COVID positive patients should delay surgery to reduce death risk

Surgery should be delayed for seven weeks after a patient tests positive for COVID-19 – as operations taking place up to six weeks after diagnosis are associated with increased risk of death, according to a new global study.

Researchers discovered that patients are more than two-and-a-half times more likely to die after their operations, if the procedure takes places in the six weeks following a positive diagnosis for SARS-CoV-2.

Led by experts at the University of Birmingham, more than 25,000 surgeons worked together as part of the COVIDSurg Collaborative to collect data from 140,727 patients in 1,674 hospitals across 116 countries including Australia, Brazil, China, India, the UAE, UK and USA – creating one of the world’s largest and broadest studies on surgery.

Publishing their findings in Anaesthesia, the researchers discovered that patients operated 0-6 weeks after SARS-CoV-2 infection diagnosis were at increased risk of postoperative death, as were patients with ongoing symptoms at the time of surgery.

Co-lead author Dr Dmitri Nepogodiev, from the University of Birmingham, commented: “We recommend that whenever possible surgery should be delayed for at least seven weeks after a positive SARS-CoV-2 test result, or until symptoms resolve if patients have ongoing symptoms for 7 weeks or more after diagnosis.”

Co-lead author Mr Aneel Bhangu, from the University of Birmingham, added: “Decisions regarding delaying surgery should be tailored for each patient, since the possible advantages of a minimum seven-week delay following SARS-CoV-2 diagnosis must be balanced against the potential risks of delay. For some urgent surgeries, for example for advanced tumours, surgeons and patients may decide that the risks of delay are not justified.”

While it is known that infection with SARS-CoV-2 during surgery increases mortality and international guidelines recommend surgery should be delayed for patients testing positive for COVID-19, there is little evidence regarding the optimal duration of delay.

Participating hospitals included all patients undergoing a surgical procedure in October 2020. Patients who became infected with SARS-CoV-2 after their surgery were excluded from the study. The primary outcome measure was 30-day postoperative death.

Statistical modelling was used to adjust for patient, disease, and operation variables and calculate adjusted 30-day mortality rates for different time periods from SARS-CoV-2 diagnosis to surgery.

Time to surgery from SARS-CoV-2 diagnosis was 0-2 weeks in 1,144 (0.8%), 3-4 weeks in 461 (0.3%), 5-6 weeks in 327 (0.2%), 7 weeks or more in 1,205 (0.9%), and 137,590 (97.8%) did not have SARS-CoV-2 infection. Adjusted 30-day mortality in patients who did not have SARS-CoV-2 infection was 1.5%. This was increased in patients operated at 0-2 weeks (4.0%), 3-4 weeks (4.0%), and at 5-6 weeks (3.6%), but not at 7-8 weeks (1.5%) after SARS-CoV-2 diagnosis.

These findings were consistent across age groups, differing severity of the patient’s condition, urgency of surgery, and grade of surgery and in sensitivity analyses for elective surgery. Following a delay of seven weeks or more, patients with ongoing COVID-19 symptoms (6.0%) had higher mortality than patients whose symptoms had resolved (2.4%) or who had been asymptomatic (1.3%).

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