Outcomes and Their State-level Variation in Patients Undergoing Surgery With Perioperative SARS-CoV-2 Infection in the USA: A Prospective Multicenter Study

Impact of non-emergency surgical timing on postoperative recovery quality in mild or asymptomatic SARS-CoV-2 infected patients: a grouped cohort study

OBJECTIVE

To explore the relationship between the timing of non-emergency surgery in mild or asymptomatic SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infected individuals and the quality of postoperative recovery from the time of confirmed infection to the day of surgery.

METHODS

We retrospectively reviewed the medical records of 300 cases of mild or asymptomatic SARS-CoV-2 infected patients undergoing elective general anaesthesia surgery at Yijishan Hospital between January 9, 2023, and February 17, 2023. Based on the time from confirmed SARS-CoV-2 infection to the day of surgery, patients were divided into four groups: ≤2 weeks (Group A), 2-4 weeks (Group B), 4-6 weeks (Group C), and 6-8 weeks (Group D). The primary outcome measures included the Quality of Recovery-15 (QoR-15) scale scores at 3 days, 3 months, and 6 months postoperatively. Secondary outcome measures included postoperative mortality, ICU admission, pulmonary complications, postoperative length of hospital stay, extubation time, and time to leave the PACU.

RESULTS

Concerning the primary outcome measures, the QoR-15 scores at 3 days postoperatively in Group A were significantly lower compared to the other three groups (P < 0.05), while there were no statistically significant differences among the other three groups (P > 0.05). The QoR-15 scores at 3 and 6 months postoperatively showed no statistically significant differences among the four groups (P > 0.05). In terms of secondary outcome measures, Group A had a significantly prolonged hospital stay compared to the other three groups (P < 0.05), while other outcome measures showed no statistically significant differences (P > 0.05).

CONCLUSION

The timing of surgery in mild or asymptomatic SARS-CoV-2 infected patients does not affect long-term recovery quality but does impact short-term recovery quality, especially for elective general anaesthesia surgeries within 2 weeks of confirmed infection. Therefore, it is recommended to wait for a surgical timing of at least greater than 2 weeks to improve short-term recovery quality and enhance patient prognosis.

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.

Is perioperative COVID-19 really associated with worse surgical outcomes among vaccinated patients?

INTRODUCTION

During the surge of the SARS-CoV-2 pandemic, studies revealed high complication and morbidity rates following surgical procedures in COVID-19 positive patients. Anesthetic and surgical societies swiftly developed strategies to mitigate these risks, including a recommended postponement of elective surgeries for a minimum of 7 weeks post-COVID infection. Nowadays, with a predominantly vaccinated population, it has become crucial to discern the influencing factors on post-COVID morbidity and mortality and a reevaluation of the existing recommendations pertaining to elective surgery.

METHODS

A single-center case-control study was conducted, including patients who underwent surgery between November 2021 and March 2022 and met the inclusion criteria. Eighty COVID-19 positive patients were matched 1:1 with 80 controls, each undergoing an identical intervention within a 2-week time frame. The primary outcome was 30-day postoperative mortality and secondary outcome postoperative complications (respiratory and thromboembolic).

RESULTS

At the time of surgery, 88.8% of patients in the case group and 92.5% in the control group had received at least one vaccine dose. Mortality and morbidity did not show a significant difference when comparing the case and control groups (7.5% vs 6.2%, p = 0.755; 11.3% vs 8.9%, p = 0.541 respectively). In the COVID-positive group, mortality was significantly associated with age over 70 years, ASA score over III, RCRI over 1, emergency procedures, and absence of thromboembolic prophylaxis.

CONCLUSIONS

In contrast to previously reported findings, we did not observe an increased morbi-mortality in patients with perioperative COVID-19 infection. It may not be necessary to delay elective interventions, except in cases with a high-risk.

