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Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy

Educational Objective
To understand the factors associated with surgical mortality and complications amongst patients during the COVID-19 pandemic
1 Credit CME
Key Points

Question  Is coronavirus disease 2019 (COVID-19) associated with early surgical mortality and complications?

Findings  In this cohort study of 41 surgical patients with COVID-19 and 82 tightly matched control patients without COVID-19, significant differences were documented regarding rates of early mortality and complications, pneumonia and thrombotic complications were significantly associated with COVID-19, and different models identified COVID-19 as the first variable associated with surgical complications.

Meaning  Whenever possible, surgery should be postponed in patients with COVID-19 because it is an additional surgical risk factor that overweighs traditional ones.


Importance  There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery.

Objective  To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties.

Design, Setting, and Participants  This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score.

Exposures  Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase–polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations.

Main Outcomes and Measures  The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors.

Results  Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-∞). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications.

Conclusions and Relevance  In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: June 2, 2020.

Corresponding Author: Federico Gheza, MD, General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy (federico.gheza1@unibs.it).

Published Online: June 12, 2020. doi:10.1001/jamasurg.2020.2713

Author Contributions: Drs Doglietto and Vezzoli had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Benvenuti, Portolani, Bonardelli, Milano, Casiraghi, Calza, and Fontanella equally contributed to the study.

Concept and design: Doglietto, Gheza, Lussardi, Domenicucci, Zanin, Panciani, Maroldi, Portolani, Bonardelli, Milano, Casiraghi, Fontanella.

Acquisition, analysis, or interpretation of data: Doglietto, Vezzoli, Gheza, Domenicucci, Vecchiarelli, Zanin, Saraceno, Signorini, Castelli, Rasulo, Benvenuti, Milano, Calza.

Drafting of the manuscript: Doglietto, Vezzoli, Lussardi, Domenicucci, Zanin, Benvenuti.

Critical revision of the manuscript for important intellectual content: Doglietto, Vezzoli, Gheza, Domenicucci, Vecchiarelli, Saraceno, Signorini, Panciani, Castelli, Maroldi, Rasulo, Portolani, Bonardelli, Milano, Casiraghi, Calza, Fontanella.

Statistical analysis: Doglietto, Vezzoli, Calza.

Administrative, technical, or material support: Domenicucci, Zanin, Saraceno, Panciani.

Supervision: Doglietto, Gheza, Domenicucci, Zanin, Signorini, Panciani, Castelli, Maroldi, Rasulo, Portolani, Bonardelli, Casiraghi, Fontanella.

Conflict of Interest Disclosures: Dr Castelli reported grants from Gilead outside the submitted work. No other disclosures were reported.

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