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Postoperative Morbidity and Mortality in Patients with Perioperative SARS-CoV-2 Infection – a Cohort Study

Volume 9, Issue 1

Original Article / Published: November 2021


Ts. Lukanova (1), I. Takorov (1), D. Vylcheva (1), S. Arnaudov (1), S. Simeonovski (1), D. Dimitrov (1), Ts. Stanimirov (1), M. Abrasheva (2)

  1. First Clinic of Abdominal Surgery, 2. Department of Anesthesiology and Intensive CareMilitary Medical Academy, Sofia


Introduction: Concerning SARS-CoV-2 pandemic strict restrictions were introduced in Bulgaria comparable to other countries worldwide in terms of elective surgical care with a cancellation of all but emergency surgery. The aim of this study is to report the results of COVID-19-positive patients in terms of postoperative morbidity and mortality following elective and emergency surgery. Material and methods: We performed a prospective cohort study of patients who underwent elective or emergency surgery at First Clinic of Abdominal Surgery, Military Medical Academy, Sofia between November 11, 2020, and January 11, 2021. For the same period, the clinic was remodelled into a combined surgical and therapeutic unit for the treatment of COVID-19 patients. Results: Twenty-five patients with SARS-CoV-2 underwent surgery or were postoperatively treated between November 11, 2020, and January 11, 2021, at First Clinic of Abdominal Surgery, Military Medical Academy, Sofia – 15 males and 10 females, the median age of 66.2 years (43-95). There were 5 (20%) elective oncological operations and 20 (80%) emergency procedures. Pulmonary complications were registered in 18/25 (72%) of the patients and cardio-vascular – at 3/25 (12%). Postoperative morbidity was 16% – postoperative haemorrhage (n=2), surgical site infection (n=1) and postoperative pancreatic fistula type B (n=1). Eleven patients were admitted to the intensive care unit. Early postoperative mortality was 24%. The median age of the deceased was 69.5 years (55-82), 83.33 % males. There was comorbidity in 100 % of lethal cases. The main cause of mortality was COVID-19 associated. Conclusion: A SARS-CoV-2 positive status increases postoperative morbidity and mortality rates in patients undergoing general and oncological operative care. If possible, elective abdominal surgery in COVID-19 patients should be postponed for 4-7 weeks in order to optimize postoperative outcomes.


