EXECUTIVE SUMMARY

Researchers found patients infected with COVID-19 die at a rate of 23.8% within 30 days after surgery.

  • Investigators observed most deaths were among patients with pulmonary complications.
  • Patients who died were more likely to be men and older than age 70 years.
  • Investigators included data about elective procedures and emergency surgeries of many different types.

Investigators found a COVID-19 infection is associated with a 23.8% mortality rate among surgery patients within 30 days after surgery.1

When COVID-19 was present, either before or after surgery, patient outcomes were worse in cases studied (between Jan. 1 and March 31, 2020). Also, men and patients older than age 70 years infected with the virus were more likely to die 30 days after surgery.

The authors researched the question of whether surgeons should cancel or postpone elective surgeries during the pandemic, particularly when patients test positive for the virus, says Haytham Kaafarani, MD, MPH, director of the Center for Outcomes & Patient Safety in Surgery and director of research at Massachusetts General Hospital in Boston.

“Maybe it’s time to shift the needle and wait until patients are no longer positive,” he offers. “If the surgery is elective, then I think the answer, based on our data, is you really should avoid elective surgery if you can.”

For instance, some procedures are elective, but time-sensitive (e.g., procedures for cancer patients). Those could be postponed for a few weeks, but maybe not longer if it would cause their condition to deteriorate, Kaafarani says. “There are some situations where we could manage the disease without surgery,” he adds.

The international, multicenter, observational cohort study included 1,128 patients with SARS-CoV-2 infection who underwent surgery at 235 hospitals in 24 countries. Overall, 268 patients died within 30 days after surgery, a 23.8% mortality rate. More than half of the 1,128 patients (577) experienced pulmonary complications, and these patients accounted for 82.6% of all deaths.

Investigators incorporated data on different types of surgeries, including elective procedures and emergency surgery. About three-fourths of the surgeries were emergency cases, and one-fourth were elective surgeries. Procedures included head and neck, cardiac, gastrointestinal, OB/GYN, neurosurgery, ophthalmology, orthopedics, thoracic, and others.

The cohort of cases included about 32% of emergency surgery patients who received a preoperative SARS-CoV-2 diagnosis and 66% who were diagnosed after surgery. Data were missing for some patients.

Half of emergency surgery patients experienced pulmonary complications with their disease. For that group, the mortality rate was 39.6%. For patients who did not experience pulmonary complications, the mortality rate was 4.6%. The preoperative COVID-19-positive patients who underwent elective surgery died at a rate of 14.3% when they experienced pulmonary complications and 6.7% if they did not.

The mortality rate also was high among patients who were diagnosed with SARS-CoV-2 after surgery. Those who underwent emergency surgery and experienced pulmonary complications died at a rate of 43.1%. For patients who did not experience pulmonary complications while undergoing emergency surgery, the mortality rate was 10.7%.

For those who underwent elective surgery and received a COVID-19-positive diagnosis after the operation, the mortality rate was 28.3% if they experienced pulmonary complications and 10.8% if they did not.

The study was created to address surgeons’ concerns about patient safety during the COVID-19 pandemic. “This study involves surgeons from all over the world coming together to replace the anecdotes with data,” Kaafarani says. “We’re all wondering if it’s safe to operate on COVID-positive patients.”

For this study, surgeons were part of a group called the COVIDSurg Collaborative. “They were [performing] all kinds of surgery, but we know that COVID-19 is a pulmonary disease, and surgery could cause a cascade [effect],” Kaafarani says. “Our most intriguing finding is that it’s not necessarily related to anesthesia. Clearly, those on general anesthesia are at higher risk, but mortality was [higher] in all these patients.”

The COVIDSurg Collaborative continues its investigation into the effect of COVID-19 on surgery. Based on their data collected to date, surgeons should avoid elective surgery for COVID-19 patients, if possible, Kaafarani concludes, unless the procedure is time-sensitive.

Surgeons could decide which elective cases could be postponed safely and even which patients could manage their condition without an operation. For example, if a patient has acute appendicitis, the standard procedure is to remove the appendix. But during the pandemic, surgeons could consider an alternative and reasonable approach of treating the patient with antibiotics, Kaafarani suggests.

“If, during the pandemic, the patient has a COVID diagnosis, then in those cases we should choose the nonoperative option, rather than take them to surgery. The risk of [complications during] surgery in a patient with COVID infection is high,” Kaafarani says. “We’re not talking about small complications; the smallest one was pneumonia. Some had prolonged need for mechanical ventilation, and some had ARDS [acute respiratory distress syndrome] ... and a good number of patients do not survive it.”

Kaafarani worked as a full-time surgeon on the frontlines of the pandemic. His takeaway is surgeons have to make judgment calls on whether to proceed with surgery on COVID-19 patients. “Nothing replaces the judgment of the surgeon,” he says. “Every patient has their own risk factors, but the data should make people think twice before offering surgery to anyone, especially patients over 70.”

Investigators tried to see what factors would predict, independently, a high risk of mortality after surgery. The subset of patients at the highest risk were those who were older than age 79 years. “Patients over 70 had about two times higher risk of dying after surgery,” Kaafarani reports.

Cancer patients and people undergoing emergency surgery also were at higher risk of dying after surgery. Men had almost twice the risk of dying after surgery if they were positive for COVID-19 vs. women, he adds.

As surgeons prepare for the pandemic to continue, and even resurge in some places, there are several important questions they should consider, according to Kaafarani:

  • How can we ensure we are not performing elective surgery on patients with active infection?
  • How can we make sure that if we perform surgery on someone with a COVID-19 infection, they do not contract the virus after the procedure?
  • If someone is positive for COVID-19 but are stable, when would it be safe to perform elective surgery on them?

“We don’t have answers to all of these questions, and we’re still trying to figure these out,” Kaafarani notes.

But the answer to the first question is for surgery center staff to test patients for SARS-CoV-2 as part of their pre-op workup. If patients are infected with the virus, then the surgery should be postponed, Kaafarani says.

“When would it be safe to do surgery on COVID patients?” Kaafarani asks. “I don’t think anybody knows the answer to this question yet, but we are starting to design a study to help us answer the question of when it’s safe to operate on patients after they recover from the COVID infection.”

Kaafarani, in his roles as an acute care surgeon and an emergency and critical care specialist, has treated hundreds of COVID-19 patients in the intensive care unit during the pandemic’s early months.

“It’s not as bad now as it was [in the spring], but it was tough for many reasons, including how these patients were very ill and some of the sickest patients you would see in the hospital,” he explains. “A good proportion of the COVID patients did not make it. Our mortality rate at MassGen was much lower than reported in other places like New York, China, and Italy. We were proud we were able to save a lot of people, but it was difficult to see some of them not survive. We [treated] patients in their 20s and 30s who were very sick.”

One of the most difficult challenges was communicating with families via video and phone. “It was hard to not have families around to look them in the eye and hold their hands if they were struggling,” Kaafarani admits. “A salute goes out to all the healthcare workers, nurses, physicians — we all came together as a team to provide the care, sometimes at the expense of our own health.”

REFERENCE

  1. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020 May 29;S0140-6736(20)31182-X. doi: 10.1016/S0140-6736(20)31182-X. [Online ahead of print].