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JOURNAL SCAN
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 297-298

The timing of a major operative intervention after a positive COVID-19 test affects post-operative mortality


Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission29-Oct-2022
Date of Acceptance21-Nov-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Dr. Chander Mohan
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_134_22

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How to cite this article:
Mohan C, Nundy S. The timing of a major operative intervention after a positive COVID-19 test affects post-operative mortality. J Med Evid 2022;3:297-8

How to cite this URL:
Mohan C, Nundy S. The timing of a major operative intervention after a positive COVID-19 test affects post-operative mortality. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:297-8. Available from: http://www.journaljme.org/text.asp?2022/3/3/297/365851




  Background Top


Infection with the coronavirus 2019 (COVID-19) is highly transmissible and its manifestations range from mild flu-like symptoms to critical disease. It affects all the major systems of the body, and patients with COVID-19 infection are also at an increased risk of complications and even death following surgery.[1],[2],[3] Studies during the early stages of the pandemic had reported high rates of mortality and pulmonary complications in COVID-infected patients at any time following operation.[4] The present authors investigated whether the time interval between a positive COVID test and a subsequent operation affected mortality.

This retrospective study was, therefore, done to estimate the optimal timing of performing a major operative intervention after a COVID-19 infection. It was conducted in the Department of Surgery, State University of New York, USA. All high-risk operations, undertaken between January 2020 and May 2021, were identified from the veterans affairs COVID-19 shared data resource and Current Procedural Terminology (CPT) codes were used to exactly match COVID-19-positive cases (n = 938) to negative controls (n = 7235). The high-risk procedures were defined as those with expected 30-day mortality rates exceeding 1%.[5] The main outcome analysed was short-term mortality that was defined as all-cause death occurring after the index surgery within 90 days. The patients were followed from the date of the index surgery to the date of death or to the end of the observation period, i.e., 1 January 2020-11 May 2021.

All the patients who were COVID-19 positive were included. Their COVID-related symptoms such as cough, dyspnoea, fever, chills, myalgia, diarrhoea, loss of smell or taste and abdominal pain that were present within 30 days before their first positive test were also noted. To assess the timing effect of the operative procedure relative to a COVID-19-positive test on mortality, they calculated the time interval between the positive tests to the index operation in days. The majority (92%) of COVID-19-positive patients had had their diagnosis confirmed preoperatively. Most of the operative interventions (95.2%) were distributed across three surgical services (orthopaedics: 48.5%, vascular: 32.9% and general: 13.8%). The highest frequencies of operative intervention in COVID-19-positive cases in the study were arthroplasties (29.4%), lower extremity amputations (13.5%) and fracture repairs (9.3%).

In the preoperative positive patients, the 90-day mortality rate of cases versus controls was 12.3% versus 4.9% when the operation was performed between 7 and 8 weeks after the positive test; 10.3% versus 3.3% when the operation took place 5-6 weeks after the positive test; 19.6% versus 6.7% for operations 3-4 weeks after a positive test and 24.7% versus 7.4% for operations 1-2 weeks after a positive test. Similarly, in patients who became positive after surgery, the mortality rates were 12.5% versus 6.5% in patients who became positive 1-2 weeks post-operatively and 8.1% versus 8% for patients with tests that became positive after 3-4 weeks.

In their retrospective analysis, the authors found that the patients who underwent major operative interventions within 8 weeks of a COVID-19 diagnosis had significantly higher 90-day mortality rates compared to COVID-negative CPT-matched controls. This was not affected by the presence of COVID-19 symptoms and the mortality increased as the time from the positive COVID test to the index operation decreased. Thus, patients undergoing major operations 9 weeks or later after the COVID-positive tests were not at an increased risk for mortality when compared to a similar control group of patients with negative results.[6]

The present analysis is also consistent with other published studies and indicates that performing a major operation within 8 weeks from a positive COVID-19 test significantly increases 90-day mortality.

