By Christina Frangou
Originally published by our sister publication, General Surgery News
The American Society of Anesthesiologists and Anesthesia Patient Safety Foundation have released an updated statement on the timing of elective surgery in patients recovering from COVID-19.
In the guidance, the two organizations recommend that elective surgery be delayed for seven weeks after a SARS-CoV-2 infection in unvaccinated patients. There is insufficient evidence to make recommendations for vaccinated patients who become infected with COVID-19, the societies concluded.
“Although there is evidence that, in general, vaccination reduces post-infection morbidity, the effect of vaccination on the appropriate length of time between infection and surgery/procedure is unknown,” according to the statement.
The guidance is based on research from earlier waves of the pandemic indicating that patients who underwent elective surgery within the first six weeks after COVID-19 had higher rates of mortality than those whose procedures were delayed. At the time of the studies, COVID-19 vaccines were not available.
The guidance, published by the two societies on Feb. 22, is intended to aid hospitals, surgeons, anesthesiologists and proceduralists in evaluating and scheduling surgical patients.
The groups’ previous guideline, published in March 2021, called for all nonurgent procedures to be delayed until patients with a recent COVID-19 infection met the criteria to discontinue isolation and had entered the recovery phase. The organizations noted that very limited data were available on surgical outcomes after a COVID-19 infection, but suggested waiting four to 12 weeks between COVID-19 diagnosis and surgery, depending on the severity of a patient’s illness.
“The purpose of these statements is really to provide a decision aid for difficult healthcare scenarios. It’s not necessarily a standard, but [addresses] challenges that clinicians are faced with,” said Daniel Cole, MD, the president of the APSF and a past president of the ASA. Dr. Cole is an anesthesiologist at University of California, Los Angeles.
He said the societies decided to update the recommendations in light of new evidence and questions from clinicians about potential risks after surgery with the omicron variant.
No significant studies to date have addressed the risk for postoperative complications or mortality in patients who had a recent infection with the omicron variant. The organizations choose to be cautious in their recommendations, Dr. Cole said.
“The question becomes, with an incomplete set of data, where do you want to make the error? Do you want to make it on being too conservative and minimizing risk, or being too liberal as far as doing surgery and potentially increasing risk? If it were a member of my family for an elective surgery that there was no harm to me or my family by waiting seven weeks, I would wait seven weeks,” he said.
Overall, both societies recommend that elective operations be performed in patients after COVID-19 infection only when anesthesiologists and surgeons agree to jointly proceed with an operation.
The decision to operate should be based on a patient’s infectious status and take into account the potential risks of proceeding with surgery versus further delaying an operation, according to the statement.
The updated recommendations are based on evidence that emerged over the last year.
One study from the CovidSurg Collaborative examined outcomes for 140,231 patients from 116 countries who underwent emergency or elective surgery in October 2020. In an adjusted model, there was a significantly higher risk for 30-day mortality in patients with a preoperative COVID-19 infection diagnosed in the six weeks before surgery compared with patients who did not have an infection (Anaesthesia 2021;76[6]:748-758).
In the United States, a study of 5,479 patients who underwent major elective surgery after SARS-CoV-2 infection revealed that surgery within zero to four weeks of infection was associated with an increased risk for postoperative complications (Ann Surg 2022;275[2]:242-246). When surgery was postponed four to eight weeks after infection, patients still experienced increased rates of postoperative pneumonia. Surgery eight weeks after a COVID-19 diagnosis was not associated with increased complications. All patients in the study were diagnosed with COVID-19 between March 1, 2020, and May 30, 2021.
These studies predate the omicron variant. According to the CDC, this variant causes less severe disease and is more likely to reside in the oropharynx and nasopharynx without infiltration and damage to the lungs. However, it’s unclear whether this will lead to fewer postoperative complications, given that SARS-CoV-2 affects organs beyond the pulmonary system, the ASA/APSF statement cautioned.
The organizations also recommended that:
- any delay in surgery needs to be weighed against the time-sensitive needs of the individual patient;
- if surgery is deemed necessary during a period of likely increased risk, potential risks should be included in the informed consent and shared decision making with the patient;
- additional delays in operating should be considered if the patient has continued symptoms not exclusive of pulmonary symptoms; and
- the decision to proceed with surgery should consider the severity of the initial infection, the potential risk for ongoing symptoms, comorbidities and frailty status, and the complexity of surgery.
American surgical organizations have not issued broad recommendations on timing of elective surgery for patients with COVID-19.
In January 2022, the American College of Surgeons issued a statement for the public that highlighted the essential nature of elective surgery, but the organization did not comment on the timing of elective surgery.
Surgeons and hospitals across North America are trying to manage backlogs of delayed operations while facing issues about how and when to go forward with elective procedures.
At Montreal’s McGill University, where Liane Feldman, MD, is the Edward W. Archibald Professor and Chair of Surgery, surgeons recommend a delay of six weeks, if possible, after COVID-19 infection in immunocompetent patients, she said.
“But ultimately, I think it comes down to a discussion, like any risk assessment situation for surgery, between the surgeon, the surgical team and the patient,” she said. “There are things that can wait and things that can’t, and it’s a balance of the risks.” Dr. Feldman is the president of the Society of American Gastrointestinal and Endoscopic Surgeons.
The ASA/APSF guidance is under continuous review, according to the organizations. Recommendations will be updated as additional evidence becomes available, they said.