Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Paraxis and Mef2d targets <i>Meox2</i> gene in the most lateral part of the presomitic mesoderm.

<p>(A) Embryos injected unilaterally with 20 ng of moParaxis1 or moMef2d1 were submitted to <i>in situ</i> hybridization with <i>Meox2</i> antisense probe at the neurula stage. Injection of either ParaxisF’ mRNA with moParaxis1 or Mef2dF with moMef2d1 was able to rescue the phenotype. (B) Unilateral injection of either ParaxisGRF or Mef2dGRF induced an increase of <i>Meox2</i> mRNA expression at the neurula stage after induction by dexamethasone (DXM) at stage 12.5. A cooperative effect was observed after co-injection of ParaxisGRF and Mef2dF. A treatment by cycloheximid (CHX) followed by induction by dexamethasone (DXM) at stage 12.5 indicated that <i>Meox2</i> is a direct target gene of Paraxis and Mef2d. (*) Injected side. Probes are in a framed box and indicated for each panel. (C) COS7 cells were transfected with p<i>meox2</i>-luc alone, or co-transfected with either Paraxis, Mef2d-V5/His or both and luciferase activity was determined 48 h after transfection. * P<0.01 (D) Protein extracts from COS7 cells transfected with Mef2d-V5/His alone or with either empty vector (Gal4) or Gal4-Paraxis construct were immunoprecipitated (IP) with Ni-NTA beads and subjected to Western blot (WB) using an anti-Gal4 antibody (upper panel). Input control experiments with anti-V5 (lower panel) or anti-Gal4 (mid panel) antibodies. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p

Lateral presomitic cells expressing <i>Meox2</i> are the dermomytome progenitors.

<p>(A) Expression of <i>Meox2</i> mRNA in the most lateral region (rounded brackets) of presomitic mesoderm at stage 14 (dorsal view and transverse section), 16 (dorsal view), 17/18 (dorsal view and transverse section) and 23 (transverse section). Dotted lines indicate the position of the medial and lateral population of myogenic cells. Vertical lines define the limit between anterior and trunk region. Nc, notochord. (B) Lineage tracing experiments: embryos were injected with WGA-rhodamine (red) in the most lateral presomitic mesoderm (a) or co-injected with WGA-fluorescein (green) in the lateral presomitic mesoderm (c) at stage 13. Transverse sections of the embryo at the trunk level and at stages 18 or 23; embryo injected with WGA-rhodamine and submitted to indirect immunofluorescence with 12/101 antibody followed by secondary Alexa fluor 488 anti-mouse antibody (green) (b) or injected with the both tracers (d, e and f). WGA-rhodamine fluorescence (d), WGA-fluorescein fluorescence (e), merge (f). Dotted lines indicate the bilateral symmetry plan. In (a) and (c): Vertical lines define the limit between anterior and trunk region. (a) and (c) dorsal views, anterior side on the left. (C, D and E). Ablation experiments of presomitic mesoderm at stage 14. After microdissection experiments, embryos were fixed at stage 19 or at the tailbud stage to analyze meox2 and pax3 expression respectively. (C) sham-operated embryos, ectoderm was incised at the lateral level (line), ectoderm and mesoderm were separated from each other on the lateral side, but mesoderm was not removed. (D) Same operation on the mediolateral level but superficial mesoderm was removed (hatched zone) (E) Same operation on the lateral level but superficial mesoderm was removed (hatched zone). Brackets show the axis level corresponding to incision. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p

<em>Mef2d</em> Acts Upstream of Muscle Identity Genes and Couples Lateral Myogenesis to Dermomyotome Formation in <em>Xenopus laevis</em>