Inhaled Nitric Oxide ReDuce postoperatIve pulmoNAry complicaTions in patiEnts with recent COVID-19 infection (INORDINATE): protocol for a randomised controlled trial

BACKGROUND

A history of SARS-CoV-2 infection has been reported to be associated with an increased risk of postoperative pulmonary complications (PPCs). Even mild PPCs can elevate the rates of early postoperative mortality, intensive care unit (ICU) admission and prolong the length of ICU and/or hospital stays. Consequently, it is crucial to develop perioperative management strategies that can mitigate these increased risks in surgical patients who have recently been infected with SARS-CoV-2. Accumulating evidence suggests that nitric oxide (NO) inhalation might be effective in treating COVID-19. NO functions in COVID-19 by promoting vasodilation, anticoagulation, anti-inflammatory and antiviral effects. Therefore, our study hypothesises that the perioperative use of NO can effectively reduce PPCs in patients with recent SARS-CoV-2 infection.

METHOD AND ANALYSIS

A prospective, double-blind, single-centre, randomised controlled trial is proposed. The trial aims to include participants who are planning to undergo surgery with general anaesthesia and have been recently infected with SARS-CoV-2 (within 7 weeks). Stratified allocation of eligible patients will be performed at a 1:1 ratio based on the predicted risk of PPCs using the Assess Respiratory Risk in Surgical Patients in Catalonia risk index and the time interval between infection and surgery.The primary outcome of the study will be the presence of PPCs within the first 7 days following surgery, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm and aspiration pneumonitis. The primary outcome will be reported as counts (percentage) and will be compared using a two-proportion χ2 test. The common effect across all primary components will be estimated using a multiple generalised linear model.

ETHICS AND DISSEMINATION

The trial is approved by the Institutional Review Board of Xijing Hospital (KY20232058-F1). The findings, including positive, negative and inconclusive results, will be published in scientific journals with peer-review processes.

TRIAL REGISTRATION NUMBER

NCT05721144.

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

Impact of perioperative SARS-CoV-2 Omicron infection on postoperative complications in liver cancer hepatectomy: A single-center matched study

OBJECTIVES

To explore the effects of perioperative SARS-CoV-2 Omicron infection on postoperative complications in patients with liver cancer.

METHODS

A propensity-matched study was conducted, which included patients with primary liver cancer who underwent hepatectomy from September 01, 2022 to January 20, 2023. Patients who infected SARS-CoV-2 Omicron during the perioperative period (7 days before to 30 days after surgery) were matched 1:1 with noninfected patients. The primary outcomes, which were COVID-19-related major complications and liver resection-specific complications, were analyzed using multivariate logistic regression.

RESULTS

A total of 243 patients were included, with 63 cases of perioperative infections, of which 62 were postoperative infections. The overall 30-day postoperative mortality rate was 1.6% (4/243). Compared to noninfected patients, those with perioperative infections showed no significant difference in the occurrence of adverse postoperative outcomes. However, they had a higher rate of 30-day readmission after surgery (11.1% vs 0%, P = 0.013). Perioperative SARS-CoV-2 infection was not associated with "major cardiorespiratory complications" or "liver resection-specific complications", but age, pre-existing comorbidities, and tumor type were related to these outcomes.

CONCLUSION

Perioperative SARS-CoV-2 Omicron infection did not increase the incidence of postoperative complications in patients with liver cancer. However, those patients had a higher rate of 30-day readmission after surgery.

Lessons Learned in Elective Surgeries After 6 Pandemic Waves of SARS-CoV-2. A Single European Center Experience

BACKGROUND

The reported high surgical morbidity and mortality in patients with SARS-CoV-2 prompted preoperative screening and modification of surgical protocols. Although vaccination and treatment of COVID-19 have resulted in lower hospitalization rates and infection severity, publications on postoperative results have not been updated. The aim of the study was to analyze the outcomes of patients undergoing surgery in two periods with high incidence of SARS-CoV-2 infection, before and after vaccination.

MATERIALS AND METHODS

This is a prospective cohort study of patients undergoing surgery in two periods: March-June 2020 (Group2020) and December 2021-February 2022 (Group2022) (after massive vaccination).

