Association of Time to Surgery After COVID-19 Infection With Risk of Postoperative Cardiovascular Morbidity

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.

Association of preoperative coronavirus disease 2019 with mortality, respiratory morbidity and extrapulmonary complications after elective, noncardiac surgery: An observational cohort study

STUDY OBJECTIVE

To assess the impact of preoperative infection with the contemporary strain of severe acute respiratory coronavirus 2 (SARS-CoV-2) on postoperative mortality, respiratory morbidity and extrapulmonary complications after elective, noncardiac surgery.

DESIGN

An ambidirectional observational cohort study.

SETTING

A tertiary and teaching hospital in Shanghai, China.

PATIENTS

All adult patients (≥ 18 years of age) who underwent elective, noncardiac surgery under general anesthesia at Huashan Hospital of Fudan University from January until March 2023 were screened for eligibility. A total of 2907 patients were included.

EXPOSURE

Preoperative coronavirus disease 2019 (COVID-19) positivity.

MEASUREMENTS

The primary outcome was 30-day postoperative mortality. The secondary outcomes included postoperative pulmonary complications (PPCs), myocardial injury after noncardiac surgery (MINS), acute kidney injury (AKI), postoperative delirium (POD) and postoperative sleep quality. Multivariable logistic regression was used to assess the risk of postoperative mortality and morbidity imposed by preoperative COVID-19.

MAIN RESULTS

The risk of 30-day postoperative mortality was not associated with preoperative COVID-19 [adjusted odds ratio (aOR), 95% confidence interval (CI): 0.40, 0.13-1.28, P = 0.123] or operation timing relative to diagnosis. Preoperative COVID-19 did not increase the risk of PPCs (aOR, 95% CI: 0.99, 0.71-1.38, P = 0.944), MINS (aOR, 95% CI: 0.54, 0.22-1.30; P = 0.168), or AKI (aOR, 95% CI: 0.34, 0.10-1.09; P = 0.070) or affect postoperative sleep quality. Patients who underwent surgery within 7 weeks after COVID-19 had increased odds of developing delirium (aOR, 95% CI: 2.26, 1.05-4.86, P = 0.036).

CONCLUSIONS

Preoperative COVID-19 or timing of surgery relative to diagnosis did not confer any added risk of 30-day postoperative mortality, PPCs, MINS or AKI. However, recent COVID-19 increased the risk of POD. Perioperative brain health should be considered during preoperative risk assessment for COVID-19 survivors.

Postoperative Outcomes Associated with the Timing of Surgery After SARS-CoV-2 Infection

OBJECTIVE

Examine the association between prior SARS-CoV-2 infection, interval from infection to surgery, and adverse surgical outcomes.

SUMMARY BACKGROUND DATA

Earlier series have reported worse outcomes for surgery after COVID-19 illness, and these findings have led to routinely deferring surgery seven weeks after infection.

METHODS

We created a retrospective cohort of patients from the US Veterans Health Administration facilities nationwide, April 2020 to September 2022, undergoing surgical procedures. Primary outcomes were 90-day all-cause mortality and 30-day complications. Within surgical procedure groupings, SARS-CoV-2 infected and uninfected patients were matched in a 1:4 ratio. We categorized patients by 2-week intervals from SARS-CoV-2 positive test to surgery. Hierarchical multilevel multivariable logistic regression models were used to estimate the association between infection to surgery interval versus no infection and primary end points.

RESULTS

We identified 82,815 veterans undergoing eligible operations (33% general, 27% orthopedic, 13% urologic, 9% vascular), of whom 16,563 (20%) had laboratory-confirmed SARS-CoV-2 infection before surgery. The multivariable models demonstrated an association between prior SARS-CoV-2 infection and increased 90-day mortality (odds ratio (OR) 1.42, 95% CI: 1.08, 1.86) and complications (OR 1.32, 95% CI: 1.11, 1.57) only for patients having surgery within 14 days of infection. ASA-stratified multivariable models showed that the associations between increased 90-day mortality (OR 1.40, 95% CI: 1.12, 1.75) and complications (OR 1.73, 95% CI: 1.34, 2.24) for patients having surgery within 14 days of infection were confined to those with ASA 4-5.

CONCLUSIONS

In a contemporary surgical cohort, patients with prior SARS-CoV-2 infection only had increased postoperative mortality or complications when they had surgery within 14 days after the positive test. These findings support revising timing recommendations between surgery and prior SARS-CoV-2 infection.

