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Background:
Systematic Review

Impact of COVID-19 History on Patients’ Outcome in the Perioperative Period—A Systematic Review

by
Cornelia Elena Predoi
1,2,*,
Alexandru Dascalu
1,2,
Raluca Goicea
1,2,
Mihai Stefan
1,2,
Daniela Filipescu
1,2 and
Niculae Iordache
2,3
1
Emergency Institute of Cardiovascular Disease “Prof. Dr. CC Iliescu”, 022322 Buchares, Romania
2
Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
3
Sf. Ioan Clinical Emergency Hospital, 042122 Bucharest, Romania
*
Author to whom correspondence should be addressed.
COVID 2025, 5(9), 148; https://doi.org/10.3390/covid5090148
Submission received: 9 August 2025 / Revised: 31 August 2025 / Accepted: 1 September 2025 / Published: 4 September 2025
(This article belongs to the Section COVID Clinical Manifestations and Management)
Browse Figure
Versions Notes

Abstract

Background: Elective surgery soon after SARS-CoV-2 infection is linked to high morbidity, but the risk > 7 weeks post-infection is uncertain. Methods: A PROSPERO-registered systematic review (CRD42023416842) following PRISMA 2020 searched PubMed, Web of Science, WHO COVID Database, Wiley, Google Scholar, and Scopus (Jane 2020–July 2025) for studies reporting postoperative outcomes in patients with confirmed COVID-19 ≥ 7 weeks before elective surgery. Primary endpoints were cardiopulmonary, neurological, renal and thrombotic complications, ICU/hospital stay and 30-day mortality. Results: Thirteen observational studies (38,055 patients) met inclusion criteria. In patients operated ≥7 weeks after mild or asymptomatic infection, overall mortality rate was 2.27% (607/26,688), with no significant excess versus uninfected controls. Pneumonia (1.66%), pulmonary embolism (1.47%), arrhythmias (2.57%) and myocardial injury (1.06%)—did not exceed baseline surgical rates. Thrombosis occurred in 2.8% but lacked a clear association with prior infection. Conversely, individuals with previous moderate-to-severe disease or recent COVID-19-related hospitalization showed higher complication rates, especially in complex procedures such as coronary bypass. Conclusions: Evidence to date indicates that COVID-19 history beyond seven weeks does not independently raise perioperative morbidity or mortality for most elective procedures.

1. Introduction

Since the onset of the coronavirus disease 2019 (COVID-19) it is estimated that around 10% of the global population has been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1,2]. Emerging evidence has demonstrated that COVID-19 infection exerts a detrimental impact on perioperative morbidity and mortality, with multiple studies indicating that surgical procedures performed soon after infection are associated with an increased risk of adverse outcomes [3,4]. The COVIDSurg Collaborative first reported that the elevated risk of postoperative mortality persists for up to seven weeks following an acute SARS-CoV-2 infection. Furthermore, additional studies have corroborated these findings, showing that patients diagnosed with COVID-19 in the perioperative period—specifically within seven days before or up to 30 days after surgery—experience significantly higher mortality rates, prolonged hospital stays, and increased incidences of acute renal failure, sepsis, and septic shock. These patients also exhibit higher rates of thromboembolic complications, including deep vein thrombosis and pulmonary embolism [5].
There is now a broad consensus regarding the optimal timing of surgery following SARS-CoV-2 infection. Evidence indicates that performing surgery within seven weeks of a confirmed COVID-19 infection is associated with increased morbidity and mortality. Consequently, elective procedures should generally be deferred for at least seven weeks after diagnosis, unless the clinical risks of delaying surgery outweigh the potential complications associated with disease progression [6].
Certain categories of surgical patients, particularly those undergoing elective cardiac surgery, are known to have an elevated risk of perioperative stroke. This risk is especially pronounced in individuals undergoing aortic valve surgery or procedures involving the ascending thoracic aorta. Additional risk factors include female gender, systemic arterial hypertension, diabetes mellitus, advanced age, reduced left ventricular ejection fraction, extracardiac arteriopathy, preoperative atrial fibrillation, and a history of cerebrovascular events (ischemic or hemorrhagic stroke or transient ischemic attack). However, to date, no data specifically address whether a prior history of COVID-19 modifies this risk profile [7].
Early in the COVID-19 pandemic, in 2020, the French Society of Anesthesiologists recommended that patients testing positive for SARS-CoV-2 should postpone cancer surgery—except in emergencies—in order to prioritize the treatment of COVID-19 infection, with oncological management to be reconsidered once the infection had resolved [8]. Nevertheless, no subsequent recommendations were issued concerning patients with a prior history of COVID-19 infection.
The present systematic review was designed to evaluate whether a history of COVID-19 infection exceeding seven-week is associated with an increased incidence of perioperative complications involving the neurological, respiratory, cardiovascular, and renal systems, as well as overall perioperative mortality. Despite the current seven weeks consensus, some studies suggest that surgery may be performed safely in selected patients even within four weeks of infection, whereas others report significant perioperative complications persisting beyond seven weeks after recovery [5]. This review further aims to identify patient characteristics that may predispose individuals with a history of COVID-19 to perioperative complications.

