Delaying surgery for patients with a previous SARS-CoV-2 infection

With at least 28 elective million operations delayed during the first three months of the COVID‐19 pandemic, the number of patients who will require surgery after a previous SARS‐CoV‐2 infection is likely to increase rapidly1. Operating on patients with an active perioperative SARS‐CoV‐2 infection is now known to carry a very high pulmonary complication and mortality rate2. Urgent information is needed to guide whether postponing surgery in patients with a previous SARS‐CoV‐2 infection leads to a clinical benefit, and the optimal length of delay. The COVIDSurg‐Cancer study was a prospective cohort study of patients undergoing curative elective cancer surgery during the COVID‐19 pandemic up to 24 May 20203. We performed a pre‐planned subgroup analysis of patients undergoing surgery with previous SARS‐CoV‐2 positive swab that were not suspected to have active COVID‐19 at the time of surgery. Propensity score matching was used to match previous SARS‐CoV‐2 swab positive patients to patients with no a positive swab test in a 1:4 ratio. Multivariable logistic regression was used to explore associations of previous SARS‐CoV‐2 with rates of postoperative pulmonary complications and death in matched groups. Full methodology is available in the Appendix. Of 122 patients with a previous positive SARS‐CoV‐2 swab, 22·1% (n = 27) were operated on within 2‐weeks of diagnosis, 49·2% (n = 60) between 2 and 4 weeks, and 28·7% (n = 35) after 4 weeks. The number of infected patients increased during each month of the study period (Supplementary Figure 1). Patients underwent surgery in 78 hospitals from 16 countries, predominantly in Italy (n = 44), UK (n = 28) and Spain (n = 20). 112 patients with a previous positive swab were matched to 448 patients with no positive swab. In the propensity score matched model, previous SARS‐CoV‐2 infection was associated with increased odds of pulmonary complications compared to no infection (10·7% [12/122] versus 3·6% [16/448], adjusted odds ratio 3·84, 95% confidence interval 1·51‐9·74, p = 0·004, Supplementary Figure 2). When split by time from swab to surgery, both pulmonary complications and mortality were lowest at least 4 weeks after notification of a positive swab test (Table 1). However, 71·3% (87/122) of patients had surgery within 4 weeks of SARS‐CoV‐2 infection in this series.