Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection: A nationwide propensity-matched analysis

The Impact of Postoperative COVID-19 Infection on 30-day Outcomes of Laparoscopic Cholecystectomy

Introduction: Preoperative Coronavirus Disease 2019 (COVID-19) infections are associated with postoperative adverse outcomes. However, there is limited data on the impact of postoperative COVID-19 infection on postoperative outcomes of common general surgery procedures.Objective: To evaluate the impact of postoperative COVID-19 diagnosis on laparoscopic cholecystectomy outcomes.Methods: Patients with symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis who underwent laparoscopic cholecystectomy with or without intraoperative cholangiogram were identified using the 2021 National Surgical Quality Improvement Program (NSQIP) database. Patients were categorized into two groups: patients with and without a postoperative COVID-19 diagnosis. Coarsened Exact Matching was used to match the groups based on preoperative risk factors, and outcomes were compared.Results: A total of 47,948 patients were included. In the aggregate cohort, 31% were male, and mean age was 50 years. Age, BMI, smoking, COPD, CHF, preoperative sepsis, and ASA class were significantly different between the two groups. After matching, there were no differences in characteristics. 30-day morbidity (OR = 2.7, 95% CI 1.4-5.1), pneumonia (OR = 5.0, 95% CI 1.7-15.0), DVT (OR = 8.22, 95% CI 1.0-66), reoperation (OR = 9.3, 95% CI 1.2-73.8), and readmission (OR = 4.8, 95% CI 2.3-10.1) continued to be significantly worse in the matched cohort.Conclusion: Postoperative COVID-19 infection was associated with worse outcomes after laparoscopic cholecystectomy. These findings suggest that even postoperative COVID-19 diagnosis increases the risk for adverse outcomes in patients recovering from laparoscopic cholecystectomy and may indicate that precautions should be taken and new COVID-19 infections even after surgery should be closely monitored.

Considerations for Perioperative Thromboembolic Risk Mitigation in Actively and Recently COVID-19-Positive Patients Undergoing Hand Surgery

Coronavirus Disease 2019 (COVID) induces a hypercoagulable state causing an increased risk of venous and arterial thromboses. Distal limb and microvascular circulation are critical to the success of many hand surgeries, and patients who are actively or recently infected with COVID may be at a higher risk for perioperative thrombotic events. Little information is available regarding how to handle actively or recently infected COVID patients, including preoperative risk assessment, intraoperative decision making, and postoperative considerations regarding thrombotic risk. Our aim was to review the literature to determine how the hand surgeon can best prepare for and manage the actively or recently COVID-positive patients undergoing hand surgeries.

The impact of COVID-19 for postoperative outcomes using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer

Background

The coronavirus disease 2019 (COVID-19) pandemic had resulted in either failure to provide required medical resources or delayed treatment for gastric cancer patients. This study aimed to investigate the impact of COVID-19 on the incidence of postoperative complications using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer.

Methods

We collected the data of patients who underwent distal gastrectomy from January 2018 to December 2021 from the National Clinical Database (NCD), a web-based surgical registration system in Japan. The number of surgical cases, the use of intensive care units, and the incidence of morbidity per month were analyzed. We also calculated the standardized mortality ratio (SMR), defined as the ratio of the number of observed patients to the expected number of patients calculated using the risk calculator established in the NCD, for several morbidities, including pneumonia, sepsis, 30-day mortality, and surgical mortality.

Results

A decrease of 568 gastrectomies was observed from April 2020 to May 2020. Although the absolute number of patients admitted to intensive care units had declined since 2020, the proportion of patients admitted to the ICU did not change before and after the pandemic. Mortality and critical morbidity (such as pneumonia and sepsis) rates were not worse during the pandemic compared to pre-pandemic periods per the SMR.

Conclusions

Surgical management was conducted adequately through the organized efforts of the entire surgery department in our country even in a pandemic during which medical resources and staff may have been limited.

