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Keeping surgery on hold for at least 7 weeks after a positive coronavirus test was associated with lower mortality risk compared with no delay, a large international study found.

Among 3,127 patients with a preoperative SARS-CoV-2 diagnosis, mortality was highest in those who had surgery the soonest after testing positive, Dmitri Nepogodiev, MBChB, of the University of Birmingham, England, and colleagues .

The 30-day postoperative mortality rates were:

• 9.1% for surgery within 2 weeks of diagnosis (104 of 1,138)
• 6.9% for surgery 3–4 weeks after testing positive (32 of 461)
• 5.5% for surgery 5–6 weeks after diagnosis (18 of 326)
• 2.0% for surgery 7 or more weeks post-diagnosis (24 of 1,202)

When compared with the adjusted 30-day mortality of 1.5% for surgery without SARS-CoV-2 infection, only the group with at least a 7-week interval between diagnosis and surgery didn't have significantly elevated risk of death at 30 days.

"Whilst cut-offs beyond 7 weeks were not formally tested, they are unlikely to offer a significant advantage, since adjusted mortality rates for delay intervals ≥7 weeks were broadly stable," the researchers wrote.

However, those with ongoing COVID-19 symptoms had elevated surgical risk even after waiting 7 weeks or more compared with those whose symptoms had resolved or who had been asymptomatic (6.0% vs 2.4% and 1.3%, respectively).

"Our results suggest that, where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection," the group concluded. "Patients with ongoing symptoms at ≥7 weeks from diagnosis may benefit from further delay."

The findings are important for patients and caregivers in deciding the right time for surgery around COVID-19 infection, commented Mike Nathanson, MBBS, president of the Association of Anaesthetists, in a press release from the journal.

However, study co-author Aneel Bhangu, MBChB, PhD, also of the University of Birmingham, emphasized in the press release that individualization is important. "Decisions regarding delaying surgery should be tailored for each patient, since the possible advantages of delaying surgery for at least 7 weeks following SARS-CoV-2 diagnosis must be balanced against the potential risks of delay," he said. "For some urgent surgeries, for example for advanced tumours, surgeons and patients may decide that the risks of delay are not justified."

"Of the millions of patients now waiting for surgery, many will have had COVID-19 and they will want to be informed about the risks," he said. "COVID-19 will be with us for many years and the number of patients with a previous infection will continue to increase."

The study included 140,231 consecutive patients undergoing elective or emergency surgery during October 2020 at participating hospitals in 116 countries in the COVIDSurg Collaborative. Among them, 3,127 (2.2%) had a pre-operative SARS-CoV-2 diagnosis.

In sensitivity analyses, results were consistent for patients having elective surgery, for those with PCR-proven infection, and across age, physical status score, and grade of surgery.

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