At least 7-week delay in surgery recommended after COVID-19 diagnosis

Surgery should be delayed for ≥7 weeks, if possible, in patients found to have preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection due to the increased risk of postoperative mortality observed in patients who underwent surgery within 6 weeks after diagnosis of the infection.

In an international prospective cohort study in 140,231 patients from 116 countries who underwent elective or emergency surgery in October 2020 (preoperative SARS-CoV-2 infection, n=3,127), the risk of 30-day postoperative mortality was significantly increased in patients with preoperative SARS-CoV-2 infection who underwent surgery within 6 weeks following diagnosis of the infection, but not in those who had surgery at ≥7 weeks. [Anaesthesia 2021, doi: 10.1111/anae.15458]

Compared with patients without a preoperative diagnosis of SARS-CoV-2 infection, the adjusted odds ratio (aOR) for 30-day postoperative mortality in those with a preoperative diagnosis of the infection who underwent surgery at 0–2 weeks, 3–4 weeks, 5–6 weeks or ≥7 weeks was 3.22 (95 percent confidence interval [CI], 2.55 to 4.07; p<0.001), 3.03 (95 percent CI, 2.03 to 4.52; p<0.001), 2.78 (95 percent CI, 1.64 to 4.71; p<0.001) and 1.02 (95 percent CI, 0.66 to 1.56; p=0.940), respectively.

The adjusted rate of overall 30-day postoperative mortality was 1.47 percent in patients with no preoperative diagnosis of SARS-CoV-2 infection. Among those with a preoperative diagnosis of SARS-CoV-2 infection, adjusted rates of overall 30-day postoperative mortality in those who underwent surgery at 0–2 weeks, 3–4 weeks, 5–6 weeks or ≥7 weeks were 4.06 percent, 3.86 percent, 3.59 percent and 1.49 percent, respectively.

“In addition, patients with ongoing symptoms of coronavirus disease 2019 [COVID-19] were found to have a higher adjusted 30-day mortality rate than those whose symptoms had resolved or those who had been asymptomatic even after a ≥7-week delay in surgery,” said co-investigator Dr Albert Chan of the Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong (CUHK).

The adjusted 30-day postoperative mortality rate was 5.96 percent in patients with ongoing COVID-19 symptoms who underwent surgery at ≥7 weeks, compared with 2.43 percent in patients with resolved symptoms and 1.3 percent in asymptomatic patients who also had a ≥7-week delay between COVID-19 diagnosis and surgery.

Postoperative pulmonary complications were also significantly more common in patients who underwent surgery within 6 weeks after COVID-19 diagnosis, but not in those who underwent surgery at ≥7 weeks, compared with patients without the infection.

Based on these findings, the investigators, from the COVIDSurg Collaborative and GlobalSurg Collaborative of >15,000 surgeons, recommend that surgery should be delayed for ≥7 weeks, where possible, following SARS-CoV-2 infection.

“Patients with ongoing COVID-19 symptoms ≥7 weeks from diagnosis may benefit from further delay in surgery,” they suggested.

“A previous study by the COVIDSurg Collaborative showed that half of the patients with perioperative SARS-CoV-2 infection developed postoperative pulmonary complications, which were associated with a high mortality rate,” said co-investigator Dr Kaori Futaba of the Department of Surgery, CUHK. [Lancet 2020;396:27-38] “While international guidelines recommend delaying surgery for patients diagnosed with COVID-19, the optimal duration of delay was unknown.”

The current study is the first to provide robust data on the optimal timing for surgery following COVID-19 diagnosis, the investigators noted.

“Potential advantages of this delay must be balanced against the clinical urgency of the individual patients’ condition,” Futaba added.