key: cord-1040286-gaiu85k4 authors: Weitzner, Zachary N.; Schumm, Max; Hu, Theodore; Wu, James title: Short-term perioperative outcomes among patients with concurrent asymptomatic and mild SARS-CoV-2 infection: a retrospective, multicenter study date: 2021-12-30 journal: Surgery DOI: 10.1016/j.surg.2021.12.024 sha: 56fc54a3bf870b2fc1d3d7e2e178202280ace837 doc_id: 1040286 cord_uid: gaiu85k4 BACKGROUND: Previous studies report high rates of postoperative morbidity and mortality among SARS-CoV-2 (COVID-19) patients. With routine preoperative screening, we are identifying an increasing number of patients with asymptomatic and mild COVID-19. Based on these prior studies, we hypothesized that patients with asymptomatic and mild COVID-19 infections have low perioperative morbidity and mortality. The purpose of this study was to determine the risk of perioperative morbidity and mortality associated with operations performed on patients diagnosed with asymptomatic or mild COVID-19. METHODS: A multicenter, retrospective study of patients with asymptomatic/mild SARS-CoV-2 (COVID-19) infection diagnosed within 8 days of surgery from March 2020 to February 2021. The primary outcome was 30-day mortality and secondary outcomes included pulmonary complications and perioperative morbidity. The Chinese Center for Disease Control and Prevention criteria of COVID severity was used for categorization. RESULTS: The initial cohort included 53 patients. COVID-19 infection was detected preoperatively in 86.8%. At admission, 90.5% of patients were asymptomatic, 7.5% had mild COVID-19 symptoms, and 1.9% were unknown due to obtundation and later determined to be asymptomatic. Of the 53 cases, 35.8% were general surgical and 18.9% orthopedic; the remaining 54.7% were other surgical subspecialties. Overall mortality was 0%. New COVID-19 symptoms developed in 13.2% of patients postoperatively, with only 11.3% developing postoperative pulmonary complications. CONCLUSION: Postoperative morbidity and mortality rates were low among patients with asymptomatic and mild COVID-19. The risks of nonoperative management should be weighed against these operative risks in such patients with surgical indications. Early in the SARS-CoV-2 (COVID-19) pandemic, reports suggested that perioperative morbidity and mortality was significantly increased in patients with COVID-19 [1] [2] [3] . Relying on this data, many surgical societies recommended the consideration of non-standard, non-operative treatment in patients with COVID-19 4, 5 . However, as testing capabilities improve, more patients who need surgery are found to have asymptomatic or mild COVID-19 1 . In this subgroup of patients, the risks of COVID-19 associated complications may be less than the risk of avoiding or delaying surgical intervention. The purpose of our study was to better characterize the rates of morbidity and mortality in patients who undergo operations who have concomitant mild or asymptomatic COVID-19. Previous studies report rates of postoperative morbidity and mortality in COVID-19 patients as high as 58% and 24%, respectively, following elective and emergent operations 1,2,6,7 . However, these studies included patients with all levels of COVID-19 disease severity 2,6,7,8. Furthermore, it remains unclear whether undergoing an operation and/or general anesthesia directly precipitates the increased risks reported in COVID-19 surgical patients or if we were observing the natural history of COVID-19 infection in patients with an indication for surgery. There are conflicting reports regarding perioperative outcomes of COVID-19 patients with asymptomatic disease 1,9-12 . We hypothesized that patients with mild or asymptomatic COVID-19 would have relatively low rates of perioperative morbidity and mortality. We performed a multicenter cohort study to evaluate the risk of 30-day perioperative morbidity and mortality amongst patients with asymptomatic or mild COVID-19 diagnosed within 7 days of surgery. Methods Study population and data source: We retrospectively reviewed adult patients >18 years of age who underwent surgery within 7 days of initial diagnosis of COVID-19 infection at an academic quaternary care center, an academic community hospital, and a university-affiliated county hospital between March 1 st , Postoperatively, COVID-19 testing was also conducted with the same PCR assays. Indications for COVID-19 testing in the postoperative period were not standardized and were based on clinical judgement and suspicion of COVID-19 infection. This was often after consultation with Infectious Disease specialists, but consultation was not required for repeat testing. Our institutions did not standardize recommendations for surgical management of patients with COVID-19 infection. However, per societal guidelines, nonoperative management was encouraged in cases when deemed of acceptable surgical risk by shared decision-making between surgeon and patient. If COVID-19 was diagnosed preoperatively, a decision was made by the operating surgeon in conjunction with discussion of risk with patients regarding choosing operative or non-operative management. The primary outcome was 30-day postoperative mortality in identified patients with asymptomatic or mild COVID-19 infection. Secondary outcome was perioperative morbidity, which included reoperations, DVT/PE, unplanned reintubations, renal failure, pneumonia, and unplanned readmissions. Descriptive data were analyzed for all study patients. We compared patient and disease characteristics between patients who experienced postoperative complications versus those who did not. For continuous data, Student's t-test was performed, and for categorical variables, Ethical approval: This study design was independently reviewed by the University of California, Los Angeles Institutional Review Board (IRB) prior to initiation. This study was deemed exempt from the university IRB due to secure data storage and minimal risk to patients. Between March 1 st , 2020 and February 1 st , 2021, 69 patients were identified. Of these patients, 3 were excluded due to moderate disease severity, 4 were excluded due to severe disease severity, and 6 due to critical disease severity. An additional 2 patients were of unknown disease severity at presentation due to obtundation, either in the setting of trauma or critical illness and died before disease severity could be ascertained. Final study cohort consisted of 53 patients (Figure) . Description of patients excluded due to moderate -to-critical COVID-19 disease severity is included in Supplemental Table 1 . Seven patients were excluded due to COVID-19 severity. The majority of patients [90.4% (n=47)], were