Impact of COVID-19 infection among patients hospitalized for conventional pacemaker implantation: Analysis of the Nationwide Inpatient Sample (NIS) 2020

Introduction

The cardiac pacemaker is indicated for treating various types of bradyarrhythmia, providing lifelong cardiovascular benefits. Recent data showed that COVID-19 has impacted procedure numbers and led to adverse long-term outcomes in patients with cardiac pacemakers. However, the impact of COVID-19 infection on the in-hospital outcome of patients undergoing conventional pacemaker implantation remains unclear.

Method

Patients aged above 18 years who were hospitalized for conventional pacemaker implantation in the Nationwide In-patient Sample (NIS) 2020 were identified using relevant ICD-10 CM and PCS codes. Multivariable logistic and linear regression models were used to analyze pre-specified outcomes, with the primary outcome being in-patient mortality and secondary outcomes including system-based and procedure-related complications.

Results

Of 108 020 patients hospitalized for conventional pacemaker implantation, 0.71% (765 out of 108 020) had a concurrent diagnosis of COVID-19 infection. Individuals with COVID-19 infection exhibited a lower mean age (73.7 years vs. 75.9 years, p = .027) and a lower female proportion (39.87% vs. 47.60%, p = .062) than those without COVID-19. In the multivariable logistic and linear regression models, adjusted for patient and hospital factors, COVID-19 infection was associated with higher in-hospital mortality (aOR 4.67; 95% CI 2.02 to 10.27, p < .001), extended length of stay (5.23 days vs. 1.04 days, p < .001), and linked with various in-hospital complications, including sepsis, acute respiratory failure, post-procedural pneumothorax, and venous thromboembolism.

Conclusion

Our study suggests that COVID-19 infection is attributed to higher in-hospital mortality, extended hospital stays, and increased adverse in-hospital outcomes in patients undergoing conventional pacemaker implantation.

Expanded analysis for patients with acute cholecystitis indicates outcomes vary based on COVID-19 status and treatment modality

BACKGROUND

The impact of different phases of COVID-19 infection on outcomes from acute calculous cholecystitis (ACC) is not well understood. Therefore, we examined outcomes of acute cholecystitis during the COVID-19 pandemic, comparing the effect of different treatment modalities and COVID-19 infection status. We hypothesized that patients with acute COVID-19 would have worse outcomes than COVID-negative patients, but there would be no difference between COVID-negative and COVID-recovered patients.

METHODS

We used 2020-2023 National COVID Cohort Collaborative data to identify adults with ACC. Treatment (antibiotics-only, cholecystostomy tube, or cholecystectomy) and COVID-19 status (negative, active, or recovered) were collected. Treatment failure of nonoperative managements was noted. Adjusted analysis using a series of generalized linear models controlled for confounders (age, sex, body mass index, Charlson comorbidity index, severity at presentation, and year) to better assess differences in outcomes among treatment groups, as well as between COVID-19 groups.

RESULTS

In total, 32,433 patients (skewed count) were included: 29,749 COVID-negative, 2112 COVID-active, and 572 (skewed count) COVID-recovered. COVID-active had higher rates of sepsis at presentation. COVID-negative more often underwent cholecystectomy. Unadjusted, COVID-active had higher 30-day mortality, 30-day complication, and longer length of stay than COVID-negative and COVID-recovered. Adjusted analysis revealed cholecystectomy carried lower odds of mortality for COVID-active and COVID-negative patients than antibiotics or cholecystostomy. COVID-recovered patients' mortality was unaffected by treatment modality. Treatment failure from antibiotics was more common for COVID-negative patients.

CONCLUSION

Acute cholecystitis outcomes are affected by phase of COVID-19 infection and treatment modality. Cholecystectomy does not lead to worse outcomes for COVID-active and COVID-recovered patients than nonoperative treatments; thus, these patients can be considered for cholecystectomy if their physiology is not prohibitive.

The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing (December 2023)

