16.06.2020
Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy
Prognosis Transversal
Doglietto F et al
JAMA Surg
Main result
123 patients including 41 with Covid-19. Among them, 33 (80%) were diagnosed Covid + preoperatively and the rest within 5 days of surgery. Overall, the majority of patients were women (78 (63%) median age 77 [+/- 14] years).
Mortality at 30 days was significantly higher for patients with Covid-19 infection compared to the rest with an Odds Ratio of 9.5 (CI 95 [1.8-96.5]). Mortality in patients with Covid-19 infection was high (20%).
Complications were also more frequent in the Covid-19+ patients group of patients: OR 5 (95% CI [1.8-16.1]), especially pulmonary (OR 36 95% CI [9.3-205.6] ) but also thrombotic (OR 13 95% CI [1,5-∞]).
Different models have identified Covid-19 as the main variable associated with these complications.
Mortality at 30 days was significantly higher for patients with Covid-19 infection compared to the rest with an Odds Ratio of 9.5 (CI 95 [1.8-96.5]). Mortality in patients with Covid-19 infection was high (20%).
Complications were also more frequent in the Covid-19+ patients group of patients: OR 5 (95% CI [1.8-16.1]), especially pulmonary (OR 36 95% CI [9.3-205.6] ) but also thrombotic (OR 13 95% CI [1,5-∞]).
Different models have identified Covid-19 as the main variable associated with these complications.
Takeaways
In this exposed / unexposed cohort, surgical mortality and early complications were higher in patients with Covid-19 compared to patients without Covid-19 infection.
Strength of evidence Moderate
This study has a relatively satisfactory level of evidence because it is :
- clinical
- a prospective longitudinal cohort
- with exposed / unexposed comparison
- matching on different confounding factors
However, there are a few limitations to note:
- a quite low number of patients: 123, 44 affected by SARS-CoV-2
- a limited follow-up period of 36 days
- an overall historical pairing (few pairings possible in the same period)
- collection of complications with non-validated classifications in all subspecialties.
Objectives
Compare the early surgical results of patients in different surgical subspecialties according to their diagnosis of Covid-19 infection.
Method
Exposed / unexposed cohorte including patients operated in general surgery, vascular, thoracic, orthopedic and neurosurgery departments of a hospital in Italy, from February 23 to April 1, 2020. Exclusion of minor procedures (sutures of superficial wounds , tracheostomies, lumbar punctures).
Exposed group included patients with Covid19 infection before or up to 5 days after surgery. They were systematically screened and considered to have Covid-19 if the rt-PCR of nasopharyngeal samples, chest radiography or CT scan were positive. They were matched with Covid-19 negative patients with a 1: 2 ratio by sex, age group, general health (American Society of Anesthesiologists score), and comorbidities (American College of Surgeons National Surgical Quality Improvement Program risk calculator). Patients over 65 were also matched according to their clinical frailty (Clinical Frailty Scale score). When possible, the pairing was carried out over the same period, otherwise on the last pairing in time.
The main outcome measure was early mortality (at 30 days) and complications (Clavien-Dindo classification). The analysis also modeled the importance of Covid-19 compared to other surgical risks concerning complications (cumulative link models and decision tree).
Exposed group included patients with Covid19 infection before or up to 5 days after surgery. They were systematically screened and considered to have Covid-19 if the rt-PCR of nasopharyngeal samples, chest radiography or CT scan were positive. They were matched with Covid-19 negative patients with a 1: 2 ratio by sex, age group, general health (American Society of Anesthesiologists score), and comorbidities (American College of Surgeons National Surgical Quality Improvement Program risk calculator). Patients over 65 were also matched according to their clinical frailty (Clinical Frailty Scale score). When possible, the pairing was carried out over the same period, otherwise on the last pairing in time.
The main outcome measure was early mortality (at 30 days) and complications (Clavien-Dindo classification). The analysis also modeled the importance of Covid-19 compared to other surgical risks concerning complications (cumulative link models and decision tree).
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