Medical Technology

Major Elective Surgery May Be Safest 8 or More Weeks After COVID-19 Infection

NEW YORK (Reuters Health) – Patients wanting to have major elective surgery after a SARS-CoV-2 infection may be less likely to have postoperative complications, such as pneumonia, respiratory failure, pulmonary embolism or sepsis, if the operation is postponed until eight weeks after COVID-19 is diagnosed, a new study suggests.

An analysis of data from nearly 5,500 COVID-19 patients revealed that those who had a major surgery within the first four weeks after diagnosis with a SARS-CoV-2 infection had 2.44-fold increased odds (95% CI, 1.20 to 4.96) of developing postoperative pneumonia, researchers report in the Annals of Surgery.

“The take-home message from our study is that if you need non-emergent, elective surgery and you previously had Covid-19, you may have a lower risk of having a postoperative complication if you can wait to get your surgery eight weeks after your recovery from Covid-19 than if you got the surgery soon after you recovered from Covid-19,” said Dr. Chi-Fu Jeffrey Yang of Massachusetts General Hospital and an assistant professor of surgery at the Harvard Medical School.

“It is important to note though, that for certain cancer patients, delaying surgery can lead to worse long-term survival because of cancer growth or spread occurring during the delay,” Dr. Yang told Reuters Health by email. “So, the balance between the risk of postoperative complications and the risk of worse overall survival associated with delayed surgery needs to be carefully discussed in a multi-disciplinary setting with the patient and the patient’s surgeon and doctors before deciding on whether surgery should be delayed.”

Dr. Yang also strongly urges all patients planning surgery to discuss getting the COVID-19 vaccine and booster with their surgeons. “The vaccines are safe and effective and are incredibly important to get before the surgery to prevent COVID-19-related complications, which in a postoperative setting can be devastating,” he said.

To take a look at the safety of surgery after a SARS-CoV-2 infection, Dr. Yang and his colleagues turned to data from Symphony Health through the COVID-19 Research Database, a pro-bono, public-private consortium of institutions that contribute de-identified data from patients with COVID-19. All patients in the analysis had a confirmed COVID-19 diagnosis between March 1, 2020 and May 30, 2021.

The researchers categorized patients by the amount of time between surgery and COVID-19 diagnosis: the peri-COVID-19 group included those who had zero to four weeks between diagnosis and surgery; the early post-COVID-19 group included patients who had surgery between four and eight weeks after diagnosis and the late post-COVID-19 group included those who had surgery eight weeks or more after diagnosis. The control group consisted of patients who had surgery at least 30 days before their COVID-19 diagnosis.

Of the 5,479 patients included in the analysis, those in the peri-COVID-19 group were significantly more likely to develop postoperative pneumonia (adjusted odds ratio, 6.46), respiratory failure (aOR, 3.37), pulmonary embolism (aOR, 2.73) and sepsis (aOR, 3.67) compared with the control group.

Early post-COVID-19 patients also had a significantly increased risk of developing postoperative pneumonia when compared to control patients (aOR, 2.44). Late post-COVID-19 patients did not have an increased risk of postoperative complications when compared to the control group.

The findings may not apply to everyone who develops a SARS-CoV-2 infection.

“Over 98% of the patients in the study had mild or moderate COVID-19, so the study findings are relevant only to mild or moderate cases of COVID-19,” Dr. Yang said.

To some extent, the results are what you would expect, since COVID-19 is a systemic infection that can lead to inflammation in all parts of the body, said Dr. Daniel Herron, a professor of surgery at the Icahn School of Medicine at Mount Sinai in New York City.

“Since the lungs are more significantly affected, you would expect more pulmonary/lung related issues in patients who had COVID-19,” he added.

“Specifically, (the authors) found that the rates of pneumonia, respiratory failure and pulmonary embolism were significantly higher in both the first four-week period and the second four-week period,” Dr. Herron said. “But over the long term, patients got back to normal.”

“Another interesting thing,” Dr. Herron said, “is that the rates of other complications – such as arrhythmias, urinary-tract infections and deep-vein thrombosis – didn’t seem to be affected in patients with COVID. I wouldn’t have been surprised to see them go up.”

One important takeaway from the study is that if the procedure is strictly elective and there is no time pressure at all, it suggests delaying until eight weeks after the infection, Dr. Herron said.

“But there are a lot of operations for major health issues that you would not want to put off for a significant amount of time,” he added. “Yes, the risks of these complications go up, but if the risks associated with the disease process are higher than that, you should still go forward with the surgery.”

Dr. Herron pointed out that delaying elective surgery due to unrelated health issues is common practice. “I don’t think this makes a huge difference in the way we are practicing surgery now,” he said. “I think that with any significant pulmonary infection, whether it’s COVID or the patient has just had the flu or a severe cold or pneumonia, most surgeons would want to hold off.”

SOURCE: Annals of Surgery, online November 18, 2021.

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