Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

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INTRODUCTIONExploratory laparotomy whether elective or emergency has always remained one of the common operations across the surgical disciplines. The closure of such a laparotomy wound is key to reduce the post-operative morbidity like wound pain, wound infections and incisional hernias.1 Wound dehiscence carries with it a substantial morbidity and mortality. Mortality associated with burst abdomen has been estimated at 16%.2 The mean time for wound dehiscence is 8-10 days after operation.2,3 Abdominal wound dehiscence is a common complication of emergency laparotomies in Indian setup.Wound dehiscence is related to technique of closure of abdomen. Many patients in India have poor nutritional status and the presentation of patients with peritonitis is often delayed. This makes the problem of wound dehiscence more common in Indian setup.4 Post-operative complete wound dehiscence is a very serious complication associated with high morbidity and mortality. 5 The optimal strategy of abdominal wall closure after midline laparotomy has remained an issue of ongoing debate. To date, various randomised clinical trials and meta-analysis have been published with heterogeneous results. While the choice may not be so important in elective patients who are nutritionally ABSTRACT Background: Abdominal wound closure technique should be efficient to perform, provide strength and be a barrier to infection. The method of closure of the abdominal wall is a critical aspect of an effective incision closure, in addition to the choice of suture material. Abdominal wound dehiscence is a common complication of emergency laparotomy. This study was done to know whether our method of abdominal closure was helpful in reducing incidence of burst abdomen. Methods: This retrospective study was carried out in the department of general surgery in a tertiary medical centre in Mumbai. 126 Patients undergoing emergency laparotomies for extensive generalised peritonitis through a vertical midline incision were included in this study; the indications for laparotomy were inflammatory, traumatic and neoplastic. Results: Out of 126 patients undergoing closure of laparotomy wound by our method, wound infection was noted in 12 (9.52%) cases and 3 (2.38%) patients developed wound dehiscence (burst abdomen). Conclusions: This retrospective study demonstrates that our method of abdominal closure was helpful in reducing the incidence of burst abdomen post-operatively. This is of extreme clinical importance in reducing morbidity, mortality and healthcare cost related to abdominal wound dehiscence in a patient undergoing emergency laparotomy.

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