Accurate molecular diagnostic tests are necessary for confirming a diagnosis of coronavirus disease 2019 (COVID-19) and for identifying asymptomatic carriage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The number of available SARS-CoV-2 nucleic acid detection tests continues to increase as does the COVID-19 diagnostic literature. Thus, the Infectious Diseases Society of America (IDSA) developed an evidence-based diagnostic guideline to assist clinicians, clinical laboratorians, patients, and policymakers in decisions related to the optimal use of SARS-CoV-2 nucleic acid amplification tests. In addition, we provide a conceptual framework for understanding molecular diagnostic test performance, discuss nuances of test result interpretation in a variety of practice settings, and highlight important unmet research needs related to COVID-19 diagnostic testing. IDSA convened a multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review to identify and prioritize clinical questions and outcomes related to the use of SARS-CoV-2 molecular diagnostics. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel agreed on 12 diagnostic recommendations. Access to accurate SARS-CoV-2 nucleic acid testing is critical for patient care, hospital infection prevention, and the public health response to COVID-19 infection. Information on the clinical performance of available tests continues to grow, but the quality of evidence of the current literature to support this updated molecular diagnostic guideline remains moderate to very low. Recognizing these limitations, the IDSA panel weighed available diagnostic evidence and recommends nucleic acid testing for all symptomatic individuals suspected of having COVID-19. In addition, testing is suggested for asymptomatic individuals with known or suspected contact with a COVID-19 case when the results will impact isolation/quarantine/personal protective equipment (PPE) usage decisions. Evidence in support of rapid testing and testing of upper respiratory specimens other than nasopharyngeal swabs, which offer logistical advantages, is sufficient to warrant conditional recommendations in favor of these approaches.

Timing of oral and maxillofacial surgery in infected COVID-19 subjects: A retrospective cohort study

This study aims to investigate the association of time to oral and maxillofacial surgery after Covid-19 infection with the risk of postoperative complications in a population from China. In the current study, a total of 1342 consecutive patients underwent general anesthesia (GA) in the maxillofacial district of the Chinese Oral and Maxillofacial COVID Collaborative, which consists of 27 teaching hospitals. Pulmonary, cardiovascular and thrombotic complications were monitored for 1 month after GA surgery (GAS) and their incidence was reported for the first 30 days. Post-operative complications were observed in 4 of 1076 cases (0.37%) who had suffered from mild Omicron infection and in none of the controls. Results from the Quasi-Poisson multivariate regression models showed that Omicron infection was not associated with increased post-operative complications compared to controls. Among the infected patients, delays of >4 but not >6 weeks were associated with lower OR of complications (0.08, 95% CI 0.01-0.78 and 0.06, 95% CI 0.01-1.80, respectively). Findings of this study suggest that delaying surgery for a period of 4-6 weeks following infection can provide a protective effect.

Impact of COVID-19 Pandemic Surge on Surgical Outcomes: A Retrospective Study

BACKGROUND

The COVID-19 pandemic posed significant challenges to healthcare systems worldwide, including surgical care. While many studies examined the effect of the pandemic on different patient outcomes, there are none to date examining the impact of the pandemic surge on surgical outcomes. Our aim is to evaluate the impact of the COVID-19 surges on surgical outcomes using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

A single-center retrospective analysis of 7436 patients who underwent surgery between February 2020 and December 2022 was conducted. Patients were divided into those who underwent surgery during the surge of the pandemic (n = 1217) or outside that period (n = 6219). Primary outcomes were 30-day mortality and morbidity. Secondary outcomes included 30-day mortality, operation time, transfusion, reoperation, and specific postoperative complications. Multivariable logistic regression was used in our analysis. All analyses were conducted using the software "R" version 4.2.1. Statistical significance was set at α = .05 level.

RESULTS

After adjusting for confounders, we found no significant difference in 30-day mortality and morbidity (OR: 1.06, 95% CI: .89-1.226, P = .5173) or 30-day mortality only (OR: 1.39, 95% CI: .788-2.14, P = .1364) between the two groups. No significant differences were observed in secondary outcomes. Sensitivity analyses yielded similar results to the multivariable logistic regression.

CONCLUSION

We found no evidence of increased 30-day mortality and morbidity in patients undergoing surgery during the COVID-19 surges compared to those undergoing surgery outside that period. Our results suggest that surgical care was maintained despite the challenges of the pandemic surges.

Cervical Spine Surgery Following COVID-19 Infection: When is it Safe to Proceed?

STUDY DESIGN

Retrospective.

OBJECTIVE

We utilized the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile of patients undergoing spine surgery during multiple time windows following the COVID-19 infection.

SUMMARY OF BACKGROUND DATA

While the impact of COVID-19 on various organ systems is well documented, there is limited knowledge regarding its effect on perioperative complications following spine surgery or the optimal timing of surgery after an infection.

METHODS

We asked the National COVID Cohort Collaborative for patients who underwent cervical spine surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0-2 weeks, 2-6 weeks, or 6-12 weeks before surgery.

