Elective major general surgery in a patient who had recovered from COVID‐19: considerations and complications

We describe unanticipated complications and subsequent management of a patient undergoing major elective general surgery following a recent hospital admission with coronavirus disease‐2019 (COVID‐19). A 63‐year‐old man was admitted to hospital with dyspnoea and hypoxia due to COVID‐19. He reported previously being able to walk for over an hour without stopping. His background history included ulcerative colitis and he was awaiting a total colectomy for a dysplastic polyp diagnosed 7 months previously. His hypoxia was managed with facemask oxygen, and during admission, he developed loose stools. An abdominal computed tomography (CT) scan indicated a flare of ulcerative colitis which was managed with intravenous antibiotics and steroids. The patient was discharged home after 2 weeks in hospital. A follow‐up thoracic CT scan 1 week later showed areas of peripheral ground glass opacities but no evidence of fibrosis.

The patient was scheduled for laparoscopic panproctocolectomy 8 weeks following his admission with COVID‐19. Pre‐operative blood tests were normal and he reported that his exercise tolerance had returned to baseline. General anaesthesia was induced uneventfully; intra‐operative ventilation was unremarkable with peak airway pressures between 20 and 26 cmH₂O. The surgery was complex, lasting 6 h and necessitating conversion to an open procedure. The patient’s urine output was less than 100 ml in total and his serum lactate increased to 7.4 mmol.l⁻¹ at the end of the procedure, despite 4.5 l of intravenous fluid and a noradrenaline infusion. It was decided to maintain tracheal intubation and transfer the patient to the intensive care unit for postoperative management.

After 24 h, the serum lactate had improved to 2.4 mmol.l⁻¹ and the noradrenaline infusion was stopped. Due to persistent haemoserous loss from his abdominal drains a CT scan of the abdomen was conducted. This excluded an abdominal collection but indicated filling defects in the pulmonary vasculature. A CT pulmonary angiogram demonstrated thrombus in left pulmonary artery and filling defects in both lower lobes and the left upper lobe (Fig. 1). Despite the pulmonary embolism the patient’s trachea was successfully extubated and he was weaned off supplementary oxygen the same day. He was discharged home 18 days later.

Figure 1.

Coronal reconstruction of computed tomography pulmonary angiogram demonstrating thrombus in the left pulmonary artery (orange arrow).

Our main concern pre‐operatively was that undiagnosed fibrotic changes may have resulted in poor lung compliance. Evidence of restrictive lung disease has been found in 25% of patients following hospital admission with COVID‐19 [1]. Ventilation was, however, unremarkable, but it is worth noting that the acute phase of his COVID‐19 illness required management with oxygen only. The risk of thrombosis is known to be greater in patients with COVID‐19, and though we had planned to offer extended thromboprophylaxis postoperatively we did not anticipate a pulmonary embolism, which was noted incidentally on an abdominal CT scan. Among patients with COVID‐19 who experience thrombotic complications, 50% are diagnosed within 24 h of presentation to hospital, which suggests that patients may be admitted to hospital with thrombosis rather than developing it during their admission [2]. Patients with COVID‐19 who are receiving long‐term anticoagulation appear to be protected somewhat from developing thrombotic complications and this could perhaps present a strategy to reduce thrombotic risk following discharge with COVID‐19 [3].

As this patient has demonstrated, thrombotic complications may persist for several weeks following apparent recovery from COVID‐19. Clinicians and patients should consider this when weighing the risks and benefits associated with elective surgery.