Context: A new coronavirus (SARS-CoV-2) appeared in late 2019, rapidly spread across the world and resulted in the COVID-19 pandemic declared by the World Health Organisation on 11th March 2020. Very little was known of the effects of the virus on surgical patients who are particularly vulnerable with risks from an operation as well as risks of infection with the virus.
Aims: To find out what happens to patients after an operation if they are infected with the virus either just before or in the first month after their operation. Specifically, we wanted to find out how many patients die after surgery, how many develop breathing complications, and identify key risk factors.
Impact: The rates of breathing complications and death associated with COVID-19 around the time of operation are important to help surgeons and patients make the safest treatment decisions.
Strategy: Surgeons from hospitals worldwide were invited to take part in this study. In 235 hospitals from 24 countries surgeons and researchers identified all patients who had an operation and tested positive for coronavirus around the time of surgery. Patients who were suspected to have the virus (but not tested) were also included as testing was not widely available in the early stages of the pandemic.
Team members collected anonymous patient data about age, gender, underlying illnesses and their operation. Patient records were followed up for 30 days after the operation. Researchers recorded if a patient had died or been diagnosed with one of three serious breathing problems: pneumonia (lung infection); unexpected ventilation (an artificial breathing machine); or acute respiratory distress syndrome (ARDS, where the lungs become badly inflamed and cannot provide the body with enough oxygen).
What did the study find?
1128 patients operated between 1 Jan and 31 March 2020 were included in the study. 53 percent of patients were men, and nearly 50% were 70 years or older. The majority of patients underwent emergency surgery (74%), and most had major operations (74%). About a quarter of patients had cancer surgery (24%).
· 268 of 1128 patients (23.8%) died within 30 days of their operation.
· Just over half of patients (51.2%) had serious breathing complications. In this group the death rate was much higher at 38%.
· With pneumonia, the death rate was 38%; those requiring unexpected ventilation had a death rate of 41% and in patients with ARDS, the death rate was 63%.
Who is at highest risk?
We identified patients and operation characteristics that increased patients’ risk of death. We found that male patients, age 70 years or over, those with underlying health problems; undergoing a ‘major’ operation, emergency surgery or cancer surgery all led to the higher risks of death.
What were the rates of serious breathing complications and death before the pandemic?
Patients with SARS-CoV-2 after an operation have overall, substantially higher rates of breathing problems and death than any studies have shown before the pandemic. A national audit in the UK (called ‘NELA’) looking at emergency abdominal surgery, showed 16.9% risk of death overall and 23.4% in frail patients >70years old. An international study (by GlobalSurg) in 58 low and middle-income countries showed 14.9% death rate in patients identified as high risk, after the same type of surgery. The death rates of patients with the virus after an operation are extremely high and similar to the death rates of the small group of severe COVID-19 patients who need intensive care.
Conclusion: The high risks of breathing complications and death have highlighted that surgical patients who contract coronavirus are particularly vulnerable. We recommend that surgeons ‘raise the threshold’ for surgery during the pandemic – surgeons should postpone operations or select non-operative management options where available. Furthermore strategies should be developed to reduce in-hospital SARS-CoV-2 transmission so minimising the risk of postoperative complications.