RESULTS

A total of 29,449 patients who underwent anterior approach cervical spine surgery and 46,379 patients who underwent posterior approach cervical spine surgery were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events, sepsis, 30-day mortality, and 1-year mortality, irrespective of the anterior or posterior approach. Among patients undergoing surgery between 2 and 6 weeks after COVID-19 infection, the 30-day mortality risk remained elevated in patients undergoing a posterior approach only. Patients undergoing surgery between 6 and 12 weeks from the date of the COVID-19 infection did not show significantly elevated rates of any complications analyzed.

CONCLUSIONS

Patients undergoing either anterior or posterior cervical spine surgery within 2 weeks from the initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events, sepsis, and mortality. Elevated perioperative complication risk does not persist beyond 2 weeks, except for 30-day mortality in posterior approach surgeries. On the basis of these results, it may be warranted to postpone nonurgent spine surgeries for at least 2 weeks following a COVID-19 infection and advise patients of the increased perioperative complication risk when urgent surgery is required.

Effect Modification of COVID-19 Symptoms on the Association Between Timing of Surgery and Postoperative Complications in Pediatric Spinal Deformity: A Prospective Cohort Study

OBJECTIVE

The purpose of this study was to explore the optimal timing and associated risks of pediatric spinal deformity surgery during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

All consecutive surgical cases for spinal deformity between September 2022 and May 2023 were included. The population was divided into several categories according to the time from diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to the day of surgery. Postoperative complications were analyzed using logistic regression, and we simultaneously showed the results from the crude model, minimally adjusted model, and fully adjusted model.

RESULTS

A total of 81 consecutive patients were enrolled. In the fully adjusted model, compared with pre-COVID-19 patients, peri-COVID-19 patients had a 4.5-fold increased risk of postoperative complications (odds ratio = 5.5, 95% confidence interval 1.1-27.2, P = 0.037), early post-COVID-19 patients had a 2.3-fold increased risk (odds ratio= 3.3, 95% confidence interval 0.7-16.1, P = 0.133), and late post-COVID-19 patients were at essentially equal risk. In asymptomatic population, early post-COVID-19 patients and late post-COVID-19 patients appeared to be at equal risk compared with pre-COVID-19 patients. For patients with persistent symptoms, is necessary to wait at least 8 weeks or even longer after SARS-CoV-2 infection. Interaction tests demonstrated that the effect of the timing of surgery on postoperative complications significantly differed in populations with different symptoms.

CONCLUSIONS

Surgery for pediatric spinal deformity should be postponed until 8 weeks after SARS-CoV-2 infection in cases with COVID-19-related symptoms within 2 weeks prior to surgery; whereas, for those who are asymptomatic within 2 weeks prior to surgery, an interval of 4 weeks seemed to be sufficient.

The impact of preoperative coronavirus disease 19 infection on early postoperative mortality during the vaccination era: a nationwide retrospective cohort study

BACKGROUND

We aimed to investigate the optimal surgical timing in patients with preoperative coronavirus disease 2019 (COVID-19) infection to minimize postoperative morbidity and mortality during the COVID-19 vaccination era.

METHODS

The Korean nationwide data on patients who underwent standard surgery under general anesthesia in 2021 were analyzed. Patients were categorized based on the time from COVID-19 diagnosis to surgery: 0-4, 5-8, > 8 weeks, and those without preoperative COVID-19 infection. Multivariable logistic regression analysis, considering preoperative COVID-19 vaccination status (fully vaccinated vs. unvaccinated or partially vaccinated), was performed to associate the preoperative COVID-19 infection timing with 30- and 90-day postoperative mortality and 30-day respiratory complications.

RESULTS

Among the 750,175 included patients, 28.2% were preoperatively fully vaccinated. Compared with patients without prior COVID-19 infection, those who had surgery 0-4 weeks (adjusted odds ratio [OR]: 4.28, 95% CI [1.81, 10.13], P = 0.001) and 5-8 weeks (adjusted OR: 3.38, 95% CI [1.54, 7.44], P = 0.002) after COVID-19 infection had a significantly increased risk of 30-day mortality. Preoperative full vaccination was significantly associated with a decrease in 90-day mortality (adjusted OR: 0.93, 95% CI [0.89, 0.98], P = 0.007) and 30-day respiratory complications (adjusted OR: 0.85, 95% CI [0.82, 0.87], P < 0.001), but not with 30-day mortality (P = 0.916).

CONCLUSIONS

COVID-19 infection eight weeks preoperatively was associated with an increased 30-day postoperative mortality. Preoperative full vaccination was not associated with 30-day mortality but was related to lower risk of 90-day mortality and 30-day respiratory complications.