2. Materials and Methods

This systematic review was conducted in accordance with a predefined protocol registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42023416842). The reporting of results adhered to the guidelines of the PRISMA 2020 statement [9]. Screening was conducted from 1 May 2023 to 15 July 2025, reflecting the substantial volume of records assessed.

2.1. Search Strategy and Selection Criteria

The populations included in the selected studies consisted of patients with a documented history of COVID-19 infection that had occurred more than seven weeks prior to surgery. The intervention of interest was any form of elective surgical procedure. Where reported, comparator groups consisted of patients without a history of COVID-19 infection who underwent similar elective surgeries. Studies involving patients with COVID-19 infection less than seven weeks prior to surgery or those undergoing emergency procedures were excluded.
The primary outcomes assessed were postoperative ICU and hospital length of stay, as well as postoperative complications encompassing cardiovascular, pulmonary, neurological, renal, and thrombotic events. The secondary outcome was mortality, defined as either in-hospital or 30-day mortality.
A comprehensive literature search was conducted in PubMed (National Library of Medicine, Bethesda, MD, USA), Web of Science (Clarivate, London, UK), the WHO COVID-19 Database (World Health Organization, Geneva, Switzerland), and Wiley Online Library databases (John Wiley & Sons, Hoboken, NJ, USA), covering the period from 1 January 2020 to 15 July 2025. No additional filters or restrictions were applied. The search strategy utilized the following terms: (“COVID” OR “COVID-19” OR “coronavirus” OR “2019 nCoV” OR “SARS-CoV-2”) AND (“surg*”) AND (“outcome*” OR “mortal*” OR “complication*” OR “hospital*”) in titles and abstracts. These database searches were supplemented by a review of the gray literature, examination of reference lists from the included studies, and targeted searches on Google Scholar (Google LLC, Mountain View, CA, USA and Scopus (Elsevier, Amsterdam, The Netherlands). For studies published in languages not known to the investigators, translations were obtained using Google Translate (web version; Google LLC, Mountain View, CA, USA).

2.2. Data Extraction

After removal of duplicate records, two independent investigators (C.E.P. and A.D., or C.E.P. and A.V., or C.E.P. and N.I.R.) screened the studies for eligibility using the web-based application Rayyan (web version; Rayyan Systems Inc., Cambridge, MA, USA). The initial screening was performed based on titles and abstracts, followed by a full-text assessment of potentially eligible studies. Any disagreements during the selection process were resolved through consultation with a third independent investigator (M.S. or R.G.).
Data extraction was conducted using a predesigned standardized form by two independent investigators (C.E.P. and A.D.). Any discrepancies in the extracted information were resolved through discussion and consensus. Extracted variables included study design, duration of follow-up, study setting, population demographics, type of surgical intervention, vaccination status, interval between COVID-19 infection and surgery, perioperative complications (neurological, cardiovascular, pulmonary, renal, and thrombotic), postoperative ICU and hospital lengths of stay, and mortality outcomes. The collected data were synthesized and presented in both narrative and tabular formats.

2.3. Data Analysis

A narrative synthesis was performed to summarize and interpret the findings of the included studies, as substantial heterogeneity in study design, patient populations, outcome measures, and perioperative settings precluded the conduct of a quantitative meta-analysis. The synthesis aimed to identify patterns and trends in postoperative outcomes among patients with a history of COVID-19. Data from each study were systematically extracted and tabulated to facilitate cross-study comparisons.
Findings were organized by outcome category and, where applicable, stratified according to the timing of surgery following COVID-19 infection, the severity of prior COVID-19 illness, and the type of surgical procedure. Two reviewers (C.E.P. and A.D.) independently reviewed and synthesized the extracted data. Any discrepancies were resolved through discussion and consensus.
No statistical pooling was undertaken. Study quality and risk of bias were assessed to contextualize the strength of the evidence, employing the Downs and Black risk of bias checklist to evaluate methodological rigor and potential sources of bias by two reviewers (C.E.P. and A.D.) [10].

