key: cord-0918862-3wykvg7c
authors: Welk, Blayne; Richard, Lucie; Rodriguez-Elizalde, Sebastian
title: The requirement for surgery and subsequent 30-day mortality in patients with COVID-19
date: 2021-04-03
journal: Can J Surg
DOI: 10.1503/cjs.022020
sha: 52c6854a7d0dd39eed1d3af15b0127dba1eb95c2
doc_id: 918862
cord_uid: 3wykvg7c

The ongoing COVID-19 pandemic has had profound effects on the provision of surgical care. The potential perioperative mortality associated with surgical procedures in patients with COVID-19 has been estimated at 20%, but the data come from jurisdictions that experienced very high surges of COVID-19 patients. A rapid assessment of the types of surgical care for patients with COVID-19 in Ontario was carried out using administrative data, and we found that during the initial wave in the spring of 2020, surgical interventions were required in 0.6% of patients with COVID-19, and mortality was higher (20%) in patients who underwent surgery in the 2 weeks before or after a positive nasopharygeal swab than in those who had surgery more than 2 weeks after COVID-19 was diagnosed.

The ongoing COVID-19 pandemic has had profound effects on the provision of surgical care. The potential perioperative mortality associated with surgical procedures in patients with COVID-19 has been estimated at 20%, but the data come from jurisdictions that experienced very high surges of COVID-19 patients. A rapid assessment of the types of surgical care for patients with COVID-19 in Ontario was carried out using administrative data, and we found that during the initial wave in the spring of 2020, surgical interventions were required in 0.6% of patients with COVID-19, and mortality was higher (20%) in patients who underwent surgery in the 2 weeks before or after a positive nasopharygeal swab than in those who had surgery more than 2 weeks after COVID-19 was diagnosed.

Can J Surg/J can chir 2021;64(2)

around the time of a COVID-19 diagnosis ( Figure 1A ). Surgical procedures were most commonly categorized as orthopedics/plastic surgery ( Figure 1B) , and hip fracture repair was the most common surgery.

Within the surgery group, 30-day postsurgical morality was 19.7% (13 of 66) for patients who underwent surgery in the 14 days before or after a positive SARS-CoV-2 swab; 30-day mortality was significantly lower in patients who had surgery in the 15-60 days after COVID-19 diagnosis (≤ 6.2% [≤ 5 of 80], p < 0.05).

It is reassuring that only a small proportion of patients with COVID-19 required surgery. The highest number of surgical procedures was recorded around the time of COVID-19 diagnosis, likely as a result of SARS-CoV-2 testing at the time of hospital admission. There was no surge in operative cases at the end of the usual 14-day infectious period of SARS-CoV-2 to suggest that emergent surgery was delayed. Surgeons in leadership positions can use the approximate proportion of patients with COVID-19 requiring surgical interventions to help plan for future operative volumes in this group.

It is important for physicians to recognize that surgery in a patient with Week relative to COVID-19 diagnosis date *Standardized differences were used to identify potential clinically significant differences (> 0.10) between groups. They are preferred over traditional hypothesis testing to assess baseline differences for population-based studies. †Comorbidities were determined using International Classification of Diseases 10 codes and Ontario Health Insurance Plan fee and diagnosis codes that were present in the previous 2 years of administrative data.

E248 Can J Surg/J can chir 2021;64 (2) COVID-19 has a 1 in 5 mortality risk; however, this risk seems to be significantly attenuated 2 weeks after COVID-19 diagnosis. The 30-day mortality in our study is consistent with the 24% reported in a multinational collaboration of 1128 patients (primarily from Italy, Spain and the United Kingdom), 2 and the approximately 20% from smaller Italian 1 and Chinese 3 case series, despite a lack of COVID-19-related health care system failures in Canada compared with some of these countries. However, our observed 30-day mortality is higher than expected when considering published rates from emergency general surgeries (6%), 4 or after hip fracture (7%). 5 The high mortality during the 2 weeks before and after COVID-19 diagnosis is likely a combination COVID-19, the emergency nature of the surgery, and the increased comorbidities in patients requiring surgery. The nature of our data did not permit more detailed information about the exact surgery and indication, or about patients' clinical status. We could not determine the cause of death or the role that COVID-19 may have played. Our small sample size and low outcome rate precluded multivariable modelling. Similar to many countries, testing capacity for SARS-CoV-2 was initial ly limited, therefore we may not have identified patients with mild symptoms or asymptomatic disease who had surgery.

As we enter future waves of COVID-19 in Canada, it will be important for surgeons to continue to advocate for patients who require surgery. At the same time, we must be careful to avoid surgical interventions if possible in patients who have or may have COVID-19.

Factors associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals

The association of female sex with application of evidence-based practice recommendations for perioperative care in hip fracture surgery

Acknowledgements: This work was supported by a grant from the St. Joseph's Health Care Foundation's Health Crisis Fund. The study was supported by ICES Western. ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Core funding for ICES Western is provided by the Academic Medical Organization of Southwestern Ontario (AMOSO), the Schulich School of Medicine and Dentistry (SSMD), Western University, and the Lawson Health Research Institute (LHRI). The opinions, results and conclusions are those of the authors and are independent from the funding sources. No endorsement by ICES, AMOSO, SSMD, LHRI, or the MOHLTC is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI.

Competing interests: None declared.Contributors: All authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.

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