On 11 March 2020, the World Health Organization characterized the spread of COVID-19 as a pandemic, marking the first global pandemic since the 2009 swine flu pandemic. Although resource utilization, such as hospitalization, and intensive care unit (ICU) admission, is well documented in COVID-19 patients, data on their surgical needs and outcomes remains limited 1. Postoperative outcomes in SARS-CoV-2 infected patients have been previously reported in certain studies 1-4. Recently published data suggests an overall postoperative 30-day mortality between 19 and 24%, with more than half of the patients having postoperative pulmonary complications. These studies are mostly from Europe, the Middle East and North America and thus a study conducted in India can help tailor policies as per local healthcare resources. The surgical needs and postoperative outcomes of COVID-19 patients, as well as the overall access to surgical care during such a pandemic have yet to be fully evaluated in an Indian setting. Also, during the early phase of the COVID-19 outbreak, many clinicians encountered a small number of asymptomatic patients who underwent elective surgeries during the incubation period of COVID-19 infection. The clinical manifestations and prognosis of these patients were beyond the expectations of the clinicians 1 .It was suggested that these represent a specific surgical patient population that deserves our attention. To address this, we conducted a single center observational retrospective study to compare the post-operative outcomes of COVID-19 positive versus COVID-19 negative patients undergoing emergency surgical procedures in a tertiary care hospital in a metropolitan city. Our hospital was the only referral center for COVID positive surgical emergencies during the pandemic in the metropolitan city of Mumbai and therefore, catered to a huge patient population requiring emergency surgery in this group.

A retrospective study was conducted in the Department of General Surgery at LTMGH, a tertiary care hospital in the metropolitan city of Mumbai, India from 11th March, 2020 to 11th March, 2022. Institutional ethics committee of LTMGH approval was taken for the same (Reg No ECR/266/Lokmanya/Inst/MH/2013RR-16 , Ref No – D02022033) .All patients undergoing emergency general surgery above the age of 12 years were included and classified into COVID 19 positive or negative. Informed consent was taken from all patients (or guardians in case of <18years). COVID-19 positivity was defined as patients with a positive Polymerase Chain Reaction (PCR) test or Rapid Antigen Test (from either an oropharyngeal swab or nasopharyngeal swab) either before surgery or within 72 hours after surgery. Convenient, consecutive sampling was done and 300 COVID positive patients were identified who underwent emergency surgery in this period. The total number of COVID negative patients undergoing emergency surgery in this period was 1240 of which 300 cases were selected by simple random sampling . We collected baseline characteristics of the COVID-19 positive patients such as the presence of symptoms at time of surgery, need for oxygen or invasive mechanical ventilation and treatment received (antiviral agents, steroids, anti thrombotics). We also recorded demographic characteristics, baseline comorbidities and type of surgery. Thirty-day survival after surgery was assessed as the primary outcome. The secondary outcomes to be assessed were – • Duration of hospital stay, • Need of ICU stay, • Duration of ventilator support, • Incidence of postoperative COVID related and surgical complications. COVID related complications noted include respiratory, thrombotic and acute kidney injury4. • Respiratory complications – pneumonia, Acute Respiratory Distress Syndrome [ARDS], unexpected post-operative ventilation 2. Unexpected postoperative ventilation was defined as either any episode of non-invasive ventilation, invasive ventilation, or extracorporeal membrane oxygenation after initial extubation after surgery; or patient could not be extubated as planned after surgery. •Thrombotic complications – pulmonary embolism, myocardial infarction, Stroke , DVT, bowel gangrene and cardiac arrest. Surgical complications evaluated were • Surgical site infections, • Anastomotic leaks, • Hemorrhage. 30-day survival of the participants was presented using Kaplan-Meier estimates with 95% confidence intervals (CI). The comparison of survival between the two study arms was done with the log-rank test. The alpha level was set at 0.05. All the statistical analyses were performed using the SPSS software latest version 24.0.

