The comparison of Post-Operative Complications pre Covid era versus during Covid-Era based on Clavien-Dindo-classification: A Systematic Review and Meta-Analysis

  1. Yeganeh Farsi
  2. Fatemeh Shojaeian
  3. Seyed Amir Ahmad Safavi-Naini
  4. Mohammadjavad Honarvar
  5. Benyamin Mohammadzadeh
  6. Mohammad Javad Nasiri

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Abstract

Introduction

Coronavirus Disease 2019 (COVID -19) pandemic challenged the healthcare system drastically, and it was concomitant with a remarkable decline in surgeries and modified routine care of patients worldwide. This systematic review and meta-analysis aimed to compare the surgical complications before COVID -19 (Pre-COVID) and after COVID -19 (post-COVID) appearance using the Clavien-Dindo classification (CDC).

Methods

between January 1, 2019, to November 3, 2021, we performed a comprehensive search in PubMed/Medline and Scopus for studies reporting the postoperative complications based on/transformable to CDC.

Result

From 909 screened articles, 34 studies were included for systematic review. Among included articles, 11 were eligible for meta-analysis. Nineteen thousand one hundred thirty-seven patients (pre-COVID: 3522, post-COVID: 15615) were included, mostly undergoing elective surgeries (86.32%). According to CDC classification, there were no significant change between pre-COVID and post-COVID for grade 1 (Odds ratio (OR) and 95% confidence interval (95-CI): 0.99, 0.60-1.63, p=0.96), grade 2 (OR and 95-CI: 0.65, 0.42-1.01, p = 0.055), grade 3 (OR and 95-CI: 0.86, 0.48-1.57, p=0.64), grade 4 (OR and 95-CI: 0.85, 0.46-1.57, p =0.60). However, the postoperative mortality was lower before the COVID -19 outbreak (OR and 95-CI: 0.51, 0.27-0.95, p= 0.035). The included studies for systematic review and meta-analysis had a low risk of bias and unsignificant publication bias.

Conclusion

Although delivering routine surgery was challenging, the postoperative complications during the pandemic remained identical to the pre-pandemic era. The stricter patient selection tending to choose more critical states and more advanced clinical stages of the operated patients may explain some extent of higher mortality during the pandemic. Adopting preventive strategies helped deliver surgeries during the outbreak of COVID -19 while limiting the capacity of operations and admissions.

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  1. ScreenIT

    SciScore for 10.1101/2022.02.25.22271519: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    BlindingType of surgeries based on urgency: According to the NCEPOD association, the surgeries can be categorized into four levels of urgency (18): Clavien-Dindo classification of post operative complications: Surgical complications are categorized into five grades due to Clavien-Dindo classification (19): Quality Assessment: Two other reviewer (FS and YF) blindly assessed the quality of the included articles by the ROBINS-I (“Risk Of Bias In Non-randomized Studies - of Interventions”) (20).
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Study Selection: The primary search results were organized by EndNote X8 (Thomson Reuters, New York, NY, USA) and duplicates removed.
    EndNote
    suggested: (EndNote, RRID:SCR_014001)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Based on previous experience from viruses such as HPV, some initial guidelines had recommended limitation of laparoscopy procedures as it may carry the risk of surgical staff contamination (67). However, with employment of proper ultrafiltration and protection methods, studies not following this recommendation did not observe such side effect (29,54) Moreover, recent guidelines recommended conservative treatment of uncomplicated appendicitis as a safe option with low failure rate especially in the COVID -19 pandemic (68,69). Prioritization of the patients, ICU preserving techniques, laparotomy with regional instead of general anesthesia (42,45) more extensive use of robotic surgery (70), and distant/home patient monitoring and follow-up were put into test. Despite all limitations, it seems that the means and measures for lowering post-operative complications are effective. m-RNA vaccines have been created for COVID -19 offering hope for HIV prevention (71). Likewise, we hope development and employment of these new strategies in healthcare and surgery could lead to positive effect not only during pandemics but also in the future practice. Studies in the available literature confirmed a decrease in admission rates (21,22,24,32) which may be a result of patients’ reluctancy to admission in fear of COVID -19. Prognostic factors and corresponding indices such as complications at presentation (e.g., perforation, abscess, etc.), Mannheim Peritonitis Index, American Association for t...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  2. Version published to 10.1101/2022.02.25.22271519v1 on medRxiv