|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 230-231
Morbidity and mortality associated with perioperative SARS-CoV-2
Toney Jose1, Joseph Mani2
1 Department of Surgical Gastroenterology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
2 Department of General and Laparoscopic Surgery, PMI Hospital, Kottayam, Kerala, India
|Date of Submission||31-Jul-2020|
|Date of Acceptance||12-Aug-2020|
|Date of Web Publication||07-Nov-2020|
Dr. Toney Jose
Department of Surgical Gastroenterology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jose T, Mani J. Morbidity and mortality associated with perioperative SARS-CoV-2. Kerala Surg J 2020;26:230-1
Since the reporting of COVID-19 in December 2019 in China, the infection has spread all over the world infecting 16,558,289 with 656,093 deaths. While countries are attempting to reopen its infrastructure, an important question is about the impact of COVID-19 infection in the provision of non-COVID-related healthcare services, including surgical services. While emergency services continued through the lockdown, many centres opted to avoid elective procedures. The impact of delayed procedures should be viewed in the context of excess morbidity and straining of limited healthcare resources – infrastructure, equipment and workforce. In this light, the article by COVIDSurg Collaborative in The Lancet provides the much-needed information on the mortality and complications amongst patients with perioperative SARS-CoV-2. These results would help clinicians to take informed decisions with regard to their patients.
The COVIDSurg Collaborative reported an overall 30-day mortality of 24.8%, with 19.1% amongst elective surgeries and 26% amongst emergency surgeries. There was an overall incidence of 51.2% for pulmonary complications. Increased age, male sex, higher ASA grade, presence of one or more comorbidities, emergency surgeries, cancer surgeries and major surgeries were seen as predictors of 30-day mortality. The diagnosis of SARS-CoV-2 in the pre-operative versus the post-operative state did not show any difference with regard to outcome.
The outcomes of COVIDSurg study are in contrast to the previously reported outcomes of 9.6% 30-day mortality in the National Emergency Laparotomy Audit (NELA). Even the high-risk group in NELA had only 16.9% 30-day mortality. The GlobalSurg collaborative had noted that emergency abdominal surgeries had a 30-day mortality of 4.5% in high-income countries, 6.0% in middle-income countries and 8.7% in low-income countries. The incidence of pulmonary complications also increased in the COVIDSurg study (51.2%), which is in contrast with the findings of the POPULAR study which noted that only 7.6% of the anaesthetised patients had pulmonary complications.
Overall, the mortality as well as the pulmonary complications was seen to be increased in patients with perioperative SARS-CoV-2 infection. Lei et al. had reported similar outcomes among 34 patients from Wuhan, who underwent elective surgeries during the incubation period of SARS-CoV-2. They noted a 100% incidence of pneumonia, with 11 (32%) developing ARDS. There was a mortality rate of 21% (7 of 34). All mortalities were due to respiratory failure. The mortality rate in patients who underwent elective surgery was higher than the reported overall case fatality of 2.3% in COVID-19 patients in the region.
Despite addressing the much-awaited issue of perioperative mortality, some concerns exist in the results of the COVIDSurg collaborative study. Primarily, the all-inclusive nature of study does not allow informed decision with regard to the impact of individual surgery on the perioperative outcomes. Authors of the COVIDSurg study did acknowledge that the all-inclusive nature was to increase the overall reporting rate of infection. Similarly, the segregation of emergency and elective surgeries in this study needs to be revisited. A definition of what constituted emergency and what constituted elective should have been better defined. It is to be noted that even patients who underwent minor breast operation, did suffer from pulmonary complications. This would indicate the aggressive nature of the COVID-19 rather than an actual post-operative complication.
In the baseline and demographic characteristics that have been described, it is seen that 681 patients who underwent emergency surgery had symptoms suggestive of SARS-CoV-2 infection at the time of admission. However, in the description, they mentioned that 269 patients of 835 emergency cases only had a pre-operative SARS-CoV-2 diagnosis. This contrast was seen despite the methodology allowing for a clinical diagnosis of SARS-CoV-2 to be made. Hence, the division as seen in this study, analysing pre-operative versus post-operative SARS-CoV-2, is inherently questionable. If clinical features were taken into consideration, 81.5% (681 out of 835) of those who underwent emergency surgeries would have SARS-CoV-2 diagnosis preoperatively. An analysis based on the time of symptom onset would have provided information that is more clinically relevant. It also raises question on the patients' clinical features prior to elective surgeries. The authors however do not report it. The overall higher mortality seen in the study might be because the patients who were operated already had pulmonary issues related to SARS-CoV-2.
Even though the collaborative included data from 24 countries, the majority of patients were from four countries – the USA (167), Spain (170), Italy (181) and the UK (484) – contributing to 88.7% (1002 out of 1129). At the time that the analysis was carried out i.e., 2 May 2020, the SARS-CoV-2 case fatality rate in these countries was 5.3% in the USA, 11.5% in Spain, 13.6% in Italy and 15.5% in the UK. The combined case fatality for these four countries for the same number of patients should be 12.7% (167 × 0.053 + 170 × 0.115 + 181 × 0.136 + 484 × 0.155). It would have been better if the authors had compared the mortality associated in perioperative setting with the case fatality rate of SARS-CoV-2 in the respective countries alongside the pre-COVID surgical mortality. Considering the above situation, whether surgical procedures entail an added risk beyond the case fatality rate of SARS-CoV-2 should be re-evaluated.
The outcomes of elective major cancer surgeries during COVID-19 were reported from Tata Memorial Centre. They reported that none of the patients while undergoing surgery had a clinical suspicion of COVID-19 infection. Of the 494 major cancer surgeries performed during 23 March to 30 April, six patients were postoperatively diagnosed to have COVID-19 infection. None of the six patients who had perioperative COVID-19 required escalated or intensive care treatment. Moreover, there was no mortality. This should be considered alongside the low case fatality rate of COVID-19 in India (~3%). Thus, it may be possible that the high complication and mortality rate associated with perioperative COVID-19 infection is a reflection of the overall case fatality rate of the region.
The false-negative rate associated with testing for COVID-19 is variable and to the tune of 38% at the time of symptom onset and 20% at day 8 of infection. Hence, there is always a chance of an asymptomatic false-negative patient to undergo an elective surgical procedure. Similarly, perioperative nosocomial infection with COVID-19 is also a possibility. The possibility of regional variation in perioperative outcomes and better outcomes in asymptomatic patients, might translate to better outcomes in patients with inadvertent perioperative COVID-19 infection in regions with low case fatality of COVID-19.
As countries are trying to restart their economy, the pent-up burden of surgical cases will manifest. It is to be kept in mind that SARS-CoV-2 would continue for some more time. Whether restarting surgical services will inadvertently add to the morbidity of patients needs to be further evaluated. With data becoming available, clinicians might be at a better place to advice surgical therapies in patients. Till further data are available, it might be pertinent to assume higher morbidity and mortality in accordance with the results of COVIDSurg collaborative and Lei et al., and to make decisions on an individual basis taking into consideration all risk–benefit scenarios.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38.
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