Analysis of the short-term outcomes after esophagectomy for esophageal cancer during the COVID-19 pandemic using data from a nationwide Japanese database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had adversely impacted cancer screening, diagnosis, and treatment. We investigated the change in medical resource, such as the intensive care unit use, and short-term outcomes after esophagectomy during the pandemic.

METHODS

Data of patients who underwent esophagectomy for esophageal cancer registered in the National Clinical Database (NCD) in Japan from January 2018 to December 2021 were analyzed. The time series change in the number of surgical cases; usage of intensive care unit; incidence of morbidity and mortality; standardized mortality and morbidity ratio (SMR) for 30-days mortality; surgical mortality; and morbidities for pneumonia, sepsis, unplanned intubation, and anastomotic leakage were evaluated.

RESULTS

The annual number of patients undergoing esophagectomy remained similar from 2018 to 2021. The negative impact of the pandemic on medical resources was strongly identified in the patients from an epidemic area where there is a higher cumulative number of infections per population as compared to all prefectures. The proportions of patients admitted to the intensive care unit were 91.4%, 93.0%, 91.6%, and 90.5% in 2018, 2019, 2020, and 2021, respectively. Moreover, 93.3%, 94.0%, 92.0%, and 90.9% patients who underwent surgery in an epidemic area were admitted to the intensive care unit in 2018, 2019, 2020, and 2021, respectively. However, the morbidity and mortality rates during the pandemic did not worsen according to the SMR values.

CONCLUSIONS

Esophagectomy was performed during the pandemic despite limited medical resources by a systematic endeavor of the entire surgical department in Japan, without increasing the incidence rate of worse outcome.

Preoperative Assessment of Patients with Vascular Disease

Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.

SARS-Co-V-2 positive status is associated with a more seriously injured population of trauma patients but not independently associated with worse outcomes of trauma care

BACKGROUND

SARS-CoV-2 positive status has been considered a predominantly incidental finding among trauma patients. We sought to examine whether concurrent infection is associated with worse outcomes in a contemporary cohort of injured patients during the COVID-19 pandemic.

METHODS

Retrospective cohort analysis of a level I trauma center's institutional registry from May 1, 2020 through June 30, 2021. The prevalence of COVID in the trauma population was compared monthly using prevalence ratios relative to population estimates. Unadjusted cohorts of COVID+ vs COVID- trauma patients were compared. COVID+ patients then were matched on age, mechanism of injury, year, and injury severity score (ISS) with COVID- controls for adjusted analysis with a primary composite outcome of mortality.

RESULTS

Out of n=2,783 trauma activations, n=51 (1.8%) were COVID+. Compared to the general population, the trauma population had prevalence ratios for COVID of 5.3 to 79.7 (median=20.8). Compared to COVID- patients, COVID+ patients had worse outcomes, including a higher proportion who were admitted to the ICU, required intubation, underwent a major operation, and had greater total charges and a longer length of stay. However, these differences appeared related to more severe injury patterns in the COVID+ cohort. In the adjusted analysis, no significant differences between groups in any of the outcome variables were observed.

CONCLUSIONS

Worse trauma outcomes in COVID+ patients appear to be correlated to the more substantial patterns of injury observed in this group. Trauma patients have substantially higher rates of SARS-CoV-2 positivity than the local population at large. These results reinforce that this population is vulnerable to multiple threats. They will guide the ongoing delivery of care in shaping the needs for testing, PPE for those delivering care, and the capacity and operational needs of trauma systems that must care for a population with such high rates of SARS-CoV-2 infection.

Mid-term Surgery Outcomes in Patients With COVID-19: Results From a Nationwide Analysis

OBJECTIVE

Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery.

BACKGROUND

COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics.

METHODS

We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (-) patients.

RESULTS

Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (-). COVID (+) status was associated with higher postoperative mortality ( P <0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (-). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (-) patients.

CONCLUSIONS

This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.

Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis

BACKGROUND

Patients undergoing surgery with perioperative COVID-19 are suggested to have worse outcomes, but whether this is COVID-related or due to selection bias remains unclear. We aimed to compare the postoperative outcomes of patients with and without perioperative COVID-19.