Association between COVID-19 diagnosis and postoperative outcomes in sleeve gastrectomy and Roux-en-Y gastric bypass: A national cohort study

BACKGROUND

We seek to determine the association between COVID-19 diagnosis and postoperative outcomes following bariatric surgery.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database, patients undergoing sleeve gastrectomy and gastric bypass without a COVID-19 diagnosis were 2:1 propensity-score matched to those with COVID-19 infection pre or postoperatively.

RESULTS

1369 (0.74 ​%) and 1331 (0.72 ​%) patients had a COVID-19 diagnosis within 14 days prior to or 30 days after their operation, respectively. Patients with preoperative COVID-19 infection had equivalent outcomes to COVID-19 negative patients (all p ​> ​0.05). Postoperative COVID-19 diagnosis was associated with worse outcomes including increased risk of anastomotic/staple line leak (1.1 ​% vs 0.1 ​%, p ​< ​0.001), postoperative pneumonia (2.9 ​% vs 0.1 ​%, p ​< ​0.001), and 30-day reoperation (2.1 ​% vs 0.9 ​%, p ​= ​0.002).

CONCLUSIONS

Postoperative diagnosis of COVID-19 after bariatric surgery is associated with worse outcomes; however, it is safe to perform these procedures on patients recently convalesced from COVID-19 infection.

How long can pulmonary resection surgery be performed after SARS-CoV-2 infection? A multicenter retrospective study

BACKGROUND

No studies to date have focused on the timing of pulmonary resection in patients with previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In the present study, the authors analyzed the surgical outcomes and evaluated the optimal time point of pulmonary resection surgery following SARS-CoV-2 infection.

MATERIALS AND METHODS

In this multicenter retrospective cohort study, patients were divided into different groups according to the time interval between SARS-CoV-2 diagnosis and pulmonary resection. The primary outcome measure was postoperative complications within 30 days after surgery, which was investigated to determine the optimal time point of pulmonary resection. Logistic regression models were used to calculate the risk factors for postoperative complications.

RESULTS

In total, 400 patients were enrolled, and the postoperative pathologic examination of 322 (80.5%) patients showed lung cancer. As the interval between SARS-CoV-2 infection and pulmonary resection increased, the incidence of complications gradually decreased in each group. The incidence of grade ≥II complications was higher in the ≤2-week and 2-week to 4-week groups than in the 4-week to 6-week, 6-week to 8-week and >8-week groups [3 (21.4%), 17 (20.2%), 10 (10.6%), 13 (7.9%), and 3 (6.5%), respectively] ( P <0.05). Multiclassification regression analysis showed that the risk of grade ≥II complications in the ≤2-week and 2-week to 4-week groups was significantly higher than that in the >8-week group [odds ratio (95% CI), 3.937 (1.072-14.459), P =0.039 and 3.069 (1.232-6.863), P =0.015]. The logistic regression analysis suggested that underlying disease, persistent SARS-CoV-2 symptoms, and surgical timing (≤4 weeks) were independent risk factors for complications of pulmonary resection after SARS-CoV-2 infection.

CONCLUSION

Pulmonary resection should be delayed for at least 4 weeks following SARS-CoV-2 infection to reduce the risk of postoperative complications.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

BACKGROUND

Previous studies on nonoperative management (NOM) of acute appendicitis (AA) indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between nonoperative and operative management groups, regardless of COVID-19 status.

METHODS

We queried the National COVID Cohort Collaborative from 2020 to 2023 to identify adults with AA who underwent operative or NOM. COVID-19 status was denoted as follows: COVID-negative, COVID-active, or COVID-recovered. Intention to treat was used for NOM. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities.

RESULTS

A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and recovered less often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of NOM between COVID groups. Adjusted analysis indicated, compared with operative, NOM carried higher odds of mortality and readmission for COVID-negative and COVID-active patients.

CONCLUSION

This study demonstrates higher odds of mortality among NOM of appendicitis and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that NOM of appendicitis is associated with worse outcomes for COVID-active and COVID-negative patients. In addition, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patient from appendectomy for AA. Surgeon clinical judgment of a patient's physiology and surgical risk should, of course, inform the decision to proceed to the operating room.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Pediatric endoscopy in times of pandemic: A nationwide retrospective analysis

BACKGROUND

Gastrointestinal endoscopy is a procedure that carries an increased risk of transmission of SARS-CoV-2 infection to medical staff. In patients, COVID-19 is a risk factor for adverse events of medical procedures. This study analyzed the real-life risk of, and factors contributing to, infection transmission to endoscopic personnel, and possible adverse events of the endoscopy procedure and anesthesia in children with COVID-19.