We observed that the mean age of the Covid positive group was 42.22 ± 17.19 years, while that of the Covid negative group was 42.34 ± 16.68 years .Most of the study participants belonged to the age group of 21 to 30 years (n = 68 in the Covid positive group, n = 67 in the Covid negative group).We observed that the Covid positive group had 201 males (67%) and 99 females (33%), while the Covid negative group had 205 males (68.33%) and 95 females (31.67%).Thus both groups were matched in terms of age and sex distribution. We observed that 108 (36%) of the Covid positive patients died in the hospital, while 189 were discharged after recovery. One patient absconded and two patients were transferred to other Covid care centres in the city (Table I) On the other hand, only 59 patients (19.67%) in the Covid negative group died, while 239 (79.67%) were discharged (two patients absconded from the hospital) (Table I). This difference was found to be highly statistically significant (p < 0.001). The mean duration of hospital stay was found to be 17.68 ± 8.41 in the Covid positive group and 9.90 ± 8.68 in the Covid negative group. This difference was found to be statistically significant (p < 0.001) We observed that 126 out of the 300 patients (42%) in the Covid positive group required ICU admission (Table II), and 110 required ventilatory support(36.67%) However, among the Covid negative patients, only 31 out of 300 (10.33%) required ICU admission and all required ventilatory support. This difference was also found to be highly statistically significant with the Chi square test (p < 0.001).The mean duration of ventilatory stay in the Covid positive group was 8.32 ± 2.99 days, while that of the Covid negative group was 5.00 ± 2.34 days. This difference was found to be statistically significant (p < 0.001). (Table III) We calculated the incidence of Covid-related complications in the two groups. We observed statistically significant differences in the incidences of ARDS (103 v/s 30, p< 0.001), pneumonia (21 v/s 6, p = 0.003), and AKI (16 v/s 2, p < 0.001), and vascular complications (13 v/s 2, p = 0.004). (Table IV) We observed statistically significant differences in the incidences of burst abdomen (17 v/s 5, p < 0.009), and wound infection (15 v/s 6, p = 0.045) . The overall incidence of surgical complications was also greater in the Covid-positive group than the Covid-negative group. The reasons for re-exploration were found to be anastomotic leak, obstruction, and burst abdomen. We observed that the most common cause of death was respiratory failure, in 99 Covid positive patients (33%) and 52 Covid negative patients (17.33%) The other two causes of deaths – septic shock and blood loss with hypotension did not show a statistically significant difference between the two groups [(15 v/s 9, p = 0.211) and (1 v/s 1) respectively. The total number of causes of deaths exceeds the total number of deaths as some patients had developed both respiratory failure and septic shock. (Table V) ASSOCIATIONS IN THE COVID POSITIVE ARM: We found that the association between Covid symptoms and outcome was highly statistically significant. (Table VI). It was found that 126 patients needed ICU admission of which 110 patients were on ventilatory support. 97 patients admitted to ICU died and 96 of these patients who were on ventilator also suffered a fatal outcome. (Table VII) We observed that steroids were used in 121 patients, out of whom 21 died and 97 were discharged. On the other hand, out of 176 patients in whom steroids were not used, 84 died and 92 were discharged. This difference was found to be statistically significant (p < 0.001). We observed that Remdesivir was used in 37 patients, out of whom 30 died and 7 were discharged. On the other hand, out of 260 patients in whom Remdesivir was not used, 78 died and 182 were discharged. This difference was found to be statistically significant (p < 0.001). We observed that Tocilizumab was used in only four patients, out of whom three died. On the other hand, out of the 293 patients in whom Tocilizumab was not used, 105 died and 188 were discharged. This difference was not found to be statistically significant (p = 0.011). Table I: Outcome of admission in the study population Outcome of Admission Covid Positive n (%) Covid Negative n (%) Chi Square value p value Discharged 189 (63) 239 (79.67) 20.217 <0.001* Died 108 (36) 59 (19.67) Absconded 1 (0.33) 2 (0.67) Total 300** 300 *indicates statistical significance **Two patients from the Covid positive group were transferred to other Covid centres Table II: ICU admission and Ventilator requirement in study population ICU Admission Ventilator Requirement Covid Positive 126(42%) 110(36.67%) Covid Negative 31 (10.33%) 31(10.33%) p value <0.001 <0.001 Chi square value 77.85 57.86 Table III: Duration of ventilator stay in the study population Group Mean ± SD (days) ‘t’ statistic ‘p’ value Covid positive 8.32 ± 2.99 15.15 < 0.001* Covid Negative 5.00 ± 2.34 *indicates statistical significance Table IV: Incidence of covid related complications in the study population Covid-related complication Covid positive Covid negative p value Number (n) Percentage (%) Number (n) Percentage (%) ARDS 103 34.33 30 10.00 < 0.001* Pneumonia 21 7.00 6 2.00 0.003* Acute kidney injury 16 5.33 2 0.67 < 0.001* Vascular complications 13 4.33 2 0.67 0.004* DIC 1 0.33 0 0.00 NA Priapism 1 0.33 0 0.00 NA Table V: Causes of deaths in the study population * Cause of death** Covid positive Covid negative p value Number (n) Percentage (%) Number (n) Percentage (%) Respiratory failure 99 33.00 52 17.33 < 0.001* Septic shock 15 5.00 9 3.00 0.211 Blood loss and hypotension 1 0.33 1 0.33 1.000 Indicates statistical significance **the total number of causes of deaths exceeds the total number of deaths as some patients developed both respiratory failure and septic shock Table VI: Association between symptoms and outcome in the study population Outcome of admission Symptoms present Symptoms absent Total Chi-square value ‘p’ value Died 101 7 108 158.13 < 0.001* Discharged 34 155 189 Total 135 162 297 *indicates statistical significance Table VII: Association between ICU admission, ventilator requirement and outcome in the study population Outcome of admission ICU admission Ventilator Needed Not needed Needed Not Needed Died 97 11 96 12 Discharged 29 160 14 174 Total 126 171 110 187 Chi square value 156.04 195.67 p value <0.001 <0.001 *indicates statistical significance

COVID-19 pandemic has been widespread and devastating and has created unprecedented challenges for the whole medical fraternity. The pandemic affected both patients with and without COVID-19 as many elective surgeries were delayed or postponed. Mainly emergency surgeries were carried out during the pandemic and data on post-operative outcomes in an Indian setting are limited. Hence, this study was planned to find out post-operative outcome of RTPCR-positive COVID-19 patients who underwent emergency surgeries in a tertiary care institute, which was the only referral centre for Covid positive patients requiring emergency surgery in the metropolitan city of Mumbai. COVIDSurg Collaborative has reported a mortality of 23.8% for patients with perioperative COVID-19 infection (26.1% preoperative infection and 71.5 % postoperative infection), compared to a 4% mortality for patients without perioperative COVID-19 infection between January and March 2020 (2). We observed a mortality of 36% (n = 108) among the Covid positive patients and 20% (n = 59) in the Covid negative group. This increased mortality among the Covid positives was found to be highly statistically significant (p < 0.001) . The most common cause of death in our study was respiratory failure, which was significantly greater in 99 Covid positive patients (33%) than 52 Covid negative patients (17.33%) (p < 0.001). Haffner et al also reported double the mortality rate in Covid positive patients (14.8%) as compared to Covid negative patients (7.1%) (5). We observed that 126 out of the 300 patients (42%) in the Covid positive cohort required ICU admission. However, among the Covid negative patients, only 31 out of 300 (10.33%) required ICU admission. In the study by Lei et. al., 15 of 34 post-operative patients required ICU care. Compared with patients who did not receive ICU care, patients who required ICU care were significantly older (median age, 55 years) and were more likely to have underlying comorbidities and cardiovascular disease. These could be interpreted as risk factors for such patients to require ICU care (1). A significantly greater proportion of patients from the infected group required ventilatory support than the non infected patients (110, 36.67% v/s 31, 10.33%). We observed statistically significant differences in the incidences of ARDS (103 v/s 30, p < 0.001), pneumonia (21 v/s 6, p = 0.003), and AKI (16 v/s 2, p < 0.001), and vascular complications (13 v/s 2, p = 0.004). One study by the COVIDSurg Collaborative examined mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection (2). The study included over 1,100 patients from 235 hospitals across 24 countries. The results showed that postoperative pulmonary complications occur in 50% of patients with perioperative COVID-19 infection and are associated with high mortality (23.8%). In another study by Carrier et. al., complications were relatively rare, with the exception of pulmonary complications (25%) and new ICU admissions (27%), which were found to be common. The authors also observed that these complications were higher in symptomatic COVID-19 patients (4). We also observed that the overall incidence of surgical complications was greater among the Covid positive than the Covid negative group. We also observed statistically