor with a diameter of 80 mm adjacent to the middle hepatic vein, which was diagnosed as hepatocellular carcinoma (HCC). After being administered baricitinib, remdesivir, dexamethasone, and heparin, the patient’s COVID-19 pneumonia improved, his oxygen demand resolved, and he was discharged on day 13. Furthermore, the patient was initially scheduled for hepatectomy 8 weeks after the onset of COVID-19 following a discussion with the infection control team. However, 8 weeks after the onset of illness, a polymerase chain reaction (PCR) test was performed on nasopharyngeal swab fluid, which was observed to be positive. The positive results persisted till 10 and 11 weeks after onset. Both Ct values were high (≥ 31) out of 45 cycles, with no subjective symptoms. Since we determined that he was no longer contagious, surgery was performed 12 weeks after the onset of COVID-19. Notably, medical staff wearing personal protective equipment performed extended anatomical resection of the liver segment 8 ventral area in a negative-pressure room. The patient had a good postoperative course, with no major complications, including respiratory complications, and was discharged on postoperative day 14. Finally, none of the staff members was infected with COVID-19. Conclusions We reported a case regarding the timing of surgery on a patient with persistently positive PCR test results after COVID-19, along with a literature review.
... The data collection methodology was validated previously, in terms of case ascertainment and data accuracy 16,17 . The hospital lead had access to the data entered by their team. ...
... There was no formal sample size calculation for the analysis proposed and all eligible patients were included. To ensure global generalizability of the results and to justify the resources put into the study, a minimum number of 300 centres contributing patient-level data from 70 countries was estimated, based on previous cohort studies (that is GlobalSurg and COVIDSurg studies) 16,17 . Assuming an average of 30 patients per centre, a minimum sample size of 10 000 patients was predicted. ...
... We have previously validated our data collection methodology in terms of case ascertainment and data accuracy. 17,18 Each hospital lead was responsible for data accuracy and data completeness collected and uploaded from their teams. The data were checked centrally and when there were missing data or invalid data, the hospital lead was contacted to complete and correct the data ...
... To ensure global generalisability of the results and to justify the resources put into the study, we estimated a minimum number of 300 hospitals contributing patientlevel data from 70 countries, based on previous cohort studies (ie, GlobalSurg, COVIDSurg). 17,18 Assuming an average of 30 patients per hospital, we predicted a minimum sample size of 10 000 patients. A sample of 10 000 equates to margins of error between 0·2% and 0·85% depending on the binary outcome and a width of 0·39 for the continuous outcome (see appendix 1 p 40 for full details). ...
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Background Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition.
... Increased mortality and pulmonary complications were also observed in patients undergoing surgery within 6 weeks of SARS-CoV-2 diagnosis. Therefore, it was indicated that surgery should be delayed for at least 7 weeks after infection, and even longer in those patients with persistent symptoms [5]. ...
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The use of lung ultrasound progressively increased during the SARS-CoV-2 pandemic. The presence of a pulmonary interstitial pattern, consolidations, and pleural alterations, with a typically bilateral, predominantly peripheral, and patchy distribution, are common ultrasound findings in COVID-19 pneumonia. In asymptomatic patients recovered from SARS-CoV-2 infection, residual lung lesions were also detected by ultrasound. Ultrasound lung abnormalities have also been found in asymptomatic patients without baseline lung pathology and with some systemic disease. Therefore, although lung ultrasonography has demonstrated comparable sensitivity to other imaging techniques, its specificity is limited, especially compared to CT for the diagnosis of COVID-19. The real impact of the lesions caused by SARS-CoV-2 must be determined by integrating the ultrasound pattern with the clinical context and laboratory results. Lung ultrasound has not only contributed to the early identification of COVID-19 but is also a very useful tool in making decisions about hospital admission and therapeutic strategies.
... The coronavirus disease 2019 (COVID-19) pandemic created unprecedented challenges for global healthcare systems and had a significant impact on perioperative management. 1 Therefore, understanding the effects of preoperative COVID-19 on postoperative outcomes has become a major concern associated with perioperative care. 2 Early during the pandemic, a multicenter prospective study by the COVIDSurg and GlobalSurg Collaborative highlighted a significant correlation between COVID-19 within 7 weeks before surgery and increased 30-day postoperative mortality. 3 This finding was pivotal to determining the proper timing for elective surgeries. However, because of its reduced virulence and the advent of vaccines, the impact of preoperative COVID-19 on postoperative outcomes has evolved. ...