METHODS

Patients with perioperative COVID-19 diagnosed within 7 days before or 30 days after surgery between February and July 2020 from 68 US hospitals in COVIDSurg, an international multicenter database, were 1:1 propensity score matched to patients without COVID-19 undergoing similar procedures in the 2012 American College of Surgeons National Surgical Quality Improvement Program database. The matching criteria included demographics (e.g., age, sex), comorbidities (e.g., diabetes, chronic obstructive pulmonary disease, chronic kidney disease), and operation characteristics (e.g., type, urgency, complexity). The primary outcome was 30-day hospital mortality. Secondary outcomes included hospital length of stay and 13 postoperative complications (e.g., pneumonia, renal failure, surgical site infection).

RESULTS

A total of 97,936 patients were included, 1,054 with and 96,882 without COVID-19. Prematching, COVID-19 patients more often underwent emergency surgery (76.1% vs. 10.3%, p < 0.001). A total of 843 COVID-19 and 843 non-COVID-19 patients were successfully matched based on demographics, comorbidities, and operative characteristics. Postmatching, COVID-19 patients had a higher mortality (12.0% vs. 8.1%, p = 0.007), longer length of stay (6 [2-15] vs. 5 [1-12] days), and higher rates of acute renal failure (19.3% vs. 3.0%, p < 0.001), sepsis (13.5% vs. 9.0%, p = 0.003), and septic shock (11.8% vs. 6.0%, p < 0.001). They also had higher rates of thromboembolic complications such as deep vein thrombosis (4.4% vs. 1.5%, p < 0.001) and pulmonary embolism (2.5% vs. 0.4%, p < 0.001) but lower rates of bleeding (11.6% vs. 26.1%, p < 0.001).

CONCLUSION

Patients undergoing surgery with perioperative COVID-19 have higher rates of 30-day mortality and postoperative complications, especially thromboembolic, compared with similar patients without COVID-19 undergoing similar surgeries. Such information is crucial for the complex surgical decision making and counseling of these patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

The potential impact of COVID-19 disease caused multi-organ injuries on patients' surgical outcomes

Purpose

To provide an expert commentary on the impact of prior COVID-19 infection on patient’s surgical outcomes and postoperative recovery. To highlight the need for greater focus on peri-operative care of patients who have recovered from COVID-19.

Methods

A narrative review of the literature was conducted by searching Pubmed and EMBASE for relevant articles using keywords such as “COVID-19”, “Coronavirus”, “surgery” and “peri-operative infection”.

Results

Post-COVID-19 condition also known as long COVID has an estimated incidence of between 3.0 to 11.7%. COVID-19 has been shown to cause a series of short and long-term sequelae including cardiopulmonary complications, renal impairment, chronic fatigue and muscular deconditioning. Peri-operative infection with COVID-19 is associated with increased peri-operative mortality. Elective surgery patients who developed COVID-19 were 26 times more likely to die whilst in hospital compared to controls without COVID-19 infection, and for emergency surgery patients with COVID-19 infection were six times more likely to die. A large international prospective cohort study identified that patients who had surgery delayed over 7 weeks from the date of COVID-19 infection had no increased 30-day postoperative mortality, except those with ongoing symptoms.

Conclusions

COVID-19 infection and its complications have been shown to adversely affect surgical outcomes. Further research is required to better characterise long COVID and the long-term sequelae that develop, which should be used to guide comprehensive peri-operative assessment of patients.

Graphical Abstract

Combinations of nerve blocks in surgery for post COVID-19 pulmonary sequelae patient: A case report and review of literature

BACKGROUND

Regional anesthesia is a promising method in patients with post coronavirus disease 2019 (COVID-19) pulmonary sequelae for preserving pulmonary function and preventing postoperative pulmonary complications, compared with general anesthesia.

CASE SUMMARY

We provided surgical anesthesia and analgesia suitable for breast surgery by performing pectoral nerve block type II (PECS-II), parasternal, and intercostobrachial nerve blocks with intravenous dexmedetomidine administration in a 61-year-old female patient with severe pulmonary sequelae after COVID-19 infection.

