Patients with recent COVID-19 may have an increased risk for mortality following some ambulatory procedures, according to a retrospective study. However, colonoscopy procedures were associated with a lower mortality risk than other surgical procedures.
“The data really point to how COVID-19 is a systemic disorder. It affects the whole body. It is not just a lung disorder,” said investigator George Williams, MD, a professor of anesthesiology and critical care at UTHealth Houston. “If it were, ambulatory surgery could be a minor thing. Instead, we saw a mortality signal. That’s the ultimate, worst outcome—to have someone die following surgery. This risk was substantial. It was two-and-a-half times baseline. That was really something that we were surprised to see.”
Dr. Williams and his co-investigators conducted a retrospective review of data from a de-identified COVID-19 electronic health record data set, assessing 30-day mortality among patients with recent COVID-19 infection who underwent procedures at ambulatory surgery centers from March 2020 to March 2021 (J Clin Anesth 2023;89:111182). The researchers used the following surgical classifications: colonoscopy; ear, nose and throat, neurosurgery and ophthalmology; general surgery; obstetrics and gynecologic surgery; plastic and orthopedic surgery; trachea, bronchi and lung surgery; urology; and “other.” They identified 4,303 patients in the data set with a recent COVID-19 diagnosis, comparing their outcomes with those of 40,673 COVID-19–negative patients.
Comorbidities and Timing Of Procedure Play Roles
Overall, patients with COVID-19 had a higher risk for all-cause mortality versus patients without the infection (odds ratio [OR], 2.51; P<0.001). Mortality also increased with the severity of comorbidities, as indicated by the Charlson Comorbidity Index.
The influence of COVID-19 seemed to vary by procedure type. Positive patients who underwent colonoscopy (OR, 0.21; P=0.01) or plastic and orthopedic surgery (OR, 0.27; P=0.01) had a lower risk for postoperative mortality than those who underwent “other” surgeries, whereas negative patients who underwent colonoscopy or plastic and orthopedic surgery had no significant difference in the likelihood of postoperative mortality from those who underwent “other” surgeries.
The timing of surgery was an important factor, according to Dr. Williams. Patients who had surgery 0 to 15 and 31 to 45 days after a positive COVID-19 diagnosis had a higher risk for mortality than those whose diagnosis was 46 to 180 before surgery (0-15 days:OR, 1.80; P=0.05 and 31-45 days: OR, 2.22; P=0.05).
“Forty-five days was more than what we bargained for,” Dr. Williams said. “We looked up to six months, just to make sure we didn’t miss anything. We thought there might be a waxing and waning … but clearly, that first month-and-a-half is really important.”
‘We Should Pay Attention’
Calling the study “provocative and interesting,” Aasma Shaukat, MD, MPH, the director of Outcomes Research in the Division of Gastroenterology and Hepatology at NYU Grossman School of Medicine, in New York City, told Gastroenterology & Endoscopy News that it’s “hard to know conclusively, but the study does signal that we should pay attention.”
She noted that “the study wasn’t able to determine what was associated with that positive test that led to an increased mortality risk, but it does give us some food for thought. For instance, maybe individuals that have a positive COVID test are also having some symptoms that they’re ignoring, or we’re ignoring, because you just want the surgery or the procedure done.”
For patients who test positive for COVID-19, “perhaps we should take a deeper history to see if there are any symptoms associated with that positive COVID test, and maybe even retest the [patients who] are positive closer to the procedure, to see if they’re still positive and, perhaps, think about postponing the procedure,” Dr. Shaukat said.
“I think it’s interesting to think about the mechanisms by which [patients with a] positive COVID test have [an increased] risk of death. Is it more vascular events or is it neurologic events that are occurring? That would give us really good insights into what to look for going forward,” Dr. Shaukat noted. “Now, we don’t test for COVID anymore before procedures because it’s very common, and in a lot of cases very mild, so we go by the patient’s symptoms. But if we knew that there were certain things that we needed to screen for, then that would help our practice.”
Dr. Williams noted that the researchers “found that lower mortality finding in colonoscopy patients very interesting. Our clinical intuition is general anesthesia itself may contribute to the physiologic insult nidus needed to instigate more acute disease. In the colonoscopy setting, the vast majority of patients would be prescribed monitored anesthesia care, which avoids invasive ventilation and the same-degree physiologic ‘takeover’ needed to provide general anesthesia. This may explain the improved outcome compared to other patient categories.”
Dr. Shaukat also noted that “because colonoscopy is a very elective procedure, we are selecting out the healthiest of the healthiest individuals. So, individuals with a positive COVID test who are otherwise asymptomatic and in good health are probably generally in better health than the average person. Perhaps that could explain some of the difference.”
—Jenna Bassett, PhD
Dr. Shaukat reported financial relationships with Freenome, Iterative Health and Motus GI. Dr. Williams reported no relevant financial disclosures.
This article is from the July 2024 print issue.