<div><p><em>Xenopus</em> myotome is formed by a first medial and lateral myogenesis directly arising from the presomitic mesoderm followed by a second myogenic wave emanating from the dermomyotome. Here, by a series of gain and loss of function experiments, we showed that <em>Mef2d</em>, a member of the Mef2 family of MADS-box transcription factors, appeared as an upstream regulator of lateral myogenesis, and as an inducer of dermomyotome formation at the beginning of neurulation. In the lateral presomitic cells, we showed that <em>Mef2d</em> transactivates <em>Myod</em> expression which is necessary for lateral myogenesis. In the most lateral cells of the presomitic mesoderm, we showed that <em>Mef2d</em> and <em>Paraxis (Tcf15)</em>, a member of the Twist family of transcription factors, were co-localized and activate directly the expression of <em>Meox2</em>, which acts upstream of <em>Pax3</em> expression during dermomyotome formation. Cell tracing experiments confirm that the most lateral <em>Meox2</em> expressing cells of the presomitic mesoderm correspond to the dermomyotome progenitors since they give rise to the most dorsal cells of the somitic mesoderm. Thus, <em>Xenopus Mef2d</em> couples lateral myogenesis to dermomyotome formation before somite segmentation. These results together with our previous works reveal striking similarities between dermomyotome and tendon formation in <em>Xenopus</em>: both develop in association with myogenic cells and both involve a gene transactivation pathway where one member of the Mef2 family, <em>Mef2d</em> or <em>Mef2c</em>, cooperates with a bHLH protein of the Twist family, <em>Paraxis</em> or <em>Scx</em> (<em>Scleraxis</em>) respectively. We propose that these shared characteristics in <em>Xenopus laevis</em> reflect the existence of a vertebrate ancestral mechanism which has coupled the development of the myogenic cells to the formation of associated tissues during somite compartmentalization.</p> </div

Sequence of oligomorpholinos.

<p>Sequence of oligomorpholinos.</p

Myod is required for lateral myogenesis.

<p>(A) Western blot with anti-flag and anti-tubulin antibodies of gastrula embryos injected bilaterally at the two-cell stage with 300 pg of 5utrMyf5F, 5utrMyodF or 70 pg of 5utrMrf4F synthetic mRNAs alone or with oligomorpholinos. Arrows point out the specific signal. Lane 1: synthetic mRNA alone, 2: synthetic mRNA+moControl, 3: synthetic mRNA+specific mo (moMyf5, moMyod1 or moMrf4-1 with 5utrMyf5F, 5utrMyodF or 5utrMrf4F respectively). (B) Whole-mount in situ hybridization of embryos unilaterally injected with 20 ng of moMyf5, moMyod1 or moMrf4-1 and fixed at stages 14 or 18/19. β-galactosidase mRNA (blue) was co-injected to identify the injected side, indicated by an asterisk (*). Dorsal views. The anterior side of the embryos is on the left; st., stage. (C) Transverse sections of the morphants at stage 26. (D) Transverse section of the <i>Myod</i> morphant submitted to whole-mount immunohistochemistry with the 12/101 antibody. (E) Rescue experiments: Embryos were injected unilaterally with 20 ng of mo<i>Myod</i>1 alone or co-injected with synthetic mRNA coding for MyodF (150 pg) and probed with <i>MyhE3</i>. Nc, notochord. Probes are in a framed box and indicated for each panel. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p

<i>Mef2d</i> drives lateral <i>Myod</i> expression.

<p>(A) In situ hybridization of <i>Myod</i> and <i>Mef2d</i> at gastrula and neurula stages realized from time-course experiment with embryos of the same fecondation pool. Brackets show initial posterior <i>Myod</i> expression. (B) Single and double <i>in situ</i> hybridization with <i>Mef2d</i> (blue) and <i>Myod</i> (purple) show that <i>Mef2d</i> precedes <i>Myod</i> expression in the posterolateral domain of presomitic mesoderm (arrows) at stage 12.5/13. (C) Embryos injected unilaterally with 400 pg of Mef2dF mRNA. (D) Western blot with anti-flag and anti-tubulin antibodies of late gastrula embryos injected bilaterally either with 300 pg of 5utrMef2dF synthetic mRNA alone (lane1) or with oligomorpholinos: moControl (lane 2), moMef2d1 (lane3), or moMef2d2 (lane 4). (E) Embryos injected unilaterally with 20 ng of moMef2d1 and submitted to in situ hybridization to detect either <i>Myod</i> or <i>Desmin</i> mRNA. (F) Co-injection of Mef2dF mRNA (200 pg) with moMef2d1 was able to rescue the phenotype of moMef2d1 embryos. (G) Unilateral injection of MyodF mRNA (300 pg) or moMyod1 and detection of <i>Actc</i> and <i>Mef2d</i> expression at stage 16. β-galactosidase mRNA (blue) was co-injected to identify the injected side, indicated by an asterisk (*). Vertical lines define the limit between anterior and trunk regions. Probes are in a framed box and indicated for each panel. Dorsal views. the anterior side of the embryos is on the left; st., stage. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p

Mef2d is required for dermomyotome formation.