3. Results

Our search strategy initially identified 49,150 records, which were screened for duplicates. After de-duplication, 32,888 records remained and were screened by title and abstract. Of these, 32,702 were excluded for not meeting eligibility criteria—specifically, studies examining surgery performed <7 weeks after SARS-CoV-2 infection, studies of emergency surgery, or reports involving patients with COVID-19 without exposure to surgery. Of these, 189 articles were deemed potentially relevant and proceeded to full-text review (Supplementary Material S.2). In total, 7 full-text articles could not be retrieved despite repeated attempts—including searches for open-access versions and access via the authors’ institutional (hospital and university) subscriptions—leaving 179 articles for eligibility assessment according to the predefined inclusion criteria.
Following full-text assessment, 89 articles were excluded due to an ineligible population or intervention, 66 for reporting non relevant outcomes, 6 for being non observational study designs, and 5 because data were not extractable. Ultimately, 13 studies met all inclusion criteria and were incorporated into the systematic review. The selection process is summarized in Figure 1.

3.1. Study Characteristics

The characteristics of the 13 included studies are summarized in Table 1. In terms of geographic distribution, six studies (46.15%) originated from the United States, two (15.38%) from China, two (15.38%) from India, and one each (7.69%) from the United Kingdom, Türkiye, and Poland. Collectively, these studies encompassed a total of 38,055 patients who underwent elective surgery more than seven weeks after confirmed SARS-CoV-2 infection.
The majority of the studies were retrospective observational in design (n = 9, 69.23%), while five studies (38.46%) were conducted across multiple centers. Regarding surgical populations, four studies (30.77%) focused on patients undergoing cancer-related surgeries, while another four (30.77%) examined outcomes in non-cardiac surgical populations. Additionally, one study (7.69%) each addressed patients undergoing cardiac surgery, thoracic surgery, bariatric procedures, elective partial hepatectomy, and neurosurgical interventions.

3.2. Patient Characteristics

According to the included studies, eight (61.53%) reported the severity of COVID-19 infection among their cohorts [4,11,13,15,16,18,21,22], encompassing a total of 2097 patients. Of these, the majority (n = 1879; 89.6%) experienced an asymptomatic or mild course of the disease, while 114 patients (5.43%) presented with mild to moderate symptoms, and 70 patients (3.33%) had a moderate to severe clinical presentation.
Five of these studies [11,13,16,18,22] also provided data on COVID-19-related hospitalization. In total, 268 patients were included in these studies, with 50 patients (18.66%) requiring hospital admission during the course of their illness.
Regarding vaccination status, three studies [12,16,17] reported relevant data. These studies included a combined total of 31,377 patients, of whom 5553 (17.69%) had received at least one dose of a COVID-19 vaccine.
Although an inclusion criterion for this systematic review was that patients must have undergone elective surgery at least seven weeks following SARS-CoV-2 infection, the reported intervals varied across studies. Six studies (46.15%) documented an interval of more than seven or eight weeks between infection and surgery. The remaining seven studies reported more precise time frames, with an average interval of 13.85 weeks between COVID-19 diagnosis and the surgical procedure.

