Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures

Anne Knisely, MD; Zhen Ni Zhou, MD, PhD; Jenny Wu, BS; Yongmei Huang, MD, MPH; Kevin Holcomb, MD; Alexander Melamed, MD, MPH; Arnold P. Advincula, MD; Anil Lalwani, MD; Fady Khoury-Collado, MD; Ana I. Tergas, MD, MPH; Caryn M. St. Clair, MD; June Y. Hou, MD; Dawn L. Hershman, MD; Mary E. D'Alton, MD; Yolanda Ya-Chin Huang, MD, PhD; Jason D. Wright, MD


Annals of Surgery. 2021;273(1):34-40. 

In This Article


These findings suggest that COVID-19 poses a substantial risk for patients undergoing urgent and emergent surgical procedures. COVID-19 is associated with significantly increased risk for serious perioperative morbidity and mortality. Nearly half of the cases of COVID-19 in patients who undergo surgery were not identified until after the surgical intervention.

To date, there are limited data describing outcomes of patients with COVID-19 or other coronavirus-related infections who undergo surgery.[7,9,16,17] A series of 34 patients from China with occult COVID-19 infections at the time of surgery reported dismal outcomes including development of pneumonia in all patients, ARDS in 32%, shock in 29% and a perioperative mortality rate of 21%.[7] Prior cases and case series of patients with H1N1 influenza who underwent surgery during the pandemic of 2009 suggest that these patients also seemed to be at increased risk of developing ARDS.[16,17] We noted that patients with COVID-19 were at a substantially higher risk for perioperative morbidity and mortality. Within our cohort of COVID-19 positive patients, 58% experienced serious complications and the perioperative mortality rate was 17%.

Surgery seems to exacerbate the disease course of COVID-19. Severe or critical COVID-19-associated disease was identified in 56% of patients in our series, a rate over 2 and half times more frequent than population-based estimates from China.[2] The vast majority of prior reports have found that most COVID-19 infections result in only mild disease. A number of factors including the physiologic stress of surgery, the need for mechanical ventilation, and the increased risk of other infections could all theoretically exacerbate the course of COVD-19 in patients undergoing operative interventions. Our cohort included only patients who underwent urgent and emergent procedures, a group that is at significant risk for adverse events. However, even compared to controls undergoing similar operations during the same time period and after adjusting for other perioperative risk factors, those with COVID-19 had higher morbidity and mortality.

Epidemiologic data suggests that a significant number of patients with COVID-19 infections are asymptomatic.[10] A cross sectional sample of consecutive women admitted to a labor and delivery unit in New York found that 15% of patients who were positive for COVID-19 and that 88% of these women were asymptomatic.[10] Among patients who develop symptoms, the median incubation period from exposure to the onset of symptoms is just over 5 days.[11] There is thus a significant risk that surgical patients without overt symptoms may harbor COVID-19 in areas where broad community spread of the virus has occurred.

Not surprisingly, nearly half of the subjects in our series had unrecognized COVID-19 at the time of surgery. The poor outcomes for COVID-19 patients we noted highlight the importance of identifying carriers before performing a surgical intervention. Accurate identification of COVID-19 carriers allows delaying surgery if feasible or implementation of protocols for known COVID-19 patients when surgery cannot be delayed.[18–20] Given the significant risk of transmission to operating room personnel, knowledge of COVID-19 status may also help to reduce exposures for healthcare workers.[21] Given these considerations, preoperative COVID-19 testing may be prudent in patients scheduled for urgent procedures when feasible.[10,19]

We acknowledge a number of important limitations. First, COVID-19 testing was not performed in all patients in the cohort. Our experience spans the initial phase of rapid spread of COVID-19 in the community and before the ability to perform preoperative testing in all subjects. Although there may have been some unrecognized COVID-19 patients in the control group, the evolution of the disease will likely be similar in other regions. Second, at the time of data lock 7.3% of the controls and 36.1% of COVID-19 patients remained hospitalized. We felt that timely reporting of our data was paramount. Further, any bias would likely result in underreporting of adverse outcomes in the COVID-19 positive cohort given that a much higher percentage of these patients remained hospitalized. Third, patients in the COVID-19 cohort had more significant underlying comorbidity. However, our findings of increased morbidity and mortality in the COVID-19 subjects were of a large magnitude and noted in a variety of sensitivity analyses including after multivariable adjustment, matching, and comparison to estimates from the NSQIP surgical calculator. Fourth, as with any observational study, decision making was at the discretion of individual surgeons and not standardized. Forth, although cases were reviewed after March 23, surgical urgency and whether to proceed with an operation was at the discretion of the attending surgeon. Lastly, although an extensive review of all medical records was performed, we cannot exclude the possibility that some clinical parameters including symptoms and comorbidities were underreported.

In sum, these data suggest that patients with COVID-19 who undergo urgent and emergent surgery are at increased risk for perioperative morbidity and mortality. These findings have a number of important clinical implications. First, as a significant number of patients with COVID-19 are asymptomatic and only identified postoperatively, symptom-based screening lacks appropriate sensitivity to accurately detect these patients. As such, institutional protocols that include universal, preoperative laboratory screening may increase the recognition of COVID-19 carriers. Second, given the extremely poor perioperative outcomes of subjects with COVID-19, every effort should be made to utilize nonoperative therapies or to delay surgery whenever feasible. Given the increasing burden of COVID-19, protocols for the detection and management of those at risk for the disease should be implemented to optimize outcomes.