- Jennifer Middleton, MD, MPH
Health care systems across the world have paused elective surgeries at various points during the COVID-19 pandemic. Numerous asymptomatic patients have also been surprised by a positive pre-op COVID-19 test and had to reschedule their planned surgery. In the health system where I work, once those patients have finished their quarantine, they are free to reschedule their procedures. A new database study suggests that a longer waiting period might reduce post-operative complications; the study reviewed the records of over 5000 persons who had a positive COVID-19 PCR test and had surgery, either in the 4 week period before their positive test or in the weeks after their COVID-19 diagnosis; the study found an increased risk of post-operative complications for patients who had elective surgery within 8 weeks of documented COVID-19 infection.
The study authors used the COVID-19 Research Database, which "includes de-identified and limited datasets from medical and pharmacy claims data, EHR data, mortality data, and consumer data" from across the United States. Over 316 million unique individuals are captured in this database, which the researchers searched to identify persons with positive COVID-19 tests who had undergone elective surgeries in the weeks prior to or following their positive test. The study authors included a wide range of major, but not urgent or emergent, surgeries including mastectomies, colorectal resections, joint replacements, spinal fusions, and coronary artery bypass grafting (CABG). They identified 5479 patients who met study criteria, about half of whom had their surgeries before their COVID-19 diagnosis and about half of whom had their surgeries after their COVID-19 diagnosis. They divided patients into 4 categories: "pre-COVID-19" (control group), "peri-COVID-19" (0-4 weeks after diagnosis), "early-post-COVID-19" (4-8 weeks after diagnosis), and "late-COVID-19" (more than 8 weeks after diagnosis). Less than 2% of included patients had COVID-19 disease considered severe or critical. The researchers found that:
After adjustment for patient characteristics and type of surgery, peri-Covid-19 patients had a significantly higher risk of developing postoperative pneumonia [adjusted odds ratio (aOR), 6.46; 95% confidence interval (CI), 4.06–10.27], respiratory failure (aOR, 3.36; 95% CI, 2.22–5.10), PE (aOR, 2.73; 95% CI, 1.35–5.53) and sepsis (aOR, 3.67; 95% CI, 2.18–6.16) when compared to pre-Covid-19 patients. For most complications, early post-Covid-19 patients did not have a higher risk when compared to pre-Covid-19 patients; however, early post-Covid-19 patients did have a higher risk of developing postoperative pneumonia (aOR, 2.44; 95% CI: 1.20–4.96).
The study authors appropriately note that "the balance between the risk of postoperative complications and the risk of worse overall survival associated with delayed surgical treatment should be carefully discussed;" for some patients, especially those with cancer, postponing surgery may not be the best balance of benefit and harms. When appropriate, though, discussing this apparent benefit of postponing surgery with our patients - and our surgical colleagues - may help decrease patients' risk of post-operative pneumonia, respiratory failure, and sepsis.
You can find AFP content with the keyword "perioperative care" here, including this article on "Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations." The AFP By Topic page on COVID-19 also continues to be regularly updated if you'd like to read more.