NOTE: After the study authors later posted a letter better explaining their methods, this post was revised.
If you read this blog, you know that one of my favorite sayings is “you can’t make this stuff up”. Today I’ll cover a new journal article that implies that surgery made people more susceptible to more severe COVID-19. Let’s dig in.
The prestigious journal The Lancet just published a paper out of Wuhan, China that has many of my surgical colleagues deeply concerned about patients about to be taken back into hospital and Ambulatory Surgery Center OR’s all over the country (1). Why? Somehow, asymptomatic patients without COVID-19 who went in for routine surgery developed COVID-19 pneumonia and about 20% died.
This all happened from January 1st to Feb 5th, 2020 in Wuhan, China, the epicenter of the outbreak during the worst part of health system overload. The average patient age was 55. The patients had no COVID-19 symptoms so they were cleared for surgery. The procedures they had included:
- Spine surgery
- Hip replacement
- Brain surgery
- C-section birth
- Tumor removals
- Lung and Kidney surgery
- Misc Orthopedic, Opthalmology, Abdominal, and OB/GYN procedures
Meaning, these were all of the same procedures that would happen in the average large American hospital or outpatient hospital surgery center, every day and all day.
During this time the health system performed many surgeries. However, these 34 patients developed COVID-19 pneumonia shortly after surgery. 44% of the patients required ICU care and 21% of the patients died.
Compared with non-ICU patients, the patients admitted to the ICU were older, more likely to have underlying health conditions, underwent more invasive surgeries and had more abnormal preoperative lab work.
Why Did This Happen?
This is what the study authors concluded: “The data in this study suggest that surgery may accelerate and exacerbate disease progression of COVID-19.” The authors reached this conclusion because:
- COVID-19 came on 2-6 days after surgery
- Surgery patients progressed to shortness of breath much more quickly than non-surgical patients in other studies (3.5 days versus 8 days)
- The fatality rate from COVID-19 was almost 10 times higher in surgery patients
The authors believe that the surgery itself was a hit to the immune system and that the systemic pro-inflammatory cytokines present after these procedures may have made COVID-19 more severe.
The Take-Home Message
I’m not sure there is any other conclusion you can draw from this study other than until we figure out why this is happening and how to prevent it, we need to be careful offering elective surgery to patients during this pandemic.
Interventional Orthobiologics vs. Orthopedic Surgery
Interventional orthobiologics is using advanced imaging guidance to treat damaged parts of the joints, spine, ligaments, tendons, and muscles. The goal is to take the natural substances derived from your body like your own platelets and stem cells and precisely place those in these areas of damage to promote healing. The reason to do this is to AVOID the need for more invasive orthopedic surgery. At Regenexx we’ve been doing this for 15 years and have gotten many medium and large companies to offer this as an insurance benefit to their employees. Previously, the goal was a less invasive and less expensive procedure, now it may be a procedure that also spares your life.
Are Orthobiologic Injections A COVID Problem?
We’ve been performing emergent in-office orthobiologic injections throughout the pandemic all over the country and have yet to see any evidence of a single patient getting COVID-19 pneumonia. In addition, orthobiologic injection procedures are a fraction of the invasiveness of the surgical procedures described by this paper, so that makes common sense.
If I’m in Pain Can’t I Just Get a Steroid Shot or Pop a Pill?
Nope, there is a growing body of evidence that corticosteroids knock down the immune system, which is the last thing you need in a pandemic. Hence, please stay away from steroid shots. In addition, NSAID drugs like Motrin, Advil, Alleve, Naprosyn, Celebrex, and the rest are also thought to also suppress your immune system (3).
What If You Need an Emergency Surgery?
What if you have a tumor that needs to be resected or emergency open-heart surgery? My guess is that if the procedure can wait two weeks, you’ll need to be in quarantine. If not, you will likely need to be tested right before surgery. In addition, wherever you get that procedure should be as COVID free as possible. Meaning, many places that rarely treated infectious disease got turned into COVID-19 treatment wards. For example, the Hospital for Special Surgery in New York is an orthopedic hospital that got retasked to treat COVID-19 cases.
The upshot? We need to all be focusing on less invasive procedures for patients in pain and helping them avoid going under the knife! In the meantime, scientists need to find out why this is happening and how we prevent it, as while it’s good to get rid of unnecessary surgeries for which there are less invasive options, patients will still need to get some surgeries done during this pandemic.
(1) Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection [published online ahead of print, 2020 Apr 5]. EClinicalMedicine. 2020;100331. doi:10.1016/j.eclinm.2020.100331
(2) Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting?. Ecancermedicalscience. 2020;14:1023. Published 2020 Mar 30. doi: 10.3332/ecancer.2020.1023
(3) Day Michael. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists BMJ 2020; 368 :m1086