  1. Lee B, Perumalswami P, Im G, Florman S, Schiano T, COBE Study Group, COVID-19 in Liver Transplant Recipients: An Initial Experience From the US Epicenter, Gastroenterology. 2020; 159(3): 1176–1178
  2. Elsabeeny W, Abd El Dayem O, Rabea A, et al. Insights of COVID-19 pandemic impact on anaesthetic management for patients undergoing cancer surgery in the National Cancer Institute, Egypt. Ain-Shams J Anesthesiol 2020; 12-59.
  3. Schrag D, Hershman DL, Basch E. Oncology Practice During the COVID-19 Pandemic. JAMA. 2020;323(20):2005–2006.
  4. Coimbra R, Edwards S, Kurihara H, et al. European Society of Trauma and Emergency Surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection. Eur J Trauma Emerg Surg 2020; 46:505-10.
  5. Francis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 2020; 34:2327-31.
  6. Wang K, Wu C, Xu J, et al. Factors affecting the mortality of patients with COVID-19 undergoing surgery and the safety of medical staff: A systematic review and meta-analysis. EClinicalMedicine. 2020;29:100612.
  7. Jonker PKC, van der Plas WY, Steinkamp PJ, et al. Perioperative SARS-CoV-2 infections increase mortality, pulmonary complications, and thromboembolic events: A Dutch, multicenter, matched-cohort clinical study. Surgery. 2021;169(2):264-274.
  8. Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy. Ann Surg. 2020 Jul;272(1):e5-e6.
  9. Novara G, Giannarini G, De Nunzio C, Porpiglia F, Ficarra V. Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery During the COVID-19 Pandemic. Eur Urol. 2020;78(1):e12-e13.
  10. Kwak HD, Kim S-H, Seo YS, et al. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med 2016;73(12):857–63
  11. Choi SH, Kwon TG, Chung SKwang, et al. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 2014;28(8):2374–80
  12. Di Marzo F, Sartelli M, Cennamo R, Toccafondi G, Coccolini F, La Torre G, Tulli G, Lombardi M, Cardi M. Recommendations for general surgery activities in a pandemic scenario (SARS-CoV-2). Br J Surg. 2020 Aug;107(9):1104-1106.
  13. Tummers FH, Draaisma WA, Demirkiran A, et al. Potential Risk and Safety Measures in Laparoscopy in COVID-19 Positive Patients. Surgical Innovation. March 2021. doi:10.1177/15533506211003527
  14. Cascella M, Rajnik M, Aleem A, Dulebohn SC, Di Napoli R. Features, Evaluation, and Treatment of Coronavirus (COVID-19). 2021 Jul 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32150360.
  15. Yuki K, Fujiogi M, Koutsogiannaki S. COVID-19 pathophysiology: A review. Clin Immunol. 2020;215:108427
  16. Karbalai Saleh S, Oraii A, Soleimani A, et al. The association between cardiac injury and outcomes in hospitalized patients with COVID-19. Intern Emerg Med. 2020 Nov;15(8):1415-1424.
  17. Gerstein NS, Venkataramani R, Goumas AM, Chapman NN, Deriy L. COVID-19-Related Cardiovascular Disease and Practical Considerations for Perioperative Clinicians. Semin Cardiothorac Vasc Anesth. 2020 Dec;24(4):293-303.
  18. Rieder M, Goller I, Jeserich M, et al. Rate of venous thromboembolism in a prospective all-comers cohort with COVID-19. J Thromb Thrombolysis. 2020;50(3):558-566.
  19. Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory and Immune Responses to Surgery and Their Clinical Impact. Ann Surg. 2016 Jul;264(1):73-80.
  20. Ball L, Costantino F, Fiorito M, Amodio S, Pelosi P. Respiratory mechanics during general anaesthesia. Ann Transl Med. 2018;6(19):379.
  21. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020 Apr 5;21:100331.
  22. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337.
  23. Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Ann Oncol 2020, 31(7):894–901
  24. Knisely А, Zhou ZN, Wu J, et al. Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures, Annals of Surgery 2021;273(1);34-40
  25. Brown WA, Moore EM, Watters DA. Mortality of patients with COVID-19 who undergo an elective or emergency surgical procedure: a systematic review and meta-analysis. ANZ J Surg. 2021 Jan;91(1-2):33-41.
  26. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020 Jul 4;396(10243):27-38.
  27. Abate S, Mantefardo B, Basu B. Postoperative mortality among surgical patients with COVID-19: a systematic review and meta-analysis. Patient Saf Surg 2020;14, 37.
  28. Giovinazzo F, Magalini S, La Greca A, et al. Mortality in patients undergoing surgery with perioperative SARS-CoV-2 infection: an Italian COVID-19 Hub point of view. Eur Rev Med Pharmacol Sci. 2020 Nov;24(22):11471-11473.
  29. Turaga KK, Girotra S. Are we harming cancer patients by delaying their cancer surgery during the COVID-19 pandemic? Ann Surg. 2020;Publish Ahead of Print doi: 10. 1097/ SLA. 0000 0000 00003967 02 Jun 2020
  30. Gupta R, Gupta J, Ammar H. Impact of COVID-19 on the outcomes of gastrointestinal surgery. Clin J Gastroenterol. 2021;14(4):932-946
Click to review Volume 9, Issue 1


COVID-19 surgery, morbidity, mortality

How to cite this article:

Ts. Lukanova, I. Takorov , D. Vylcheva, S. Arnaudov , S. Simeonovski , D. Dimitrov , Ts. Stanimirov, M. Abrasheva . Postoperative Morbidity and Mortality in Patients with Perioperative SARS-CoV-2 Infection – a Cohort Study. Journal of Endourology and Minimally Invasive Surgery 2021; 9 (1): 59-66

Corresponding author:

Assoc. prof. Tsonka Lukanova. MD, PhD

First Clinic of Abdominal Surgery Military Medical Academy

Sofia 1606, 3 “Georgi Sofiiski” blvd., Bulgaria

E-mail:; Тel.: +359 2 9225711