METHODS

Nationwide retrospective analysis of medical records of children with confirmed SARS-CoV-2 infection who underwent gastrointestinal endoscopy in Poland between February 2020 and February 2022.

RESULTS

Fifty-eight patients were included in the analysis, 35% of whom had COVID-19 symptoms at the time of endoscopy. The dominant indications for endoscopy were foreign body or corrosive substance ingestion and gastrointestinal bleeding. Nine cases of virus transmission were registered among endoscopic personnel. In all of these cases, the endoscopy team was unaware of the patient's infection (p < 0.01), although symptoms were present in 78% of the children. Lack of use of personal protective equipment was the strongest predictor of SARS-CoV-2 transmission (p < 0.01). The risk of infection was not statistically significantly dependent on the method of anesthesia, intubation or the type of endoscopy. No statistically significant correlation was found between symptomatic infection and adverse events of endoscopy or anesthesia occurrence. There was one reported anesthesia-related adverse event involving extubation difficulties due to worsening respiratory infection symptoms.

CONCLUSIONS

The risk of transmitting SARS-CoV-2 to endoscopic personnel during procedures in children is low and depends on compliance with infection prevention and control measures. Performing gastrointestinal endoscopy in children with COVID-19 does not appear to be associated with an increased risk of adverse events.

Perioperative Mortality of the COVID-19 Recovered Patient Compared to a Matched Control: A Multicenter Retrospective Cohort Study

BACKGROUND

Surgical procedures performed on patients with recent exposure to COVID-19 infection have been associated with increased mortality risk in previous studies. Accordingly, elective surgery is often delayed after infection. The study aimed to compare 30-day hospital mortality and postoperative complications (acute kidney injury, pulmonary complications) of surgical patients with a previous COVID-19 infection to a matched cohort of patients without known previous COVID-19. The authors hypothesized that COVID-19 exposure would be associated with an increased mortality risk.

METHODS

In this retrospective observational cohort study, patients presenting for elective inpatient surgery across a multicenter cohort of academic and community hospitals from April 2020 to April 2021 who had previously tested positive for COVID-19 were compared to controls who had received at least one previous COVID-19 test but without a known previous COVID-19-positive test. The cases were matched based on anthropometric data, institution, and comorbidities. Further, the outcomes were analyzed stratified by timing of a positive test result in relation to surgery.

RESULTS

Thirty-day mortality occurred in 229 of 4,951 (4.6%) COVID-19-exposed patients and 122 of 4,951 (2.5%) controls. Acute kidney injury was observed in 172 of 1,814 (9.5%) exposed patients and 156 of 1,814 (8.6%) controls. Pulmonary complications were observed in 237 of 1,637 (14%) exposed patients and 164 of 1,637 (10%) controls. COVID-19 exposure was associated with an increased 30-day mortality risk (adjusted odds ratio, 1.63; 95% CI, 1.38 to 1.91) and an increased risk of pulmonary complications (1.60; 1.36 to 1.88), but was not associated with an increased risk of acute kidney injury (1.03; 0.87 to 1.22). Surgery within 2 weeks of infection was associated with a significantly increased risk of mortality and pulmonary complications, but that effect was nonsignificant after 2 weeks.

CONCLUSIONS

Patients with a positive test for COVID-19 before elective surgery early in the pandemic have an elevated risk of perioperative mortality and pulmonary complications but not acute kidney injury as compared to matched controls. The span of time from positive test to time of surgery affected the mortality and pulmonary risk, which subsided after 2 weeks.

EDITOR’S PERSPECTIVE

Perioperative Respiratory-Adverse Events Following General Anesthesia Among Pediatric Patients After COVID-19

BACKGROUND

The perianesthetic morbidity, mortality risk and anesthesia-associated risk after preoperative coronavirus disease 2019 (COVID-19) omicron variant in pediatric patients have not been fully demonstrated. We examined the association between preoperative COVID-19 omicron diagnosis and the incidence of overall perioperative adverse events in pediatric patients who received general anesthesia.

METHODS

This retrospective study included patients aged < 18 years who received general anesthesia between February 1 and June 10, 2022, in a single tertiary pediatric hospital. They were divided into two groups; patients in a COVID-19 group were matched to patients in a non-COVID-19 group during the omicron-predominant period in Korea. Data on patient characteristics, anesthesia records, post-anesthesia records, COVID-19-related history, symptoms, and mortality were collected. The primary outcomes were the overall perioperative adverse events, including perioperative respiratory adverse events (PRAEs), escalation of care, and mortality.

