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); P¼0.158) but the mortality rate was significantly
higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P