CONCLUSION

Sufficient analgesia for 7 h was provided via PECS-II, parasternal, and intercostobrachial blocks perioperatively.

Long-term cardiac symptoms following COVID-19: a systematic review and meta-analysis

Background

There is growing body of literature on the long-term cardiac symptoms following COVID-19. We conducted a systematic review and meta-analysis to synthesize and evaluate related evidence to inform clinical management and future studies.

Methods

We searched two preprint and seven peer-reviewed article databases from January 1, 2020 to January 8, 2022 for studies investigating cardiac symptoms that persisted for at least 4 weeks among individuals who survived COVID-19. A customized Newcastle-Ottawa scale was used to evaluate the quality of included studies. Random-effects meta-analyses were performed to estimate the proportion of symptoms with 95% confidence intervals (CI), and stratified analyses were conducted to quantify the proportion of symptoms by study characteristics and quality.

Results

A total of 101 studies describing 49 unique long-term cardiac symptoms met the inclusion criteria. Based on quality assessment, only 15.8% of the studies (n=16) were of high quality, and most studies scored poorly on sampling representativeness. The two most examined symptoms were chest pain and arrhythmia. Meta-analysis showed that the proportion of chest pain was 10.1% (95% CI: 6.4-15.5) and arrhythmia was 9.8% (95% CI: 5.4-17.2). Stratified analyses showed that studies with low-quality score, small sample size, unsystematic sampling method, and cross-sectional design were most likely to report high proportions of symptoms. For example, the proportion of chest pain was 21.3% (95% CI: 10.5-38.5), 9.3% (95% CI: 6.0-14.0), and 4.0% (95% CI: 1.3-12.0) in studies with low, medium, and high-quality scores, respectively. Similar patterns were observed for other cardiac symptoms including hypertension, cardiac abnormalities, myocardial injury, thromboembolism, stroke, heart failure, coronary disease, and myocarditis.

Discussion

There is a wide spectrum of long-term cardiac symptoms following COVID-19. Findings of existing studies are strongly related to study quality, size and design, underscoring the need for high-quality epidemiologic studies to characterize these symptoms and understand their etiology.

Heightened 30-Day Postoperative Complication Risk Persists After COVID-19 Infection

BACKGROUND

Current literature describing the riskiness of operating on actively infected COVID-19 patients far outnumbers that on the risk of operating on recovered patients. The purpose of this study was to analyze a single, tertiary referral center experience regarding postoperative complications and readmissions in COVID-19-recovered patients versus COVID-19-naïve (never previously infected) patients undergoing elective and emergency surgery across all surgical subspecialties.

METHODS

All PCR positive COVID-19 patients that underwent a surgical procedure between February 1, 2020, and November 1, 2020, were included in the COVID-positive cohort. These patients were then matched to COVID-naïve controls that underwent similar procedures within the same time frame. Primary outcomes included 30-day postoperative complications as well as 90-day readmissions. Multivariable analyses were also performed.

RESULTS

112 COVID-positive patients met inclusion criteria and were all matched to COVID-naïve controls. 76 patients (68%) underwent surgery > 30 days from their COVID diagnosis. COVID-positive patients were at significantly higher risk of 30-day complications compared to the COVID-naïve cohort (22% versus 8%, respectively; p < 0.01). Multivariable analyses found ambulatory/asymptomatic infections, undergoing surgery between 30 and 120 days from diagnosis, initial presentation to the emergency department and elevated ASA scores to be significantly associated with 30-day complications. No differences were found for 90-day readmissions.

CONCLUSION

Patients with previous COVID-19 infections carry a higher perioperative risk profile for 30-day complications compared to COVID-naïve counterparts in unvaccinated populations.

