Risk Factors Associated With Postoperative Mortality Among COVID-19 Positive Patients

Results of 3027 Operations and Procedures

Sumeyye Yilmaz, MD; Ipek Sapci, MD; Xue Jia, MPH; Maged Argalious, MD, MBA; Mark A. Taylor, MD; Beri M. Ridgeway, MD; Georges-Pascal Haber, MD; Scott R. Steele, MD, MBA


Annals of Surgery. 2022;276(6):969-974. 

In This Article

Abstract and Introduction


Objective: To investigate the predictors of postoperative mortality in coronavirus disease 2019 (COVID-19)–positive patients.

Background: COVID-19–positive patients have more postoperative complications. Studies investigating the risk factors for postoperative mortality in COVID-19–positive patients are limited.

Methods: COVID-19–positive patients who underwent surgeries/procedures in Cleveland Clinic between January 2020 and March 2021 were identified retrospectively. The primary outcome was postoperative/procedural 30-day mortality. Secondary outcomes were length of stay, intensive care unit admission, and 30-day readmission.

Results: A total of 2543 patients who underwent 3027 surgeries/procedures were included. Total 48.5% of the patients were male. The mean age was 57.8 (18.3) years. A total of 71.2% had at least 1 comorbidity. Total 78.7% of the cases were elective. The median operative time was 94 (47.0–162) minutes and mean length of stay was 6.43 (13.4) days. Postoperative/procedural mortality rate was 4.01%. Increased age [odds ratio (OR): 1.66, 95% CI, 1.4–1.98; P < 0.001], being a current smoker [2.76, (1.3–5.82); P = 0.008], presence of comorbidity [3.22, (1.03–10.03); P = 0.043], emergency [6.35, (3.39–11.89); P < 0.001] and urgent versus [1.78, (1.12–2.84); P = 0.015] elective surgery, admission through the emergency department [15.97, (2.00–127.31); P = 0.009], or inpatient service [32.28, (7.75–134.46); P < 0.001] versus outpatients were associated with mortality in the multivariable analysis. Among all specialties, thoracic surgery [3.76, (1.66–8.53); P = 0.002] had the highest association with mortality. Total 17.5% of the patients required intensive care unit admission with increased body mass index being a predictor [1.03, (1.01–1.05); P = 0.005].

Conclusions: COVID-19–positive patients have higher risk of postintervention mortality. Risk factors should be carefully evaluated before intervention. Further studies are needed to understand the impact of pandemic on long-term surgical/procedural outcomes.


In December 2019, an outbreak of a novel coronavirus infection was identified in Wuhan, China. Later named "Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)," the pathogen responsible for pneumonia was referred as "coronavirus disease 2019 (COVID-19)" by the World Health Organization (WHO).[1] Since being declared a pandemic on March 11, 2019,[2] COVID-19 has impacted virtually every aspect of health care. This includes challenges for clinicians, surgeons, and patients regarding the access to health care, concerns about safety, and limitations of supplies. Surgeons were advised to give priority to the urgent, emergent, and nondeferrable oncological cases[3] to limit the viral spread, protect patients and caregivers, and use limited resources effectively.

Considering the proinflammatory cytokine release and immunosuppression after surgery, COVID-19–positive patients were feared to have higher complication rates in the postoperative period.[4] In the early phase of pandemic, the effect of COVID-19 on postoperative outcomes was reported in small retrospective series, and it was suggested that COVID-19 infection itself, whether symptomatic or asymptomatic, was associated with higher postoperative complication and 30-day mortality rates.[5,6] Later, larger series[4,7] were published and reported higher postoperative morbidity and mortality among COVID-19–positive patients as well. Ultimately, the impact of the pandemic on health care outcomes may not be realized for decades.

Graselli et al[8] reported the outcomes of COVID-19–positive patients admitted to the intensive care units (ICU) in Lombardy, Italy. Older age, male sex, history of chronic obstructive pulmonary disease, hypercholesterolemia, and type 2 diabetes mellitus were independent risk factors for mortality. The COVIDSurg Collaborative group[4] investigated the outcomes of 1128 COVID-19–positive surgical patients and found that male sex, age older than 70 years, American Society of Anesthesiologists (ASA) scores 3 to 5, underlying malignancy, emergency versus elective surgery and major versus minor surgery were associated with increased postoperative mortality. Despite these initial results, there remains a lack of literature investigating the risk factors for postoperative mortality in COVID-19–positive patients, especially when stratified by the type of surgery and/or procedure.

Therefore, the aim of this study is to investigate the risk factors for perioperative/procedural mortality in COVID-19 positive patients undergoing a wide array of operations and procedures from a large cohort in a quaternary medical center. We hypothesized that in COVID-19–positive patients, higher ASA scores, emergency surgery, and presence of comorbidity would increase the risk of postoperative/procedural mortality.