RESULTS

In total, 618 patients who underwent surgery were included in the analysis (Group2020: 343 vs. Group2022: 275). Significantly more oncological procedures were performed in Group2020, and there were no differences in postoperative complications. Nosocomial SARS-CoV-2 infection occurred in 4 patients in Group2020 and 1 patient in Group2022. In Group 2022, 70 patients (25.4%) had COVID-19 prior to surgery, and 68 (97.1%) were vaccinated. Comparative analysis between patients with past COVID-19 and those without showed no difference in postoperative morbidity and mortality. According to the time elapsed between SARS-CoV-2 infection and surgery (≤ 7 or > 7 weeks), comparative analysis showed no significant differences.

CONCLUSION

The establishment of preoperative screening protocols for SARS-CoV-2 infection results in a low incidence of nosocomial infection and optimal postoperative outcomes. Preoperative SARS-CoV-2 infection in vaccinated patients was not associated with increased postoperative complications, even in shorter periods after infection. In surgical patients, individualized preoperative evaluation after SARS-CoV-2 infection may be more important than strict time limitation.

Racial Differences and Injury Pattern Variation: Impact of COVID-19 on a Bronx Trauma Center

BACKGROUND

New York City (NYC) became the epicenter of the COVID-19 pandemic in 2020. The Bronx, with the highest rates of poverty and violent crime of all NYC boroughs and a large Black and Hispanic population, was at increased risk of COVID-19 and its sequelae. We aimed to identify temporal associations among COVID-19 and trauma admission volume, demographics, and mechanism of injury (MOI).

METHODS

A retrospective review of prospectively collected data was conducted from a Level II trauma center in the Bronx. January 1st-September 30th for both 2019 (Pre-COVID) and 2020 (COVID) were compared. Pre-COVID and COVID cohorts were subdivided into EARLY (March-May) and LATE (June-September) subgroups. Demographics and trauma outcomes were compared.

RESULTS

Trauma admissions were similar between Pre-COVID and COVID. During COVID, there was an increased percentage of Black patients (Black Hispanic 20.1% vs 15.2% and Black Non-Hispanic 39.4% vs 34.1%, P < .05), younger patients (26-35 years old: 22.6% vs 17.6%, P < .05), and out-of-pocket payors (6.0% vs 1.6%, P < .05). Trauma severity outcomes were mixed-some measures supported increased severity; others showed no difference or decreased severity. During COVID, there was a rise in total penetrating injuries (27.4% vs 20.8%, P < .05), MVC (13.2% vs 7.1, P < .05), and firearm injuries (11.6% vs 6.0%, P < .05). Additionally, during LATE COVID, there was a resurgence of total penetrating, total blunt, MVC, falls, cyclists/pedestrians struck, and firearm injuries.

DISCUSSION

Our results emphasize MOI variations and racial differences of trauma admissions to a Level II trauma center in the Bronx during COVID-19. These findings may help trauma centers plan during pandemics and encourage outreach between trauma centers and community level organizations following future healthcare disasters.

Prioritizing rapid COVID-19 testing in emergency general surgery patients decreases burden of inpatient hospital admission

Objectives

The COVID-19 pandemic has changed delivery of emergency general surgery (EGS) and contributed to widespread bed shortages. At our institution, rapid testing is not routinely approved for EGS patients. We examined common EGS conditions (appendicitis and acute cholecystitis), hypothesizing that necessity of testing for COVID-19 significantly delayed operative intervention.

Methods

We performed a prepost study to examine a 2-month timeframe, or historical control, prior to COVID-19 testing (January 1, 2020-March 1, 2020) as well as a 2-month timeframe during the COVID-19 era (January 1, 2021-March 1, 2021). We chose conditions that are frequently treated surgically as outpatient or observation status. We examined time for COVID-19 test to result, and associated time to operative intervention (operating room (OR)) and need for admission.

Results

Median time to COVID-19 test results was 7.4 hours (IQR 5.8-13.1). For appendectomy, time to surgical consultation or case request did not differ between cohorts. Time to OR after case request was significantly longer (12.5 vs 1.9 hours, p<0.001) and patients more frequently required admission prior to operative intervention if receiving treatment in the COVID-19 timeframe. Similarly, for cholecystectomy there were no differences in time to surgical consultation or case request, but time to OR after case request was longer in the COVID-19 era (21.1 vs 9.0 hours, p<0.001).