3.3. Patient Outcomes

Across the included studies, patients predominantly experienced respiratory and cardiovascular complications, although other types of postoperative complications were also reported. A total of 10 studies [11,12,13,14,15,16,17,18,19,20], encompassing 36,316 patients, provided data on pulmonary complications.
The reported respiratory complications included atelectasis, residual air space, pneumonia, bronchopleural fistula, reintubation, postoperative hypoxemia, pleural effusion, pneumothorax, and pulmonary embolism. Among these, pneumonia was the most frequently reported complication, occurring in 605 patients (1.66%), followed by pulmonary embolism in 535 patients (1.47%). Postoperative hypoxemia was documented in 78 cases (0.21%). Other pulmonary complications were relatively rare, as detailed in Table 2.
Seven studies [4,13,15,16,17,19,20], comprising a total of 27,499 patients, reported cardiovascular outcomes in individuals with a history of COVID-19 infection occurring at least seven weeks prior to undergoing elective surgery. A wide range of cardiac complications was documented, including perioperative myocardial injury, various cardiac arrhythmias (e.g., atrial fibrillation, atrial flutter, ventricular arrhythmias), myocardial infarction, carditis, cardiogenic shock, acute heart failure, MACE, cardiac arrest, and hypertensive crises.
Among these, cardiac arrhythmias were the most frequently reported complication [4,13,16,17,20], occurring in 709 patients (2.57%). Perioperative myocardial injury was observed in 293 patients (1.06%), while myocardial infarction was reported in 217 cases (0.78%). Carditis was identified in 94 patients (0.34%). Severe cardiovascular events such as cardiogenic shock occurred in 95 patients (0.34%), acute heart failure in 237 patients (0.86%), and cardiac arrest in 163 patients (0.59%). MACE were less frequently reported, with 56 cases (0.20%) documented across the included studies, as detailed in Table 3.
AKI was less commonly described and was reported in four studies [4,11,15,16], encompassing 1871 patients. Of these, 51 patients (2.72%) developed AKI during the perioperative period.
Neurological complications were reported in three studies [16,17,22], which collectively included a total of 22,255 patients. Among these, cerebrovascular events such as stroke were documented in 28 patients (0.12%), while transient cerebral ischemic events were reported in 99 patients (0.44%).
With regard to thrombotic complications, VTE was reported in four studies [4,13,17,19], encompassing a combined population of 26,017 patients. Among these, 724 individuals (2.78%) experienced VTE, as seen in Table 4. Although pulmonary embolism was previously categorized under pulmonary complications, it is important to acknowledge that it also constitutes a thrombotic event and should be interpreted within that broader clinical context. In cross-study summaries, VTE totals exclude PEs that are already tabulated under pulmonary outcomes; thus, cumulative counts are mutually exclusive across domains.
Data regarding hospitalization and ICU length of stay are presented in Table 5. However, due to substantial heterogeneity among studies and the limited frequency of reporting, no pooled analysis could be performed for these outcomes.
Mortality was a reported outcome in eight studies [11,13,14,15,16,17,18,20], encompassing a total of 26,688 patients. Two of these studies [18,20] reported no mortality events. Across all included studies that addressed this outcome, the overall postoperative mortality rate was 2.27%, corresponding to 607 deaths among 26,688 patients.

3.4. Risk of Bias

The methodological quality of the included studies was evaluated using the Downs and Black checklist and was determined to be of moderate quality overall. Summary percentages for the risk of bias assessment are presented in Table 1, while detailed individual scores are available in Supplementary Material S.3.
Mean scores were calculated based on the average ratings provided by two independent reviewers (CP and AD) across each domain of the checklist. The overall mean total score was 20.11 out of a possible 32 (SD = 2.88). Subscale means were as follows: reporting quality, 8.07 out of 11 (SD = 1.28); external validity, 2.1 out of 3 (SD = 0.65); internal validity—bias, 4.07 out of 7 (SD = 0.73); internal validity—confounding, 2.76 out of 6 (SD = 0.72); and power, 2.93 out of 5 (SD = 1.03).

