To the Editor:

Global health systems have been significantly impacted by the coronavirus disease-19 pandemic. During the initial peak disruption, millions of elective procedures were postponed or canceled, and for a variety of reasons, it was anticipated that elective surgery case volumes would continue to fall. A notable worry is the safety of the patient. Early research has shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surgical patients had higher mortality rates and cardiovascular problems, possibly more than non-surgical SARS-CoV-2 hospitalized patients. The relative risk of these problems in SARS-CoV-2 patients compared to uninfected controls, however, it was not clearly characterized¹.

A combination of lower virulence of circulating variations, vaccination programs, and natural immunity from prior infection are likely to be responsible for the observed trends toward less severe infection and fewer sequelae associated with SARS-CoV-2 infection, compared with 2020. It is pre-mature to assume that this will result in a decrease in perioperative problems from SARS-CoV-2 infection and a consequent change the recommended window of time between infection and elective surgery². Although it is positive that all infections tend to be less severe in hospitalized patients with acute medical illnesses, it is unclear how this applies to perioperative patients and the resulting impact on morbidity and mortality after surgery. Evidence from surgical patients does not support the claim that the gap between asymptomatic SARS-CoV-2 infection and elective surgery might be reduced to 5 days.

The prospective CovidSurg Week research provides the most reliable data on the timing and safety of surgery following SARS-CoV-2 infection worldwide. These data comprised patients receiving both elective (n = 97,442) and emergency (n = 42,778) surgery during October and November 2020 in 116 countries. Seven weeks after infection, the unfavorable effects of SARS-CoV-2 infection remained in both asymptomatic and symptomatic individuals having both major and minor procedures. This is mirrored in multidisciplinary consensus guidelines issued by the Centre for Perioperative Care, which advocate a 7-week wait following SARS-CoV-2 infection, including in patients without symptoms, before surgery. The lack of data regarding the impact of vaccination or the Omicron variation on perioperative outcomes is highlighted in a fairly recent update to these guidelines, which also challenges the notion that a mild or asymptomatic infection does not raise the risk of perioperative complications³,⁴. Given evolving viral pathogenicity, rising vaccination rates, and innate immunity, it is conceivable that there may come a time in the future when no delay is necessary for vaccinated patients with asymptomatic infection. Besides, it’s possible that even people with the symptomatic disease will be treated similarly to those who have upper or lower respiratory tract infections, with delays only as long as they are needed for the patient to become asymptomatic and return to baseline health. It is unknown, though, whether or when we will reach this position or in what circumstances. The most recent study evaluated the outcomes of asymptomatic SARS-CoV-2 polymerase chain reaction (PCR)-positive patients who underwent general anesthesia and surgery and were compared with controls. The study found that surgery among asymptomatic PCR-positive patients was not associated with increased mortality⁵.

The choice to postpone surgery may be impacted by a number of competing hazards, which may differ between nations and health systems. We must encourage the use of consensus recommendations that incorporate the best available data. Nevertheless, there are still gaps in the literature as it pertains to the dynamic international clinical setting.