RESULTS

In total, 992 patients were included in the data analysis (n = 496, COVID-19; n = 496, non-COVID-19) after matching. The overall incidence of perioperative adverse events was significantly higher in the COVID-19 group than in the non-COVID-19 group (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.89-1.94). The difference was significant for PRAEs (OR, 2.00; 95% CI, 1.96-2.02) but not in escalation of care or mortality. The most pronounced difference between the two groups was observed in instances of high peak inspiratory pressure ≥ 25 cmH2O during the intraoperative period (OR, 11.0; 95% CI, 10.5-11.4). Compared with the non-COVID-19 group, the risk of overall perioperative adverse events was higher in the COVID-19 group diagnosed 0-2 weeks before anesthesia (OR, 6.5; 95% CI, 2.1-20.4) or symptomatic on the anesthesia day (OR, 6.4; 95% CI, 3.30-12.4).

CONCLUSION

Pediatric patients with the preoperative COVID-19 omicron variant had increased risk of PRAEs. Patients within 2 weeks after COVID-19 or those with symptoms had a higher risk of PRAEs.

A temporal analysis of perioperative complications following COVID-19 infection in patients undergoing lumbar spinal fusion: When is it safe to proceed?

Background Context

COVID-19 has been shown to adversely affect multiple organ systems, yet little is known about its effect on perioperative complications after spine surgery or the optimal timing of surgery after an infection. We used the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile in patients undergoing spine surgery during multiple time windows following COVID-19 infection.

Methods

We queried the National COVID Cohort Collaborative, a database of 17.4 million persons with 6.9 million COVID-19 cases, for patients undergoing lumbar spinal fusion surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0 to 2 weeks, 2 to 6 weeks, or 6 to 12 weeks before surgery.

Results

A total of 60,541 patients who underwent lumbar spinal fusion procedures were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events (OR 2.29, 95% CI 1.58-3.32), sepsis (OR 1.56, 95% CI 1.03-2.36), 30-day mortality (OR 5.55, 95% CI 3.53-8.71), and 1-year mortality (OR 2.70, 95% CI 1.91-3.82) compared with patients who were COVID negative during the same period. There was no significant difference in the rates of acute kidney injury or surgical site infection. Patients undergoing surgery between 2 and 6 weeks or between 6 and 12 weeks from the date of COVID-19 infection did not show significantly elevated rates of any complication analyzed.

Conclusions

Patients undergoing lumbar spinal fusion within 2 weeks from initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events and sepsis. This effect does not persist beyond 2 weeks, however, so it may be warranted to postpone non-urgent spine surgeries for at least 2 weeks following a COVID-19 infection or to consider a more aggressive VTE chemoprophylaxis regimen for urgent surgery in COVID-19 patients.

Association between post-COVID-19 status and perioperative morbidity and mortality: protocol for an ambispective cohort study

INTRODUCTION

With COVID-19 bringing persistent impact on the worldwide population, perioperative management after SARS-CoV-2 infection needs to be revisited in the new period of different circulating coronavirus variants, vaccination status, increased reinfection rate and new disease control policies. This study aims to explore the association between time to surgery after COVID-19 diagnosis and the risk of postoperative morbidity and mortality.

METHODS AND ANALYSIS

This is a single-centre ambispective cohort study. Patients with preoperative SARS-CoV-2 infection who require inpatient surgical intervention from 1 December 2022 to 28 February 2023 will be included. Baseline assessment will include the time interval between preoperative SARS-CoV-2 infection and surgery, COVID-19 diagnosis and symptoms, vaccination status and routine preoperative evaluations. The primary outcome will be postoperative composite complications within 30 days after surgery. Association between post-COVID-19 interval and the outcomes will be explored using logistic regression after adjusting for confounding variables.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of Peking Union Medical College Hospital (IRB K3570). We aim to publish and disseminate the findings in peer-reviewed journals, scientific conferences and on social media.

TRIAL REGISTRATION NUMBER

NCT05689840.