Conclusion

While COVID-19 positivity rates have declined, the purpose of this study was to reflect on one element of our hospital system's response to the COVID-19 pandemic. Based on our institutional experience, waiting for COVID-19 test results directly impacts time to surgery, as well as the need for admission for a historically outpatient procedure. In the future, if the healthcare system is asked to respond to another pandemic or similar situation, expediting time to OR to eliminate unnecessary time in the hospital and non-critical admissions should be paramount.

Level of evidence

Level III, prognostic/epidemiological.

Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery

OBJECTIVE

To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery.

BACKGROUND

Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19.

METHODS

Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models.

RESULTS

This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure.

CONCLUSIONS

Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Obstructive jaundice treatment during the COVID-19 pandemic: retrospective cohort study at a single tertiary care center in Serbia

OBJECTIVE

We aimed to compare mortality and complication rates in patients treated for obstructive jaundice before and during the COVID-19 pandemic in a tertiary care center in Serbia.

METHODS

We conducted a retrospective cohort study among a first group of patients treated between 1 January 2017 and 1 January 2019. The second group was treated between 1 March 2020 and 1 March 2022.

RESULTS

The first group comprised 35 patients, and the second group (in which all patients were SARS-CoV-2 positive) included 18 patients; 37 and 16 patients were treated for malignant and benign diseases, respectively. The groups did not differ significantly regarding the diagnoses and treatment received. The second group showed significantly higher aspartate aminotransferase levels and lower white blood cell, C-reactive protein, and interleukin 6 levels. Mortality and complication rates did not differ significantly between groups. All deceased patients in the second group had significant radiologic findings associated with COVID-19 pneumonia.

CONCLUSIONS

COVID-19 infection is a risk factor in treating obstructive jaundice. This study illustrates the potential influence of COVID-19 on mortality after obstructive jaundice treatment. COVID-19 pneumonia may be a significant risk factor for mortality in patients treated for obstructive jaundice.

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.

The association between preoperative COVID-19-positivity and acute postoperative complication risk among patients undergoing orthopedic surgery

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Methods

Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events.

Results

Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events.

Conclusion

COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic.

Crossing borders to change lives: Surgical mission amidst the COVID-19 pandemic

INTRODUCTION

During the COVID pandemic, elective global surgical missions were temporarily halted for the safety of patients and travelling healthcare providers. We discuss our experience during our first surgical mission amidst the pandemic. We report a safe and successful treatment of the patients, detailing our precautionary steps and outcomes.

METHODS

Retrospective manual chart review and data collection of patients' charts was conducted after IRB approval. We entail our experience and safety steps followed during screening, operating and postoperative care to minimize exposure and improve outcomes during a surgical mission in an outpatient setting during the pandemic. The surgical mission was from February 8 to February 12, 2022.

RESULTS

A total of 60 patients who were screened. 33 patients underwent surgical intervention. One patient required postoperative hospitalization for a biliary duct leak. No patient or healthcare provider tested positive for COVID at the end of the mission. The average age of patients was 46.9 years. The average operative time was 116 min, and all patients had local nerve blocks. It included 45 health work providers.

CONCLUSIONS

It is safe to perform outpatient international surgery during the pandemic while following pre-selected precautions.

Impact of SARS-CoV-2 infection on postoperative complications of patients undergoing surgery after general outbreak in China: a protocol for multicentre prospective cohort study

INTRODUCTION

There is currently limited evidence addressing perioperative prognosis of surgical patients during COVID-19 pandemic; especially targeting on the Chinese population since the wave in 2022. Considering a distinct feature from the rest of the world demonstrated and the fast mutation and spread of the virus, evidence most relevant to China is urgently in need. The objective of this study is to seek for supporting evidence via evidence-based risk evaluations for postoperative complications to accumulate experience for coming infection waves.