4. Discussion

Our synthesis of 13 observational studies suggests that elective surgery performed at least seven weeks after SARS-CoV-2 infection is generally safe for patients with prior asymptomatic or mild disease, as evidenced by low rates of postoperative mortality (~2%) and serious cardiopulmonary complications. For example, both Kothari et al. [13] and Ranganathan et al. [15] found no significant increase in composite adverse outcomes—including death, readmission, pneumonia, cardiac injury, or venous thromboembolism (VTE)—when surgery occurred a minimum of 20 days post-infection among mild cases.
Similarly, Gabryel et al. [11] observed no difference in overall pulmonary complications or 90-day mortality among lung cancer surgery patients with prior COVID-19 history, although minor local complications (e.g., re-drainage) were slightly more frequent.
This topic holds particular relevance within the field of cardiac surgery, given reports of increased pulmonary complications associated with such procedures. In a study by Erçen Diken et al. [16], two cohorts were examined: one consisting of 140 patients without a documented history of COVID-19 pneumonia and another comprising 28 patients with a confirmed history of the disease. The overall incidence of postoperative pulmonary complications was significantly higher among patients with prior COVID-19 pneumonia (17.9% vs. 3.6%; p = 0.013). Notably, pleural effusion occurred more frequently in this group (14.3% vs. 2.1%; p = 0.015). Other pulmonary complications—including atelectasis, pneumonia, and ARDS—were infrequent and showed no significant difference between the groups. Importantly, no statistically significant difference in postoperative mortality was observed.
Another study highlighting the potential impact of prior COVID-19 infection on perioperative outcomes in cardiac surgery is that conducted by Gabriyelyan et al. [23], which assessed postoperative results following off-pump coronary CABG in 20 patients with a history of COVID-19 compared to a control group. The authors reported a significantly higher incidence of acute myocardial infarction (20% vs. 10%) and acute renal failure (30% vs. 10%) in the COVID-19 group. Additionally, these patients experienced longer durations of postoperative mechanical ventilation and extended ICU stays. These findings underscore the heightened postoperative morbidity observed in individuals with a history of moderate-to-severe COVID-19 undergoing major cardiac surgery. However, it is important to note that the mean interval between COVID-19 infection and elective surgery in this cohort was relatively short, averaging only 17.5 days.
On contrast, there was a study performed in cardiac surgery by Şahin et al. [24] that found no significant difference in incidence of vein thrombosis or thrombophlebitis between the COVID-19 and non-COVID groups (p = 0.626). Also, histopathological analyses revealed no signs of vasculitis or inflammation in graft tissues from either cohort. Postoperative mortality and morbidity undergoing CABG at least four weeks after mild COVID-19 recovery appears safe regarding early postoperative vascular outcomes, and prior mild SARS-CoV-2 infection did not confer increased risk of graft inflammation, thromboembolic complications, or adverse mortality/morbidity (p > 0.05).
Internationally, data from the COVIDSurg/GlobalSurg cohort [14] indicate elevated 30-day postoperative mortality when surgery is performed within 6 weeks of COVID-19 diagnosis, with adjusted odds ratios decreasing from approximately 4.1 (0–2 weeks) to baseline levels (OR ≈ 1.5) by week seven and beyond. These results align with current consensus guidelines advocating a ≥7-week delay for elective surgery following SARS-CoV-2 infection, especially in cases of ongoing symptoms, which are independently associated with higher mortality (e.g., 6% in persistent symptom subgroup vs. ~1–2% in asymptomatic/recovered).
Importantly, patients with moderate-to-severe COVID-19—particularly those requiring hospitalization—exhibited significantly higher risk of postoperative complications. Kothari et al. [13] reported an adjusted odds ratio of 7.4 for adverse postoperative events in patients who had been hospitalized for COVID-19 before surgery, even when operated beyond 20 days post-infection. Emerging data, including from epidemiological studies during the Omicron era, further underscore that vaccination status mitigates perioperative risk, reducing incidences MACE and mortality.
Although the overall incidence of thrombotic events was low, occurrences such as pulmonary embolism and deep vein thrombosis remained clinically relevant among patients with a history of COVID-19. Across four studies [4,13,17,19], VTE was reported in approximately 2.8% of cases. However, it is important to note that this rate did not differ significantly from that observed in patients undergoing elective surgery without a prior history of COVID-19.
In particular, Lazzareschi et al. [19] utilized a large administrative dataset of commercially insured adults in the United States to assess the combined impact of surgery and prior COVID-19 infection on the incidence of postoperative VTE and MACE within 90 days. After adjusting for confounders, the analysis revealed that only surgical exposure—rather than prior COVID-19 infection—was significantly associated with thrombotic complications (adjusted odds ratio [aOR] 4.07; 95% confidence interval [CI] 3.81–4.36). The interaction between surgical exposure and a history of COVID-19 was minimal (interaction aOR 1.25; 95% CI 0.96–1.61; synergy index = 0.76), suggesting that resolved COVID-19 did not confer a significant additive risk of perioperative thrombotic events beyond that attributable to surgery itself. In contrast, several studies, such as that of Li et al. [25], have demonstrated that a recent mild to moderate COVID-19 infection constitutes an independent risk factor for postoperative DVT in patients with hip fractures. Accordingly, systematic and active screening for DVT is recommended in this patient population.
With respect to cardiovascular complications, arrhythmias and myocardial injury have been reported at incidences of approximately 2.5% and 1%, respectively, in patients with a history of COVID-19 more than seven weeks prior to elective surgery; however, these rates did not differ significantly from those observed in patients without prior COVID-19 infection. Deng et al. [4] conducted an analysis of 5470 patients who underwent major elective surgery between April and November 2020, comparing outcomes among individuals with active COVID-19, those with recently resolved infection, and those with no history of COVID-19. Their findings indicated that postoperative cardiac complications—including myocardial infarction, cardiac arrest, new arrhythmias, and heart failure—within 30 days of surgery were significantly more frequent in patients with active COVID-19 at the time of surgery, relative to COVID-negative controls. Conversely, patients with resolved COVID-19 infection (defined as more than four weeks after the initial illness) did not exhibit a statistically significant increase in cardiac complications compared to controls.
Abraham et al. [26] conducted a retrospective case–control study at a tertiary care center in Kerala, India, comparing outcomes in 166 post-COVID-19 surgical patients with those of matched controls who had no history of prior infection. The study found no statistically significant differences between the two groups with respect to postoperative pulmonary complications, acute kidney injury, thromboembolic events, or 30-day mortality. These findings align with broader trends observed in the literature, suggesting that patients who have recovered from mild COVID-19 and undergo surgery at least seven weeks following infection are not at increased perioperative risk. Notably, however, the study did not clearly specify the interval between COVID-19 diagnosis and elective surgical intervention.
A key strength of this review is its focus on a diverse set of observational studies evaluating real-world outcomes across surgical specialties, with the inclusion of both cancer surgery cohorts and broader surgical populations. Nonetheless, limitations are inherent: heterogeneity in surgical types, timing intervals, and COVID-19 severity definitions precluded meta-analysis. Most studies were retrospective, potentially subject to selection bias and incomplete data capture [27,28,29,30,31]. Vaccination status and variant information were inconsistently reported—which is particularly relevant given evolving perioperative risk in the era of the Omicron variant and widespread immunization. Despite these limitations, consistent findings across large, prospective international cohorts and matched retrospective cancer surgery cohorts lend credibility to the safety of surgery ≥ 7 weeks post mild disease, particularly within vaccinated populations [32].
These findings support current perioperative guidelines recommending elective surgery be delayed for at least seven weeks following COVID-19 infection [33], with longer intervals considered for patients with ongoing symptoms, hospitalization, or complex medical conditions. Multidisciplinary, individualized risk assessment should consider patient age, comorbidities, disease severity, vaccination status, functional recovery, and procedure urgency. Future research should evaluate the impact of vaccination status and viral variant on postoperative outcomes, refine time intervals beyond seven weeks, particularly in patients with moderate disease or persistent symptoms, and investigate targeted perioperative strategies such as enhanced thromboprophylaxis or pulmonary prehabilitation to mitigate residual risk.

