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Timing of a major operative intervention after a positive COVID-19 test substantially affects postoperative mortality.
Panos Kougias1, Sherene Sharath2, David H. Berger1, Francis C. Brunicardi1
1Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York, United States, 2Vascular Surgery, Michael E. DeBakey VAMC, Houston, Texas, United States

Objectives. Published data indicate that COVID-19 infection before or soon after operative interventions increases mortality, but they do not inform on the most appropriate timing of such an intervention after COVID-19 diagnosis. We sought to determine the optimal wait time after which it is safe for COVID-19 diagnosed patients to undergo major operative interventions.

Methods. High-risk operations were identified from the Veterans Affairs COVID-19 Shared Data Resource. Current Procedural Terminology (CPT) codes were used to exact match COVID-19 positive cases (n=938), defined as diagnosis with a positive test or presumptive positive, to COVID-19 negative controls (n=7,235). A positive diagnosis could occur at any time preoperatively and up to 30-days post-index surgery. The effect of time was calculated as a continuous variable, from date of positive test to index operation in days, and then grouped into two-week intervals (10-time bins that spanned the preoperative period to 4 weeks after the index operation). The primary outcome was 90-day, all-cause postoperative mortality.

Results. Between January 2020 and May 2021, procedures among COVID-19 positive patients were most frequently completed among orthopedic (48.5%), vascular (32.9%), and general (13.8%) surgery specialties. 90-day mortality in cases and controls was similar when the surgical procedure was performed within 9 weeks or longer after the positive COVID-19 test; but significantly higher in cases vs. controls when the surgical procedure was performed within 7-8 weeks (12.3% vs. 4.9%), 5-6 weeks (10.3 vs. 3.3%), 3-4 weeks (19.6 vs. 6.7%), and 1-2 weeks (24.7 vs. 7.4%) from the COVID-19 diagnosis (Figure 1). This effect was more pronounced in older patients, particularly after the age of 60 (Figure 2). We analyzed in more detail the high-risk cohort of patients who underwent surgery within 8 weeks from COVID -19 diagnosis. Within this cohort the 90-day mortality was 16.6% for the COVID-19 positive patients, vs. 5.8% for the controls (P<0.001). In the same high-risk cohort, interaction terms between case status and any symptom (P=0.91), case status and either respiratory symptoms or fever (P=0.16), and case status and number of symptoms (P=0.12) were not significant statistically. This analysis suggested that the detrimental effect of COVID diagnosis on mortality is not modified by the patientís symptomatic status, or the number of presenting symptoms.

Conclusions. Patients undergoing major operative interventions within 8 weeks after a positive COVID-19 test have substantially higher postoperative 90-day mortality than CPT-matched controls without a COVID-19 diagnosis, regardless of presenting symptoms. When possible, major operations should be deferred to 9 weeks or more after the positive COVID-19 test.

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