METHODS AND ANALYSIS

This protocol proposes a multicentral, prospective, observational cohort study aiming to explore the link between SARS-CoV-2 infection and postoperative complications among surgical patients under general or regional anaesthesia between 16 January 2023 and 31 December 2023. A retrospective cohort covering the same period in 2019 is extracted for historic reference. Data are extracted from the health information system and anaesthesia information management system. The COVID-19 information is collected via an online survey. Missing values in weight or height will be imputed by each other with age and gender via multiple imputation. Other missing values will not be handled specially. Standard descriptive statistics will be reported followed by statistical modelling. Binomial regression with logit link is used for binary outcome. The time-to-event outcome is analysed using Cox regression with discharge from hospital further treated as a competing state. Hierarchical models will be assessed to account for temporal or central random effects. Temporal trends will be displayed with future expectations.

ETHICS AND DISSEMINATION

Ethical approval is obtained from the ethical committee in Xijing Hospital (No. KY20232002-C-1); approvals are expected for each participating institute. Verbal consent will be informed and obtained prior to online survey collection. Personal information remains confidential, and publications will be deidentified.

TRIAL REGISTRATION NUMBER

NCT05677815.

Changes in early postoperative outcomes and complications observed in a single center during the 2022 COVID-19 pandemic wave in China: A single-center ambispective cohort study

BACKGROUND

Currently, the effect of the 2022 nationwide coronavirus disease 2019 (COVID-19) wave on the perioperative prognosis of surgical patients in China is unclear. Thus, we aimed to explore its influence on postoperative morbidity and mortality in surgical patients.

METHODS

An ambispective cohort study was conducted at Xijing Hospital, China. We collected 10-day time-series data from December 29 until January 7 for the 2018-2022 period. The primary outcome was major postoperative complications (Clavien-Dindo class III-V). The association between COVID-19 exposure and postoperative prognosis was explored by comparing consecutive 5-year data at the population level and by comparing patients with and without COVID-19 exposure at the patient level.

RESULTS

The entire cohort consisted of 3350 patients (age: 48.5 ± 19.2 years), including 1759 females (52.5%). Overall, 961 (28.7%) underwent emergency surgery, and 553 (16.5%) had COVID-19 exposure (from the 2022 cohort). At the population level, major postoperative complications occurred in 5.9% (42/707), 5.7% (53/935), 5.1% (46/901), 9.4% (11/117), and 22.0% (152/690) patients in the 2018-2022 cohorts, respectively. After adjusting for potential confounding factors, the 2022 cohort (80% patients with COVID-19 history) had a significantly higher postoperative major complication risk than did the 2018 cohort (adjusted risk difference [aRD], 14.9% (95% confidence interval [CI], 11.5-18.4%); adjusted odds ratio [aOR], 8.19 (95% CI, 5.24-12.81)). At the patient level, the incidence of major postoperative complications was significantly greater in patients with (24.6%, 136/553) than that in patients without COVID-19 history (6.0% [168/2797]; aRD, 17.8% [95% CI, 13.6-22.1%]; aOR, 7.89 [95% CI, 5.76-10.83]). Secondary outcomes of postoperative pulmonary complications were consistent with primary findings. These findings were verified through sensitivity analyses using time-series data projections and propensity score matching.

CONCLUSION

Based on a single-center observation, patients with recent COVID-19 exposure were likely to have a high incidence of major postoperative complications.

REGISTRATION

NCT05677815 at https://clinicaltrials.gov/.

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.

Severity of Prior COVID-19 Infection is Associated with Postoperative Outcomes Following Major Inpatient Surgery

Objective

To determine the association between severity of prior history of SARS-CoV-2 infection and postoperative outcomes following major elective inpatient surgery.

Summary Background Data

Surgical guidelines instituted early in the COVID-19 pandemic recommended delay in surgery up to 8 weeks following an acute SARS-CoV-2 infection. Given that surgical delay can lead to worse medical outcomes, it is unclear if continuation of such stringent policies is necessary and beneficial for all patients, especially those recovering from asymptomatic or mildly symptomatic COVID-19.