significant differences in the incidences of burst abdomen (17 v/s 5, p < 0.009), and wound infection (15 v/s 6, p = 0.045) (Table 11). The reasons for re_exploration in our study were found to be anastomotic leak, obstruction, and burst abdomen. We found statistically significant associations between the symptoms, incidence of ICU admission, ventilatory requirement and use of steroids with the outcomes in the Covid positive patients (p < 0.001 for each comparison) . We did not observe any significant association between the use of tocilizumab and the outcomes in this population. However, the number of patients who received tocilizumab was only four and this is a very small number to perform any comparison, and could be the reason for the lack of association observed in our study. Also, the supply of both remdesivir and tocilizumab in our institute was erratic, and therefore, they could not be used at the appropriate time. This limits our interpretation regarding the benefit of both observed in our study. Overall, SARS-CoV-2 infected patients have not experienced many surgeries during the pandemic. This could probably be due to a combination of limited surgical needs in this population and a restriction to surgical care imposed on them until they recover from their infection to potentially reduce postoperative complications (2, 6). In fact, routine preoperative testing for SARS-CoV-2 itself has been associated with less postoperative pulmonary complications in major surgeries, probably by allowing to postpone or cancel surgery in active cases (7). The COVIDSurg Collaborative group recommends that thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. They also suggest that consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery (7).Thus, our study adds weight to the concept that the risk and incidence of mortality and other complications increases in Covid positive patients undergoing surgery, when compared to Covid negative patients, undergoing similar surgeries. This increased risk may be attributable to the Covid-19 infection directly, or due to the hypercoagulable state, as a result of Covid 19, or both of these, or may be other factors might also be at play. However, considering the current body of evidence, it seems more prudent to delay the surgeries in Covid positive patients, especially the elective surgeries, so as to reduce the possibility of any complications. Another important consideration is regarding the factors that might enable a surgeon to achieve improved outcomes in Covid positive patients undergoing emergency surgery. These factors include the use of corticosteroids, and early weaning off ventilators. The administration of corticosteroids has consistently shown better outcomes, in terms of reduction in the post-operative duration of stay, and incidence of post-operative complications (2,8,). In 2021 and 2022, the availability of COVID-19 vaccinations increased, which could be effective to reduce the number of infections and severity of cases (9

Although the severity of the pandemic has abated, Covid-19 continues to affect many parts of the world and new variants may still emerge. With the recent rise in number of cases in India hospitals may again face a surge of admissions and this data can help guide decision making and policy guidelines in the Indian scenario. Moreover Covid-19 survivors may face long term health effects like lung fibrosis or cardiovascular issues and these can influence management during surgery.

1. Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020; 21:100331. 2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohor t study. Lancet. 2020;396(10243):27–38. 3. Doglietto F, Vezzoli M, Gheza F, Lussardi GL, Domenicucci M, Vecchiarelli L, et al. Factors associated with surgical mortality and complications among patients with and without coronavirus Disease 2019 (COVID-19) in Italy. JAMA Surg. 2020;155(8):1–14. 4. Carrier FM, Amzallag É, Lecluyse V, Côté G, Couture ÉJ, D'Aragon F, et. al. Postoperative outcomes in surgical COVID-19 patients: a multicenter cohort study. BMC Anesthesiol. 2021;21(1):15. 5. Haffner MR, Le HV, Saiz Jr AM. Postoperative In-Hospital Morbidity and Mortality of Patients With COVID-19 Infection Compared With Patients Without COVID-19 Infection. JAMA Netw Open. 2021;4(4):e215697 6. Urbach DR, Martin D. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ. 2020;192(21):E585–6. 7. COVIDSurg Collaborative. Delaying surgery for patients with a previous SARS-CoV-2 infection. Br J Surg. 2020;107(12):e601–2. 8. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et. al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020 Apr 7;15(1):25 9. Shirata C, Halkic N. Impact of COVID-19 pandemic on surgical outcomes after hepatopancreatobiliary (HPB) surgery. Glob Health Med. 2023 Apr 30;5(2):67-69. doi: 10.35772/ghm.2023.01015. PMID: 37128228; PMCID: PMC10130550.