Impact of COVID-19 on Surgical Outcomes: A Study of Postoperative Complications and Mortality

Background

The COVID-19 pandemic has presented serious challenges for global healthcare systems, particularly in surgical care for infected patients. The main concerns included increased risk of perioperative complications and the potential spread of the virus.

Early in the pandemic, both mainstream and scientific understanding of COVID-19 was limited, complicating surgical care. Recent studies have explored the link between COVID-19 and postoperative complications. Reports from Europe and the Middle East indicated high 30-day mortality rates (19%–24%) and that over half of patients suffered pulmonary complications after surgery. Although COVID-19 has become less severe with rising population immunity, the emergence of new strains reinforces the need to learn from early pandemic data to improve surgical care during future health crises.

Methods

Design and Setting

This study did not involve patients or the public directly.

Study Participants

We included all adult patients who tested positive for COVID-19 by PCR before surgery or within 72 hours postoperatively. Systematic testing began on June 8, 2020. We excluded patients under 18 years and those already enrolled.

Exposure Variables

For our main objective, we focused on symptoms at the time of surgery, including fever and respiratory failure, as reported by clinicians. For our secondary objective, we examined the time elapsed from the first positive COVID-19 test to surgery and categorized the infection status as ‘recovered’ or ‘active and asymptomatic’.

Patient Groups

We categorized patients into three groups:

1. Symptomatic active infection: Positive COVID-19 test with symptoms at surgery.
2. Asymptomatic active infection: Positive test without symptoms at surgery.
3. Recovered infection: Positive test at least 10 days before surgery with certain recovery criteria.

Outcomes

Our main outcome was any postoperative pulmonary complication, including atelectasis, pneumonia, ARDS, and pneumothorax. We assessed secondary outcomes, including hospital mortality, non-pulmonary infectious complications, kidney injury, thromboembolic events, surgical reinterventions, ICU admissions, hospital stay length, mechanical ventilation needs, and organ dysfunction-free days.

Data Collection

Data were collected prospectively and retrospectively from medical records between April 4, 2020, and April 30, 2021. Each site entered data into a central database, ensuring standardization.

Statistical Analyses

We analyzed eligible patients using descriptive and multivariable mixed-effect logistic regression to evaluate the link between symptoms and postoperative complications. We adjusted for potential confounding factors such as preoperative hospitalization and oxygen requirements.

Results

We included 105 COVID-19 patients undergoing surgery and 206 who had recovered from COVID-19. Of the symptomatic patients, 47 (45%) had symptoms, while 58 (55%) were asymptomatic. Symptomatic patients reported more pulmonary infiltrates and required more preoperative support.

Postoperative outcomes showed that 64% of symptomatic patients had complications compared to 33% of asymptomatic ones. Symptomatic patients experienced more pulmonary issues, ICU admissions, and had a higher mortality rate (32% vs. 10%).

Symptomatic patients had a higher risk for pulmonary complications (OR 3.19) and higher in-hospital mortality (HR 3.67).

Patients who recovered from COVID-19 did not show increased risk for postoperative complications or mortality compared to asymptomatic carriers.

Discussion

Our study included 105 surgical patients infected with COVID-19 and 206 who had recovered. Symptomatic patients were at higher risk for pulmonary complications and mortality. Excluding patients undergoing tracheostomy weakened the association but did not eliminate it.

Asymptomatic patients had outcomes similar to those who had recovered. The time since recovery did not impact complication rates or mortality.

This research improves understanding of surgical care for COVID-19 patients and is consistent with other studies noting that preoperative COVID-19 increases postoperative risks. Clinicians should consider patients’ symptomatic status carefully.

The clinical context has changed since the pandemic began, with vaccinations and new variants. Findings may not apply to all current cases, but they inform future pandemic preparedness and response.

Strengths and Limitations

This study had strengths and limitations. Data were sourced from electronic records, leading to potential inaccuracies. The sample size was modest, especially for certain subgroups, which may have limited the power of the analyses. Most symptomatic patients had severe respiratory issues, indicating that complication rates could relate more to these underlying conditions than to surgery.

The study’s multicenter design improved the diversity of the patient population. Through extensive data collection over a year, we captured various pandemic phases. This study provides valuable insights into COVID-19’s impact on surgical patients and informs clinical guidelines for managing these patients efficiently.