COVID-19 patients who undergo surgery are at increased risk of postoperative death

3-Jun-2020 1:15 PM EDT, by Massachusetts General Hospital

Newswise — Patients undergoing surgery after contracting coronavirus are at greatly increased risk of postoperative death, a new global study published in The Lancet reveals. Researchers found that amongst SARS-CoV-2 infected patients who underwent surgery, mortality rates approach those of the sickest patients admitted to intensive care after contracting the virus in the community.

Experts from different institutions including the University of Birmingham-led NIHR Global Research Health Unit on Global Surgery and the Department of Surgery at Massachusetts General Hospital have now published their findings that SARS-CoV-2 infected patients who undergo surgery experience substantially worse postoperative outcomes than would be expected for similar patients who do not have SARS-CoV-2 infection.

Researchers examined data for 1,128 patients from 235 hospitals. A total of 24 countries participated, predominantly in Europe, although hospitals in Africa, Asia, and North America also contributed.

Overall 30-day mortality in the study was 23.8%. Mortality was disproportionately high across all subgroups, including elective surgery (18.9%), emergency surgery (25.6%), minor surgery such as appendicectomy or hernia repair (16.3%), and major surgery such as hip surgery or colon cancer surgery (26.9%).

The study identified that mortality rates were higher in men (28.4%) versus women (18.2%), and in patients aged 70 years or over (33.7%) versus those aged under 70 years (13.9%). In addition to age and sex, risk factors for postoperative death included having severe pre-existing medical problems, undergoing cancer surgery, undergoing major procedures, and undergoing emergency surgery.

Patients undergoing surgery are a vulnerable group at risk of SARS-CoV-2 exposure in hospital. They may be particularly susceptible to subsequent pulmonary complications, due to inflammatory and immunosuppressive responses to surgery and mechanical ventilation.

The study found that overall in the 30 days following surgery 51% of patients developed a pneumonia, acute respiratory distress syndrome, or required unexpected ventilation. This may explain the high mortality, as most (81.7%) patients who died had experienced pulmonary complications.

"The decision in most hospitals to postpone elective surgery was made to both protect our patients as well as increase capacity to take care of the COVID-19 patients during the peak of the pandemic," says report co-author Haytham Kaafarani, MD, MPH, from the department of surgery at Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School. "The high mortality and morbidity rates of the elective surgery patients in this study is proving that the decision was sound, as we would normally expect mortality for patients having minor or elective surgery to be under 1-3%."

"We recommend that thresholds for surgery during the SARS-CoV-2 pandemic should be raised compared to normal practice, says Aneel Bhangu, MD, PhD, Senior Lecturer in Surgery at the University of Birmingham, the co-author and overall study lead. "For example, men aged 70 years and over undergoing emergency surgery are at particularly high risk of mortality, so these patients may benefit from their procedures being postponed."

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Funding: National Institute for Health Research Global Health Research Unit Grant (NIHR 16.136.79), Association of Coloproctology of Great Britain and Ireland, Association of Upper Gastrointestinal Surgeons, Bowel Disease Research Foundation, Yorkshire Cancer Research, Sarcoma UK, the British Association of Surgical Oncology, the Vascular Society for Great Britain and Ireland, and the European Society of Coloproctology.

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