<p>(A) Embryos injected unilaterally with 400 pg of Mef2dF mRNA or 20 ng of moMef2d1 were fixed at stage 26 and submitted to staining with the specific muscle 12/101 antibody (red). (B) Expression of <i>Pax7</i> and <i>Pax3</i> mRNA at stage 17/18 (dorsal view or transverse sections at the trunk level). Co-staining of <i>Pax3</i> mRNA (purple) and differentiated muscle cells detected by 12/101 antibody (blue). Dotted lines indicate the position of the medial and lateral population of myogenic cells <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359-Hinits1" target="_blank">[5]</a>. (C) Expression of <i>Pax3</i> mRNA on a transverse section at stage 22. (D) <i>Pax3</i> mRNA expression on lateral view (left) or on transverse section (right) at the tailbud stage after unilateral injection of Mef2dF or moMef2d1. Rescue experiments restored the phenotype of moMef2d1. Arrows indicate the sites of lateral ectopic expression of <i>Pax3</i>. (*) Injected side. Probes are in a framed box and indicated for each panel. Nc, notochord. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p

Schematic representation of myotome and dermomyotome formation in <i>Xenopus</i>.

<p>(A) The most lateral <i>Meox2</i> expressing cells of the paraxial mesoderm give rise to the dermomyotome (De) whereas the lateral myogenic cells give rise to a dorsomedial (DoMe) and a ventrolateral (VeLa) cell population. The medial myogenic cells differentiate first and remain associated with the notochord <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359-Hinits1" target="_blank">[5]</a>. Arrows design the movement of lateral paraxial mesoderm. Dotted arrows design the movement of invagination of neurectodermal cells. NT, neural tube. Nc, notochord. (B) Mef2d couples lateral myogenesis to dermomyotome formation: In lateral presomitic cells, Mef2d transactivates the <i>Myod</i> gene and in the most lateral presomitic cells Mef2d and Paraxis transactivates the <i>Meox2</i> gene.</p

Paraxis and Mef2d have a cooperative effect on dermomyotome formation.

<p>(A) Expression of <i>Paraxis</i> mRNA during neurulation. Costaining of <i>Mef2d</i> (blue) and <i>Paraxis</i> (purple) mRNA at stage 13 in comparison with <i>Mef2d</i> expression alone. Rounded brackets indicate the region of colocalization of <i>Paraxis</i> and <i>Mef2d</i>. Dorsal views. The anterior side of the embryos is on the left; st., stage. Vertical lines define the limit between anterior and trunk region. (B) Transverse sections of the costained embryos compared to <i>Mef2d</i> staining at stage 13 (upper panels). Expression of <i>Paraxis</i> and <i>Mef2d</i> at stage 17/18 (lower panels). Dotted lines indicate the position of the medial and lateral population of myogenic cells. (C) Expression of <i>Paraxis</i> mRNA on a transverse section at stage 23. (D) Western blot with anti-flag and anti-tubulin antibodies of late gastrula embryos injected bilaterally either with 300 pg of 5utrParaxis synthetic mRNA alone (lane1) or with oligomorpholinos: moControl (lane 2) or moParaxis1 (lane3). (E) Embryos injected unilaterally with 20 ng of moParaxis1 were submitted to <i>in situ</i> hybridization with <i>Pax3</i> antisense probe at the tailbud stage (lateral view or transverse section). A co-injection of ParaxisF’ mRNA (150 pg) with moParaxis1 was able to rescue the phenotype of moParaxis1 injected embryos (lateral view). (F) Unilateral injection of ParaxisGRF (150 pg) induced an increase of <i>Pax3</i> mRNA expression at the tailbud stage. Pax3 expression after co-injection of ParaxisF+Mef2dF or ParaxisGRF+Mef2dF. ParaxisGRF injection with moMef2d1 had no effect on <i>Pax3</i> expression. (*) Injected side. Probes are in a framed box and indicated for each panel. Nc, notochord. For complete statistical data, see supporting information, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0052359#pone.0052359.s002" target="_blank">figure S2</a>.</p