5. Conclusions

This systematic review demonstrates that a history of COVID-19 infection occurring more than seven weeks prior to elective surgery does not, in most cases, confer a significant increase in perioperative morbidity or mortality, particularly in patients who experienced asymptomatic or mild disease. Across the 13 included studies encompassing over 38,000 patients, the overall rates of cardiopulmonary, thrombotic, neurological, and renal complications—as well as postoperative mortality—were comparable to those observed in cohorts without prior SARS-CoV-2 infection. Importantly, certain subgroups, such as patients with a history of moderate-to-severe COVID-19, prior hospitalization for COVID-19, or persistent symptoms, exhibited a higher incidence of postoperative complications, underscoring the need for individualized risk stratification.
The evidence supports current international guidelines recommending a delay of at least seven weeks between SARS-CoV-2 infection and elective surgery while also emphasizing the relevance of factors such as vaccination status, baseline comorbidities, and surgical complexity. Although some studies indicate elevated risks in specific settings—such as major cardiac procedures or recent infection in hip fracture surgery—the majority of available data suggest that proceeding with elective operations beyond the seven-week threshold is generally safe. Future research should focus on refining optimal timing in patients with moderate disease or residual symptoms, clarifying the role of vaccination and viral variants, and developing tailored perioperative management strategies (e.g., enhanced thromboprophylaxis or pulmonary optimization) to further mitigate residual risks.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/covid5090148/s1, S.1. PRISMA 2020 Checklist; S.2. Justification of Exclusions at Full-Text Review; S.3. Risk of Bias Assessment for Included Studies Using the Downs and Black Checklist.

Author Contributions

Conceptualization, C.E.P. and N.I.; methodology, C.E.P.; software, C.E.P., A.D., M.S. and R.G.; validation, D.F., N.I. and M.S.; formal analysis, C.E.P. and A.D.; investigation, C.E.P., A.D., R.G. and M.S.; resources, C.E.P.; data curation, C.E.P.; writing—original draft preparation, C.E.P.; writing—review and editing, C.E.P., A.D., R.G., M.S., D.F. and N.I.; supervision, N.I. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The research data is found on Rayyan, but can be accessed only by investigators with account. The link is https://new.rayyan.ai/reviews/664961/overview (accessed on 15 July 2025).