[Features of surgical patients of COVID-19 patients]

The novel coronavirus pandemic has significantly increased the workload of surgical service worldwide. Restrictive measures led to postponement of elective surgical and diagnostic interventions and reduced the number of emergency manipulations around the world. Large-scale studies identified optimal period for postponing surgical procedures and advisability of this postponement. The authors present opinions of surgeons and their views on treatment strategy for various elective and emergency surgical interventions in abdominal surgery, traumatology-orthopedics and oncology. The main factors reducing perioperative mortality in patients with a new coronavirus infection are observance of anti-epidemic measures by patients and medical personnel, competent use of personal protective equipment, as well as adherence to protocols and algorithms for the treatment of these patients.

Positive SARS-CoV-2 detection on intraoperative nasopharyngeal viral testing is not associated with worse outcomes for asymptomatic elective surgical patients

Background

It has been demonstrated that surgical patients with COVID-19 are at increased risk for postoperative complications. However, this association has not been tested in asymptomatic elective surgical patients.

Methods

A retrospective cohort study among elective gynecological and spine surgery patients at a single tertiary medical center from July 2020 through April 2022 (n = 1,130) was performed. The primary endpoint was prolonged (>75th percentile for the corresponding surgical service) length of stay. Secondary endpoints included postoperative respiratory complications, duration of supplemental oxygen therapy, and other major adverse events. The association between SARS-CoV-2 detection and the above outcomes was investigated with univariate and multivariable analyses.

Findings

Of 1,130 patients who met inclusion criteria, 30 (2.7%) experienced intraoperative detection of SARS-CoV-2. Those with intraoperative viral detection did not experience an increased incidence of prolonged length of stay [16.7% vs. 23.2%; RR, 0.72 (95% CI, 0.32-1.61); P = 0.531] nor did they have a longer mean length of stay (4.1 vs. 3.9 days; P = 0.441). Rates of respiratory complications [3.3% vs. 2.9%; RR, 1.15 (95% CI, 0.16-8.11); P = 0.594] and mean duration of supplemental oxygen therapy (9.7 vs. 9.3 h; P = 0.552) were similar as well. All other outcomes were similar in those with and without intraoperative detection of SARS-CoV-2 (all P > 0.05).

Interpretation

Asymptomatic patients with incidental detection of SARS-CoV-2 on intraoperative testing do not experience disproportionately worse outcomes in the elective spine and gynecologic surgical population.

Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal.

METHODS

PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism.

RESULTS

A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms).

CONCLUSIONS

Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.

Impacts of severity of Covid-19 infection on the morbidity and mortality of surgical patients

Introduction

One of the challenges of surgery on patients with active SARS-CoV-2(severe acute respiratory syndrome coronavirus 2) infection is the increased risk of postoperative morbidity and mortality.

Aim

This study will describe and compare the postoperative morbidity and mortality in asymptomatic patients or those with mild infection with those with severe COVID-19 infection undergoing elective or and emergency surgery.

Materials and methods

This is a retrospective study of 37 COVID₁₉ patients who had the infection 7 days prior to and 30 days after emergency or elective surgery. Patients were divided to two groups. Group1: the asymptomatic or those with mild infection that is diagnosed just before surgery (14 patients). Group 2: those who were admitted to the hospital because of severe COVID-19 and were operated for COVID-19 related complications (23 patients). Morbidity and mortality of both groups was studied.

Results

There was no significant difference in gender between the two groups. There were 5 females (2 in group 1, and 3 in group 2) and 32 males (12 in group 1, and 20 in group 2). Mean age for all patients was 49.8years (38 for group 1 and 57 for group2). Median age for all patients was 50 years (37.5 for group 1 and 57 years for group 2). Sepsis developed in 7 patients (1 patient in group 1 and in 6 patients in group 2). Statistically there was no significant difference in occurrence of sepsis between the two groups. There was a significant difference in the intensive care stay between the two groups (higher in group 2). Four deaths were reported in group 1 and fourteen in group 2. Eighteen out of thirty-seven patients died.

Conclusion

Severity of COVID-19 infection will prolong the hospitalization and ICU stay in surgical patients with no significant effect on mortality.