asymptomatic upon initial presentation with surgical disease and 7.7% (n=4) presented with mild COVID-19 symptoms. Patient characteristics are presented in Table 1 . Common comorbidities among this cohort included obesity (35.8%), diabetes (18.8%), hypertension (17.0%), and malignancy (11.3%). Over half the population were never smokers, with 22.6% reporting active smoking status at the time of diagnosis. The majority of patients underwent general surgical procedures (35.8%) followed by orthopedic procedures (18.9%). General anesthesia was used in 86.8% of cases with 81.1% of patients requiring endotracheal intubation. Laparoscopy was performed in 26.4% of cases. The majority of patients were diagnosed with COVID-19 preoperatively, with only 7 postoperative diagnoses after initial negative testing. Surgical disease and COVID-19 presentation are listed in Table 2 . Postoperative surgical and respiratory complication rates are presented in Table 3 . The overall 30-day mortality was 0%. The overall complication rate was 24.5%, with infection, (Table 4 ). Seven patients were excluded due to moderate-to-critical COVID severity. The overall mortality rate was 28.6% and overall complication rate was 85.7%. The group excluded due to COVID severity was older (mean 49.9 years), weighed more (mean BMI 31.1 kg/m2), and was more likely to be pregnant (28.6%) than the 53 patients in the study cohort. However, there is no statistical significance between the groups due to the small sample size. In this retrospective multicenter study, we observed a 0% mortality rate and a 24.5% overall complication rate in patients with asymptomatic or mild COVID-19 disease diagnosed We acknowledge several limitations to our study. First, we are limited by our retrospective study design, which is subject to selection bias. As described earlier, our current testing protocol screens all patients preoperatively, but patients are only repeatedly screened in the postoperative phase if they demonstrate symptoms, need additional procedures, or if clinically indicated by provider evaluation. Patients with postoperative complications and unfavorable outcomes are more likely to undergo postoperative testing, especially with COVID-19 PCR testing in patients with unexplained fever or clinical deterioration. In these patients, the detection of asymptomatic to mild COVID-19 infection is certainly more likely than in patients J o u r n a l P r e -p r o o f without postoperative complications. Secondly, there was no appropriate group to serve as matched controls. We considered using COVID-19 positive patients who underwent interventional radiology and endoscopic cases as matched controls, but the sample size at our institution was insufficient. We additionally considered spontaneous vaginal deliveries as a comparison, but deemed it biased due to the physiologic changes of pregnancy and lack of male comparison. We could not use in-patients with COVID-19 as matched controls since patients with asymptomatic or mild disease would not require hospitalization. Another important limitation is that studies conducted reviewing patients in different locations during different periods of the COVID-19 pandemic are likely to have multifactorial differences in COVID-19 outcomes. This could be due to differing amounts of strain on healthcare systems, evolution of knowledge of how to manage COVID-19 patients, different proportions of COVID-19 strains, and other more subtle factors. Additionally, our study is limited by a small sample size of patients with moderate-to-critical COVID-19 infection. During the study period, only 7 patients with moderate-to-critical COVID-19 infection underwent surgical intervention within 7 days of diagnosis. Drawing conclusions from this small population is of limited use, and comparison is also limited by the differences in surgical disease severity. Additionally, this data was collected before widespread vaccination efforts. Elderly patients and healthcare providers were eligible for vaccination only in the last 2 months of the study period, so the likelihood of capturing fully vaccinated patients is low. Additionally, history and physical exam notes were reviewed during patient assessment, and no patients were reported to have been partially or fully vaccinated either through study participation or early eligibility. Our study demonstrates 0% mortality, a 24.5% overall complication rate, and a 13.2% COVID-19 associated complication rate in patients with asymptomatic or mild COVID-19 infection diagnosed within 7 days before or after surgical intervention. Although more investigation into the safety of operative intervention in patients with asymptomatic-to-mild COVID-19 infection is required, our data suggests that initial reports of high morbidity and Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet Is Elective Cancer Surgery Safe During the COVID-19 Pandemic? Updated Intercollegiate General Surgery Guidance on COVID-19. Royal College of Surgeons SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy Perioperative SARS-CoV-2 infections increase mortality, pulmonary complications, and thromboembolic events: A Dutch, multicenter, matched-cohort clinical study A Proposed Framework and Timeline of the Spectrum of Disease Due to SARS-CoV-2 Infection: Illness Beyond Acute Infection and Public Health Implications Early respiratory outcomes following cardiac surgery in patients with COVID-19 Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection Clinical and Transmission Characteristics of Covid-19 -A Retrospective Study of 25 Cases from a Single Thoracic Surgery Department Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patients: A Call for Global Consideration of Sampling all Asymptomatic Patients Before Surgical Treatment The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) -China Risk factors for developing severe COVID-19 in China: an analysis of disease surveillance data | Infectious Diseases of Poverty | Full Text Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis Low prevalence (0.13%) of COVID-19 infection in asymptomatic pre-operative/pre-procedure patients at a large, academic medical center informs approaches to perioperative care Zachary N Weitzner, MD a , Max Schumm, MD a , James Wu, MD a Article Summary: Retrospective review of patients with mild and asymptomatic COVID-19 infection undergoing urgent surgery finding no mortality and low morbidity. These findings help guide physician and patient decision making as the increase in testing and disease prevalence have led to high numbers of patients with asymptomatic and mild COVID-19 infection and concomitant surgical disease.