Methods

Utilizing the National Covid Cohort Collaborative (N3C), we assessed postoperative outcomes for adults with and without a history of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from SARS-CoV-2 infection to surgery were each used as independent variables in multivariable logistic regression models.

Results

This study included 387,030 patients, of which 37,354 (9.7%) had a diagnosis of preoperative COVID-19. History of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of mortality and other complications.

Conclusions

Impact of COVID-19 on postoperative outcomes is dependent on severity of illness, with only moderate and severe disease leading to higher risk of adverse outcomes. Existing wait time policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Big Data in Surgery

The emergence of Big Data has been facilitated by technological advancements in the processing, storage, and analysis of large quantities of data. Its strength is derived from its size, ease of access, and speed of analysis, and it has enabled surgeons to investigate areas of interest that traditional research models have historically been unable to address. In the future, Big Data will likely assist in the incorporation of more advanced technologies into surgical practice, including artificial intelligence and machine learning to realize the full potential of Big Data in Surgery.

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.

Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic

PURPOSE

The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves.

METHODS

This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs.

RESULTS

Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99).

CONCLUSION

Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.

Surgical Implications of Coronavirus Disease-19

As the coronavirus disease-19 (COVID-19) pandemic continues to evolve in 2022 with the surge of novel viral variants, it is important for physicians to understand and appreciate the surgical implications of the pandemic. This review provides an overview of the implications of the ongoing COVID-19 pandemic on surgical care and provides recommendations for perioperative management. Most observational studies suggest a higher risk for patients undergoing surgery with COVID-19 compared with risk-adjusted non-COVID-19 patients.

[Consequences of the COVID-19 pandemic for surgical service]

The COVID-19 pandemic has a serious impact on surgical service, emergency and especially elective surgical care. Many hospitals were re-designated as COVID hospitals due to resource constraints and large number of COVID-19 patients requiring hospitalization. This led to cancellation or postponement of scheduled surgeries. In addition, restrictions in elective surgery were associated with the risk of infection in surgical patients. Various protocols and guidelines recommended non-surgical or outpatient treatment if possible. During the pandemic, postoperative morbidity and mortality in emergency surgery increased significantly. The same is true for elective surgeries in 7-8 weeks after previous coronavirus infection. The authors analyze the issues of organization, priorities for restoration of elective surgery and criteria for patient selection.

The unseen pandemic: treatment delays and loss to follow-up due to fear of COVID

Background

Fear of contracting SARS-CoV-2 has transformed public interaction with healthcare professionals and hospitals alike. In turn, this has resulted in a collateral impact on patients’ health across medical and surgical paradigms. Understanding the causative factors of this fear, and tackling it head on, is vital to return to pre-pandemic levels of healthcare.

Main body

In this editorial, we explore the evidence base behind the fear of healthcare professionals and facilities that has developed during the course of the SARS-CoV-2pandemic. We also reflect on the ways in which these fears have affected the general public. In so doing, we review a recent article from Montalto et al. that has explored fear of SARS-CoV-2 among patients undergoing surgery in Italy.

Conclusion

While fear of SARS-CoV-2 is uncommon among surgical patients, there are still those who delay or avoiding seeking medical care due to fear of transmission. Physicians must lead the fight against this fear in a hope to regain the trust of the public.

COVID-19 in the perioperative setting: A review of the literature and the clinical landscape

The COVID-19 pandemic has dramatically affected societies and healthcare systems around the globe. The perioperative care continuum has also been under significant strain due to the pandemic—tasked with simultaneously addressing surgical strains and backlogs, infection prevention strategies, and emerging data regarding significantly higher perioperative risk for COVID-19 patients and survivors. Many uncertainties persist regarding the perioperative risk, assessment, and management of COVID-19 survivors—and the energy to catch up on surgical backlogs must be tempered with strategies to continue to mitigate COVID-19 related perioperative risk. Here, we review the available data for COVID-19-related perioperative risk, discuss areas of persistent uncertainty, and empower the perioperative teams to pursue evidence-based strategies for high quality, patient-centered, team-based care as we enter the third year of the COVID-19 pandemic.