Irrespective of aetiology, by delaying the surgery for at least 9 weeks after the initial COVID-19-positive test reduced the risk of post-operative mortality. However, this was possible only in those cases where delaying the surgery would not further increase the mortality. The asymptomatic patients with a COVID-positive test who underwent surgery within 8 weeks of a positive test were also at an equally high risk of post-operative mortality as their symptomatic counterparts. This study did not, however, assess the effect of the severity of COVID-19-related respiratory symptoms on mortality. Patients with positive COVID-19 tests but who were in severe respiratory distress, intubated patients and other frail and sick patients who might not even have been offered a surgical intervention because its perceived futility were not included in the study. They also found that patients, who underwent an operative intervention within 8 weeks from the COVID-19 diagnosis, were observed to have a three-fold increase in the adjusted odds for mortality compared to controls. This is similar or slightly lower than other studies reported in the literature.


  Commentary Top


COVID-19 infection is a new complication that also affects post-operative surgical outcomes and mortality. In the earlier days of the pandemic, studies reported high post-surgical mortality because of early disease, the lack of a comparative control group and the absence of vaccination in the general population. Furthermore, in these studies, the operations were limited to patients who were tested positive of COVID-19 at the time of surgery and most of these were done as emergencies which generally carry higher mortality rates than elective procedures. It thus became important to determine what might be an appropriate and safe timing to perform a major elective operative intervention in COVID-19-positive patients. This is partly answered by this study which found that patients who underwent major operations within 8 weeks after a positive COVID-19 test, irrespective of their presenting symptoms, had higher post-operative mortality than a matched control group without a COVID-19 infection.

This retrospective study, however, has its own limitations. Most of the patients included were in the orthopaedics (48.5%) and vascular (32.9%) groups and few patients from other specialities were included, so the results cannot probably be more widely applied. Moreover, the patients in the intensive care unit, intubated patients and other frail patients were not included in the study. The majority of the patients included had not been vaccinated, so this cannot be applicable to the vaccinated group, as the mortality is overall lower in the latter group.[7] Since all emergency surgeries cannot be postponed, the elective and emergency data should have been analysed separately which was not done in the present study.[8] Other studies have also shown a greater risk of post-operative pulmonary complications in patients with ongoing COVID-19 infection. Thus, the authors recommend that patients with a history of a recent COVID-19 infection should have their elective surgical procedures delayed for at least 8 weeks but more studies are needed to confirm this.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hendren NS, Drazner MH, Bozkurt B, Cooper LT Jr. Description and proposed management of the acute COVID-19 cardiovascular syndrome. Circulation 2020;141:1903-14.  Back to cited text no. 1
    
2.
Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med 2020;38:1504-7.  Back to cited text no. 2
    
3.
Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med 2020;382:2268-70.  Back to cited text no. 3
    
4.
Nepogodiev D, Bhangu A, Glasbey JC, COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;96:27-38.  Back to cited text no. 4
    
5.
Schwarze ML, Barnato AE, Rathouz PJ, Zhao Q, Neuman HB, Winslow ER, et al. Development of a list of high-risk operations for patients 65 years and older. JAMA Surg 2015;150:325-31.  Back to cited text no. 5
    
6.
Deng JZ, Chan JS, Potter AL, Chen YW, Sandhu HS, Panda N, et al. The risk of postoperative complications after major elective surgery in active or resolved covid-19 in the United States. Ann Surg 2022;275:242-6.  Back to cited text no. 6
    
7.
Prasad NK, Lake R, Englum BR, Turner DJ, Siddiqui T, Mayorga-Carlin M, et al. COVID-19 vaccination associated with reduced postoperative SARS-CoV-2 infection and morbidity. Ann Surg 2022;275:31-6.  Back to cited text no. 7
    
8.
Prasad NK, Lake R, Englum BR, Turner DJ, Siddiqui T, Mayorga-Carlin M, et al. Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening. Am J Surg 2022;223:380-7.  Back to cited text no. 8
    




 

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