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Background: We evaluated the impact of preoperative COVID-19 on early postoperative mortality in patients undergoing time-sensitive cancer surgery. Methods: This retrospective, nationwide cohort study included adult patients who underwent various cancer (thyroid, breast, stomach, colorectal, hepatobiliary, genitourinary, lung, and multiple cancer) surgeries under general anesthesia in South Korea in 2022. Patients were grouped according to the duration from the date of COVID-19 confirmation to the date of surgery (0–2 weeks, 3–4 weeks, 5–6 weeks, and ≥7 weeks). Patients without preoperative COVID-19 also were included. Multivariable logistic regression analysis with Firth correction was performed to investigate the association between preoperative COVID-19 and 30-day and 90-day postoperative mortality. The covariates encompassed sociodemographic factors, the type of surgery, and vaccination status in addition to the aforementioned groups. Results: Of the 99,555 patients analyzed, 30,933 (31.1%) were preoperatively diagnosed with COVID-19. Thirty-day mortality was increased in those who underwent surgery within 0–2 weeks after diagnosis of COVID-19 (adjusted odds ratio [OR], 1.47; 95% confidence interval [CI], 1.02–2.12; P = 0.038); beyond 2 weeks, there was no significant increase in mortality. A similar pattern was observed for 90-day mortality. Full vaccination against COVID-19 was associated with reduced 30-day (OR 0.38; 95% CI 0.29–0.50; P < 0.001) and 90-day (OR 0.39; 95% CI 0.33–0.46; P < 0.001) mortality. Conclusions: Cancer surgery within 2 weeks of COVID-19 diagnosis was associated with increased early postoperative mortality. These findings support current guidelines that recommend postponing elective surgery for at least 2 weeks after the diagnosis of COVID-19.
... This prior study focused on overall 30-day mortality with specific reporting on pulmonary complications. The methods and findings of this study were published previously [12]. ...
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Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery is poorly understood. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality. The secondary outcome measure was pulmonary complications (pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation). Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p < 0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p < 0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p < 0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p = 0·046), emergency versus elective surgery (1·67 [1·06–2·63], p = 0·026), and major versus minor surgery (1·52 [1·01–2·31], p = 0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than normal practice, particularly in men aged 70 years and older.
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The COVID-19 pandemic is unlikely to end until there is global roll-out of vaccines that protect against severe disease and preferably drive herd immunity. Regulators in numerous countries have authorised or approved COVID-19 vaccines for human use, with more expected to be licensed in 2021. Yet having licensed vaccines is not enough to achieve global control of COVID-19: they also need to be produced at scale, priced affordably, allocated globally so that they are available where needed, and widely deployed in local communities. In this Health Policy paper, we review potential challenges to success in each of these dimensions and discuss policy implications. To guide our review, we developed a dashboard to highlight key characteristics of 26 leading vaccine candidates, including efficacy levels, dosing regimens, storage requirements, prices, production capacities in 2021, and stocks reserved for low-income and middle-income countries. We use a traffic-light system to signal the potential contributions of each candidate to achieving global vaccine immunity, highlighting important trade-offs that policy makers need to consider when developing and implementing vaccination programmes. Although specific datapoints are subject to change as the pandemic response progresses, the dashboard will continue to provide a useful lens through which to analyse the key issues affecting the use of COVID-19 vaccines. We also present original data from a 32-country survey (n=26 758) on potential acceptance of COVID-19 vaccines, conducted from October to December, 2020. Vaccine acceptance was highest in Vietnam (98%), India (91%), China (91%), Denmark (87%), and South Korea (87%), and lowest in Serbia (38%), Croatia (41%), France (44%), Lebanon (44%), and Paraguay (51%).
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Background There are limited data on surgical complications for patients that have delayed surgery after severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. We aimed to analyze the surgical outcomes of patients submitted to surgery after recovery from SARS‐CoV‐2 infection. Methods Asymptomatic patients that had surgery delayed after preoperative reverse‐transcription polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 were matched in a 1:2 ratio for age, type of surgery and American Society of Anesthesiologists to patients with negative RT‐PCR for SARS‐CoV‐2. Results About 1253 patients underwent surgical procedures and were subjected to screening for SARS‐CoV‐2. Forty‐nine cases with a delayed surgery were included in the coronavirus disease (COVID) recovery (COVID‐rec) group and were matched to 98 patients included in the COVID negative (COVID‐neg) group. Overall, 22 (15%) patients had 30‐days postoperative complications, but there was no statistically difference between groups –16.3% for COVID‐rec and 14.3% for COVID‐neg, respectively (odds ratio [OR] 1.17:95% confidence interval [CI] 0.45–3.0; p = .74). Moreover, we did not find difference regarding grades more than or equal to 3 complication rates – 8.2% for COVID‐rec and 6.1% for COVID‐neg (OR 1.36:95%CI 0.36‐5.0; p = .64). There were no pulmonary complications or SARS‐CoV‐2 related infection and no deaths within the 30‐days after surgery. Conclusions Our study suggests that patients with delayed elective surgeries due to asymptomatic preoperative positive SARS‐CoV‐2 test are not at higher risk of postoperative complications.