Increased Lengths of Stay, ICU, and Ventilator Days in Trauma Patients with Asymptomatic COVID-19 Infection

Background

The SARS-Cov-2 coronavirus has varying clinical effects—from asymptomatic patients to life-threatening illness and death. At the only Level 1 Trauma Center in a rural state, outcomes appeared worse in trauma patients who tested positive for COVID despite these patients presumably being asymptomatic or only mildly affected before their traumatic event. This study compares all trauma admissions that were COVID-positive to those who were not.

Methods

The institutional database was queried for all level 1 and 2 trauma activations from March 2020-July 2021. The analysis consisted of a multivariate regression between COVID-negative and the COVID-positive group controlling for age, injury severity score (ISS), and Glasgow Coma Score (GCS). Outcomes compared were hospital length-of-stay (LOS), ICU LOS, ventilator days, days to discharge to a facility, and in-hospital mortality.

Results

Hospital LOS was 2.7 days longer in the COVID-positive group (P < .0005). ICU LOS was 2.9 days longer for patients admitted to the ICU in the COVID positive-group (P = .017). Ventilator days were 4.7 days longer for patients requiring mechanical ventilation in the COVID-positive group (P = .002). Discharge to a post-acute facility required 6.1 more days in the COVID-positive group (P = .005).

Conclusion

Trauma patients presenting positive for COVID-19 are presumed to be asymptomatic before their traumatic event. Despite this, the physiologic toll of trauma combined with the COVID infection causes significantly worse clinical outcomes, including increasing hospital days in this patient population, which continues to tax the already burdened healthcare system.

COVID-19 Vaccination Associated With Reduced Postoperative SARS-CoV-2 Infection and Morbidity

OBJECTIVE

The purpose of this study was to determine the effect of COVID-19 vaccination on postoperative mortality, pulmonary and thrombotic complications, readmissions and hospital lengths of stay among patients undergoing surgery in the United States.

BACKGROUND

While vaccination prevents COVID-19, little is known about its impact on postoperative complications.

METHODS

This is a nationwide observational cohort study of all 1,255 Veterans Affairs facilities nationwide. We compared patients undergoing surgery at least 2 weeks after their second dose of the Pfizer BioNTech or Moderna vaccines, to contemporary propensity score matched controls. Primary endpoints were 30-day mortality and postoperative COVID-19 infection. Secondary endpoints were pulmonary or thrombotic complications, readmissions, and hospital lengths of stay.

RESULTS

30,681 patients met inclusion criteria. After matching, there were 3,104 in the vaccination group (1,903 received the Pfizer BioNTech, and 1,201 received the Moderna vaccine) and 7,438 controls. Full COVID-19 vaccination was associated with lower rates of postoperative 30-day COVID-19 infection (Incidence Rate Ratio and 95% confidence intervals, 0.09 [0.01,0.44]), pulmonary complications (0.54 [0.39, 0.72]), thrombotic complications (0.68 [0.46, 0.99]) and decreased hospital lengths of stay (0.78 [0.69, 0.89]). Complications were also low in vaccinated patients who tested COVID-19 positive before surgery but events were too few to detect a significant difference compared to controls.

CONCLUSION

COVID-19 vaccination is associated with lower rates of postoperative morbidity. The benefit is most pronounced among individuals who have never had a COVID-19 infection before surgery.

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening

Background

The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.

Methods

This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.

Results

Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.

Discussion

Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

SARS-CoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England

The scale of the COVID‐19 pandemic means that a significant number of patients who have previously been infected with SARS‐CoV‐2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and expert opinion to highlight key principles in the timing of surgery. Shared decision‐making regarding timing of surgery after SARS‐CoV‐2 infection must account for severity of the initial infection; ongoing symptoms of COVID‐19; comorbid and functional status; clinical priority and risk of disease progression; and complexity of surgery. For the protection of staff, other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre‐ and peri‐operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS‐CoV‐2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID‐19. SARS‐CoV‐2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7‐week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID‐19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. The time before surgery should be used for functional assessment, prehabilitation and multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS‐CoV‐2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. As further data emerge, these recommendations may need to be revised, but the principles presented should be considered to ensure safety of patients, the public and staff.