Acknowledgments

The screening was performed with the help of Nina Iulia Rotaru (N.I.R.) and Alexandra Vlad (A.V.).

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
PRISMApreferred reporting items for systematic reviews and meta-analyses
ICUintensive care unit
MACEmajor acute cardiac events
AKIacute kidney injury
VTEvenous thromboembolism
CABGcoronary artery bypass grafting
ARDSacute respiratory distress syndrome
DVTdeep vein thrombosis

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Covid 05 00148 g001
Figure 1. Identification of studies via databases and registers.
Figure 1. Identification of studies via databases and registers.
Covid 05 00148 g001
Table 1. Characteristics of the included studies.
Table 1. Characteristics of the included studies.
StudyCountryYear of PublishingLanguage of the StudyStudy DesignSample Size (Number of Patients)Type of
Surgery		Time (Weeks) from COVID-19 Infection to SurgeryRisk of Bias
Assessment
(Percentage, %), Down and Black Checklist
Gabryel (2022) [11]Poland2022EnglishRetrospective, observational, single center cohort study72Thoracic surgery18.6559.37
Le, S.T. (2022) [12]United States2022EnglishRetrospective, observational, single center cohort study9170Non—cardiac surgery>860.93
Kothari (2021) [13]United States2022EnglishRetrospective, observational, single center cohort study, propensity—matched114Cancer surgery7.4260.93
COVIDSurg Collaborative (2021) [14]United Kingdom2021EnglishProspective observational, cohort study, international, multicentric1202Cancer surgery, obstetrics>762.5
Ranganathan (2023) [15]India2022EnglishAmbi-directional, observational (retrospective and prospective) study138Cancer surgery>764.06
Diken (2024) [16]Turkiye2024EnglishRetrospective, observational, multicentric cohort study28Cardiac surgery—Coronary artery bypass1251.56
SenthilKumar (2023) [17]United States2023EnglishRetrospective, observational, multicentric cohort study22,179Elective non cardiac surgery>860.93
Cheung (2021) [18]United States2021EnglishRetrospective, observational, single center cohort study6Bariatric surgery11.7148.43
Deng (2022) [4]United States2022EnglishRetrospective, observational, multicentric, cohort study1633Major non-cardiac surgery>862.57
Lazzareschi (2024) [19]United States2023EnglishRetrospective, observational, multicentric, cohort study2091Major non-cardiac surgery8.173.43
Shen (2024) [20]China2024EnglishProspective observational multicentric, cohort study1316Lung cancer surgery>882.81
Fang (2024) [21]China2024EnglishRetrospective, observational, multicentric, cohort study58Elective partial hepatectomy11.971.87
Bansal (2024) [22]India2024EnglishProspective monocentric observational study48Neurosurgery2857.81
Table 2. Pulmonary outcomes of the included patients.
Table 2. Pulmonary outcomes of the included patients.
StudyRAS (no pts)Pneumonia (no pts)BF (no pts)Reint. (no pts)PH (no pts)P.eff. (no pts)Ptx (no pts)Atelect. (no pts)RF (no pts)PE (no pts)Prol. AL (no pts)Empyema (no pts)
Gabryel (2022) [11]7111--------
Le, S.T. (2022) [12]-431----------
Kothari (2021) [13]-5--334------
COVIDSurg Collaborative (2021) [14]-42----------
Ranganathan (2023) [15]-1---31-----
Diken (2024) [16]-----4-5----
SenthilKumar (2023) [17]------------
Cheung (2021) [18]------------
Deng (2022) [4]-23------4516--
Lazzareschi (2024) [19]------------
Shen (2024) [20]-981- --7831--2461
Fang (2024) [21]-3-----4----
Bansal (2024) [22]------------
no pts = number of patients; RAS—residual air space; BF—bronchopleural fistula; Reint.—reintubation; PH—postoperative hypoxemia; P.eff.—pleural effusion; Ptx—pneumothorax; Atelect.—atelectasis; RF—respiratory failure; PE—pulmonary embolism; Prol. AL—prolonged air leak; VTE totals exclude PE when PE appears under pulmonary to prevent double counting. If a study reported only a composite VTE (DVT + PE), the composite is shown as published and marked accordingly.