Preoperative SARS-CoV-2 infection increases risk of early postoperative cardiovascular complications following noncardiac surgery

As the coronavirus disease 2019 (COVID-19) pandemic progresses to an endemic phase, a greater number of patients with a history of COVID-19 will undergo surgery. Major adverse cardiovascular and cerebrovascular events (MACE) are the primary contributors to postoperative morbidity and mortality; however, studies assessing the relationship between a previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and postoperative MACE outcomes are limited. Here, we analyzed retrospective data from 457,804 patients within the N3C Data Enclave, the largest national, multi-institutional data set on COVID-19 in the United States. However, 7.4% of patients had a history of COVID-19 before surgery. When comorbidities, age, race, and risk of surgery were controlled, patients with preoperative COVID-19 had an increased risk for 30-day postoperative MACE. MACE risk was influenced by an interplay between COVID-19 disease severity and time between surgery and infection; in those with mild disease, MACE risk was not increased even among those undergoing surgery within 4 wk following infection. In those with moderate disease, risk for postoperative MACE was mitigated 8 wk after infection, whereas patients with severe disease continued to have elevated postoperative MACE risk even after waiting for 8 wk. Being fully vaccinated decreased the risk for postoperative MACE in both patients with no history of COVID-19 and in those with breakthrough COVID-19 infection. Together, our results suggest that a thorough assessment of the severity, vaccination status, and timing of SARS-CoV-2 infection must be a mandatory part of perioperative stratification.NEW & NOTEWORTHY With an increasing proportion of patients undergoing surgery with a prior history of COVID-19, it is crucial to understand the impact of SARS-CoV-2 infection on postoperative cardiovascular/cerebrovascular risk. Our work assesses a large, national, multi-institutional cohort of patients to highlight that COVID-19 infection increases risk for postoperative major adverse cardiovascular and cerebrovascular events (MACE). MACE risk is influenced by an interplay between disease severity and time between infection and surgery, and full vaccination reduces the risk for 30-day postoperative MACE. These results highlight the importance of stratifying time-to-surgery guidelines based on disease severity.

Association between COVID-19 and Postoperative Neurological Complications and Antipsychotic Medication Use after Cancer Surgery: A Retrospective Study

INTRODUCTION

Millions of Americans infected with the severe acute respiratory syndrome-associated coronavirus-19 (COVID-19) need oncologic surgery. Patients with acute or resolved COVID-19 illness complain of neuropsychiatric symptoms. How surgery affects postoperative neuropsychiatric outcomes such as delirium is unknown. We hypothesize that patients with a history of COVID-19 could have an exaggerated risk of developing postoperative delirium after undergoing major elective oncologic surgery.

METHODS

We conducted a retrospective study to determine the association between COVID-19 status and antipsychotic drugs during postsurgical hospitalization as a surrogate of delirium. Secondary outcomes included 30 days of postoperative complications, length of stay, and mortality. Patients were grouped into pre-pandemic non-COVID-19 and COVID-19-positive groups. A 1:2 propensity score matching was used to minimize bias. A multivariable logistic regression model estimated the effects of important covariates on the use of postoperative psychotic medication.

RESULTS

A total of 6003 patients were included in the study. Pre- and post-propensity score matching demonstrated that a history of preoperative COVID-19 did not increase the risk of antipsychotic medications postoperatively. However, respiratory and overall 30-day complications were higher in COVID-19 individuals than in pre-pandemic non-COVID-19 patients. The multivariate analysis showed that the odds of using postoperative antipsychotic medication use for the patients who had COVID-19 compared to those who did not have the infection were not significantly different.

CONCLUSION

A preoperative diagnosis of COVID-19 did not increase the risk of postoperative antipsychotic medication use or neurological complications. More studies are needed to reproduce our results due to the increased concern of neurological events post-COVID-19 infection.

Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms

Currently, antithrombotic therapy is the basis of the pathogenetic treatment of many cardiovascular diseases, such as coronary heart disease, stroke, peripheral vascular disease, as well as mechanical heart valves, heart rhythm disturbances, venous thromboembolism. At the same time, chronic use of antiplatelet and/or anticoagulant drugs is a complicating factor in invasive and surgical procedures, as it increases the risk of bleeding. In this regard, a fundamentally important and complex question arises: how to minimize the risk of periprocedural bleeding without exposing the patient to an increased risk of ischemic and thromboembolic complications? Perioperative management of patients who take antithrombotic drugs for a long time is a complex problem that depends on many factors - the risk of surgery, anesthesia, cardiovascular risks, and the urgency of surgery. Each clinical situation should be assessed individually, collegially, with the participation of surgeons, anesthesiologists, and therapists. The introduction of a checklist into clinical practice for each planned surgical patient will allow us to calculate the individual risk of bleeding and thromboembolic complications, and provide an optimal preventive strategy for perioperative management of the patient. The algorithms and schemes presented in the article for the perioperative management of patients with non-cardiac interventions are aimed at standardizing the management of patients before non-cardiac surgical interventions, which will reduce hemorrhagic risks in the presence of the necessary antithrombotic therapy.