KUALA LUMPUR, June 1 — Covid-19 patients undergoing surgery face much higher risk of postoperative death than non-coronavirus patients, including in minor operations, a new global study revealed.
The study led by the University of Birmingham, which focused predominantly on European hospital patients, found disproportionately high mortality among Covid-19 patients across all surgery sub-groups, including elective surgery (18.9 per cent), emergency surgery (25.6 per cent), minor surgery such as appendicectomy or hernia repair (16.3 per cent), and major surgery such as hip surgery or colon cancer surgery (26.9 per cent). Overall 30-day mortality in the study was 23.8 per cent.
The fatality rates for coronavirus patients undergoing minor surgery (16.3 per cent) and elective surgery (18.9 per cent) were found to be higher than those reported for even the highest-risk patients before the Covid-19 pandemic. Mortality for patients having minor or elective surgery was previously estimated to be under 1 per cent.
Study co-author Aneel Bhangu, senior lecturer in surgery at the University of Birmingham, cited the 2019 UK National Emergency Laparotomy Audit that reported 30-day mortality of 16.9 per cent in the highest-risk patients, and a previous study across 58 countries that reported a 30-day mortality of 14.9 per cent in patients undergoing high-risk emergency surgery.
“We recommend that thresholds for surgery during the SARS-CoV-2 pandemic should be raised compared to normal practice,” Bhangu said, referring to the virus that causes Covid-19 disease.
“For example, men aged 70 years and over undergoing emergency surgery are at particularly high risk of mortality, so these patients may benefit from their procedures being postponed.”
The study by the NIHR Global Research Unit on Global Surgery, led by the University of Birmingham, which was published in medical journal The Lancet, identified higher mortality rates among men (28.4 per cent) versus women (18.2 per cent), and in patients aged 70 years or over (33.7 per cent) versus those aged under 70 years (13.9 per cent).
Other risk factors for dying after surgery included having severe pre-existing medical problems, undergoing cancer surgery, undergoing major procedures, and undergoing emergency surgery.
The study also found that overall in the 30 days following surgery, about half of patients, or 51 per cent, developed pneumonia, acute respiratory distress syndrome, or required unexpected ventilation. This, said researchers, may explain the high mortality, as most (81.7 per cent) patients who died had experienced pulmonary complications.
Researchers noted that patients undergoing surgery were vulnerable to coronavirus exposure in hospital and that they may be particularly susceptible to subsequent pulmonary complications, due to inflammatory and immunosuppressive responses to surgery and mechanical ventilation.
College of Surgeons, Academy of Medicine of Malaysia (CSAMM) president, Professor Dr April Camilla Roslani, said the results of the study, though based on a mainly European cohort, were consistent with a Chinese study that similarly showed poorer surgical outcomes in Covid-19 patients.
“This validates the Malaysian policy decisions at national and institutional levels to postpone non-urgent surgeries in SARS-CoV-2 patients. It also supports the role of risk assessment and pre-operative Covid-19 testing in those undergoing elective surgery, which we are already practising. Nevertheless, this practice has cost implications,” she said in the statement.
“As Malaysia ramps up its elective surgical services, there is now an urgent need for investment by the government and health providers to ensure that patient and health care worker safety is prioritised. This includes provision of adequate personal protective equipment (PPE), establishment of pathways for rapid preoperative SARS-CoV-2 testing, and maintenance of dedicated ‘cold’ surgical centres.”
“Cold” surgical sites refer to elective operations, as compared to “hot” (emergency) sites.
A study by the CovidSurg Collaborative previously projected that 28.4 million elective surgeries worldwide were at risk of cancellation or postponement this year amid the coronavirus pandemic, based on a 12-week period of peak disruption to hospital services. This includes an estimated deferral of 151,717 surgeries in Malaysian hospitals.
Dmitri Nepogodiev, research fellow at the University of Birmingham and co-author of the latest study in The Lancet, said: “Our data suggests that it was the right decision to postpone operations at a time when patients were at risk of being infected with SARS-CoV-2 in hospital.”
The global study examined data for 1,128 patients from 235 hospitals. A total of 24 countries participated, predominantly in Europe, although hospitals in Africa, Asia, and North America also contributed.