Table 3. Cardiac outcomes of the included patients.
Table 3. Cardiac outcomes of the included patients.
StudyPMI/MACE (no pts)PCA (no pts)M.Is (no pts)Hy.Cr. (no pts)AFIB (no pts)AFL (no pts)VA (no pts)Carditis (no pts)Ac.IHD (no pts)MI (no pts)AHF (no pts)CA (no pts)CS (no pt)
Gabryel (2022) [11]-- ----------
Le, S.T. (2022) [12]-------------
Kothari (2021) [13]45-----------
COVIDSurg Collaborative (2021) [14]-------------
Ranganathan (2023) [15]--21---------
Diken (2024) [16]----2--------
SenthilKumar (2023) [17]----393226449428721723716395
Cheung (2021) [18]-------------
Deng (2022) [4] 37-----------
Lazzareschi (2024) [19]56------------
Shen (2024) [20]----2--------
Fang (2024) [21]-------------
Bansal (2024) [22]-------------
no pts = no of patients; PMI/MACE—postoperative myocardial injury/major cardiac events; PCA—postoperative cardiac arrythmia; M.Is—myocardial ischemia; Hy.Cr—hypertensive crisis; AFIB—postoperative atrial fibrillation; AFL—atrial flutter; Ac. IHD—acute ischemic heart disease; MI—myocardial infarction; AHF—acute heart failure; CA—cardiac arrest; CS—cardiogenic shock.
Table 4. Thrombotic, renal, and neurological outcomes of the included patients.
Table 4. Thrombotic, renal, and neurological outcomes of the included patients.
StudyDVT (no. pts)PE (no. pts)SVT (no. pts)AKI (no. of pts)Stroke (no. pts)TCI (no. pts)
Gabryel (2022) [11]-- ---
Le, S.T. (2022) [12]------
Kothari (2021) [13]1--- -
COVIDSurg Collaborative (2021) [14]------
Ranganathan (2023) [15]---1--
Diken (2024) [16]---1--
SenthilKumar (2023) [17]492517159-2099
Cheung (2021) [18]------
Deng (2022) [4]28--48--
Lazzareschi (2024) [19]44-----
Shen (2024) [20]------
Fang (2024) [21]------
Bansal (2024) [22]----8-
no pts = number of patients; DVT—deep venous thrombosis; PE—pulmonary embolism; SVT—superficial vein thrombosis; AKI—Acute Kidney Injury; TCI—transient cerebral ischemia; VTE totals exclude PE when PE appears under pulmonary to prevent double counting. If a study reported only a composite VTE (DVT+PE), the composite is shown as published and marked accordingly.
Table 5. Hospitalization days and mortality of the included patients.
Table 5. Hospitalization days and mortality of the included patients.
StudyHospitalization Days (No. of Days)ICU Days (No. of Days)Mortality (No.)
Gabryel (2022) [11]6 (IQR 4–7)-1
Le, S.T. (2022) [12]---
Kothari (2021) [13]4-1
COVIDSurg Collaborative (2021) [14]--18
Ranganathan (2023) [15]--1
Diken (2024) [16]5.71 ± 3.51.71 ± 1.742
SenthilKumar (2023) [17]--584
Cheung (2021) [18]--0
Deng (2022) [4]---
Lazzareschi (2024) [19]---
Shen (2024) [20]530
Fang (2024) [21]8.5--
Bansal (2024) [22]5--
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Predoi, C.E.; Dascalu, A.; Goicea, R.; Stefan, M.; Filipescu, D.; Iordache, N. Impact of COVID-19 History on Patients’ Outcome in the Perioperative Period—A Systematic Review. COVID 2025, 5, 148. https://doi.org/10.3390/covid5090148

AMA Style

Predoi CE, Dascalu A, Goicea R, Stefan M, Filipescu D, Iordache N. Impact of COVID-19 History on Patients’ Outcome in the Perioperative Period—A Systematic Review. COVID. 2025; 5(9):148. https://doi.org/10.3390/covid5090148

Chicago/Turabian Style

Predoi, Cornelia Elena, Alexandru Dascalu, Raluca Goicea, Mihai Stefan, Daniela Filipescu, and Niculae Iordache. 2025. "Impact of COVID-19 History on Patients’ Outcome in the Perioperative Period—A Systematic Review" COVID 5, no. 9: 148. https://doi.org/10.3390/covid5090148

APA Style

Predoi, C. E., Dascalu, A., Goicea, R., Stefan, M., Filipescu, D., & Iordache, N. (2025). Impact of COVID-19 History on Patients’ Outcome in the Perioperative Period—A Systematic Review. COVID, 5(9), 148. https://doi.org/10.3390/covid5090148

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