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Objective To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways. Design Systematic review and meta-analysis. Data sources Published studies in Medline from 1 January 2000 to 10 April 2020. Eligibility criteria for selecting studies Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models. Results The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings. Conclusions Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.
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Background A direct comparison of severe acute respiratory syndrome coronavirus 2-positive patients with a severe acute respiratory syndrome coronavirus 2 negative control group undergoing an operative intervention during the current pandemic is lacking, and a reliable estimate of the assumed difference in morbidity and mortality between both patient categories remains unknown. Methods We included all consecutive patients with a confirmed pre- or postoperative severe acute respiratory syndrome coronavirus 2 positive status (operated in 27 hospitals) and negative control patients (operated in 4 hospitals) undergoing emergency or elective operations. A propensity score-matched comparison of clinical outcomes was performed between severe acute respiratory syndrome coronavirus 2 positive and negative tested patients (control group). Primary outcome was overall 30-day mortality rate between both groups. Main secondary outcomes were overall, pulmonary, and thromboembolic complications. Results In total, 161 severe acute respiratory syndrome coronavirus 2 positive and 342 control severe acute respiratory syndrome coronavirus 2 negative patients were included in this study. The 30-day overall postoperative mortality rate was greater in the severe acute respiratory syndrome coronavirus 2 positive cohort compared with the negative control group (16% vs 4% respectively; P = .007). After propensity score matching, the severe acute respiratory syndrome coronavirus 2 positive group consisted of 123 patients (median 70 years of age [interquartile range 59–77] and 55% male) were compared with 196 patients in the matched control group (median 69 years (interquartile range 58–75] and 53% male). The 30-day mortality rate and risk were greater in the severe acute respiratory syndrome coronavirus 2 positive group compared with the matched control group (12% vs 4%; P = .009 and odds ratio 3.4 [95% confidence interval 1.5–8.5]; P = .005, respectively). Overall, pulmonary and thromboembolic complications occurred more often in severe acute respiratory syndrome coronavirus 2 positive patients (P < .01). Conclusion Patients diagnosed with perioperative severe acute respiratory syndrome coronavirus 2 have an increased risk of 30-day mortality, pulmonary complications, and thromboembolic events. These findings serve as an evidence-based argument to postpone elective surgery and selected emergency cases.
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Background Since a national lockdown was introduced across the UK in March, 2020, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred, and only urgent symptomatic cases prioritised for diagnostic intervention. In this study, we estimated the impact of delays in diagnosis on cancer survival outcomes in four major tumour types. Methods In this national population-based modelling study, we used linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15–84 years, diagnosed with breast, colorectal, and oesophageal cancer between Jan 1, 2010, and Dec 31, 2010, with follow-up data until Dec 31, 2014, and diagnosed with lung cancer between Jan 1, 2012, and Dec 31, 2012, with follow-up data until Dec 31, 2015. We use a routes-to-diagnosis framework to estimate the impact of diagnostic delays over a 12-month period from the commencement of physical distancing measures, on March 16, 2020, up to 1, 3, and 5 years after diagnosis. To model the subsequent impact of diagnostic delays on survival, we reallocated patients who were on screening and routine referral pathways to urgent and emergency pathways that are associated with more advanced stage of disease at diagnosis. We considered three reallocation scenarios representing the best to worst case scenarios and reflect actual changes in the diagnostic pathway being seen in the NHS, as of March 16, 2020, and estimated the impact on net survival at 1, 3, and 5 years after diagnosis to calculate the additional deaths that can be attributed to cancer, and the total years of life lost (YLLs) compared with pre-pandemic data. Findings We collected data for 32 583 patients with breast cancer, 24 975 with colorectal cancer, 6744 with oesophageal cancer, and 29 305 with lung cancer. Across the three different scenarios, compared with pre-pandemic figures, we estimate a 7·9–9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis, corresponding to between 281 (95% CI 266–295) and 344 (329–358) additional deaths. For colorectal cancer, we estimate 1445 (1392–1591) to 1563 (1534–1592) additional deaths, a 15·3–16·6% increase; for lung cancer, 1235 (1220–1254) to 1372 (1343–1401) additional deaths, a 4·8–5·3% increase; and for oesophageal cancer, 330 (324–335) to 342 (336–348) additional deaths, 5·8–6·0% increase up to 5 years after diagnosis. For these four tumour types, these data correspond with 3291–3621 additional deaths across the scenarios within 5 years. The total additional YLLs across these cancers is estimated to be 59 204–63 229 years. Interpretation Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer. Funding UK Research and Innovation Economic and Social Research Council.