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Youssef, M., T. E. Baradie, and F. F. A. saleep, " Superficial Bladder Cancer, the Problem of T1 G3 Tumours – an Egyptian Experience", European Journal of Cancer, vol. 47, issue S1, pp. S513, 2011.
Youssef, M., "“Superficial Bladder Cancer”, is a New Terminology Needed? the Problem of T1 G3 Tumours - an Egyptian Experience", European Journal of Surgical Oncology, vol. 38, issue 9, pp. 878, 2012.
Youssef, M., D. Cameron, M. Cooper, D. Ferguson, and M. Davies, "Micrometastasis in axillary lymph nodes: A five years review", European Journal of Surgical Oncology, vol. 39, issue 5, pp. 500-501, 2013.
Townsend, G., N. Siddiqi, M. Youssef, and T. Graja, "Are we doing too many re-excisions? Review of practice in breast conserving surgery", European Journal of Surgical Oncology, vol. 40, issue 11, pp. S76, 2014.
Youssef, M., D. Cameron, and D. Ferguson, "Re: Acute painful breast in a non-lactating woman", The BMJ, issue 353, pp. i2646, 2016.
Leishman, F., M. Wiltsher, M. Youssef, S. Olsen, D. Ferguson, and R. Tillett, "Reducing implant loss rates in breast reconstruction at the Royal Devon and Exeter Hospital: A complete audit cycle", European Journal of Surgical Oncology, vol. 42, issue 5, pp. S52, 2016.
, "Variation in the management of ductal carcinoma in situ in the UK: Results of the Mammary Fold National Practice Survey.", European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, vol. 42, issue 8, pp. 1153-61, 2016 Aug. Abstract

INTRODUCTION: Ductal carcinoma in situ (DCIS) accounts for approximately 10% of all newly-diagnosed breast cancers in the UK. The latest national guidelines were published in 2009 and may not reflect current best practice. We aimed to explore variation in the current management of DCIS to support the need for updated guidelines.

METHODS: A national practice questionnaire was developed by the Mammary Fold Academic Committee (MFAC) focussing on the pre, intra and post-operative management of DCIS. Trainees at UK breast units were invited to complete the questionnaire at their multidisciplinary team meeting to provide a comprehensive picture of current national practice.

RESULTS: 76 of 144 UK breast units (52.8%) participated in the survey. Variation was observed in radiological pre-operative assessment with only 33/76 units (43.4%) performing routine ultrasound assessment of the tumour or axilla. There was no clear consensus regarding indications for mastectomy; multifocality (38.2%) and extensive microcalcifications (34.2%) were the most frequent indications. 34/76 units (44.7%) offered nipple sparing mastectomy. 33/76 units (43.3%) perform sentinel node biopsy in the presence of a palpable/mass lesion and 51/76 (67.1%) at the time of mastectomy. The most widely accepted pathological radial margin remained 2 mm (36.8%). The commonest factors in decision-making for radiotherapy were tumour grade (51.3%) and size (35.5%). Only 12 units (15.8%) routinely used the Van Nuys Prognostic Index. Approximately half of all breast units offer clinical long-term follow-up.

DISCUSSION: There is marked variation in the management of DCIS in the UK. Updated evidence-based guidelines may standardise practice and improve outcomes for patients.

Youssef, M. M. G., P. H. Pucher, K. Kennedy, C. Osborne, and T. Graja, "Use of Acellular Dermal Matrix versus Latissimus Dorsi Flap for Breast Reconstruction: Clinical and Patient-Reported Outcomes.", The breast journal, 2016 Aug 10.
Youssef, M. M. G., D. Cameron, P. H. Pucher, S. Olsen, and D. Ferguson, "The significance of sentinel lymph node micrometastasis in breast cancer: Comparing outcomes with and without axillary clearance.", Breast (Edinburgh, Scotland), vol. 30, pp. 101-104, 2016 Dec. Abstract

BACKGROUND: Management of micrometastasis in the sentinel node is a controversial topic. Most of the guidelines don't recommend further axillary treatment if micrometastasis are the only finding in the sentinel node. However, some evidence suggests that micrometastasis have significant effect on long term outcomes and therefore indicate systemic treatment.

METHOD: Retrospective cohort study reviewing the management of patients with micrometastasis in the sentinel nodes. Two groups were compared, those who had further axillary clearance and those who had not. The primary endpoints were loco-regional recurrence and lymphedema rate. The secondary endpoints were distant metastasis rate, OS and DFS.

RESULTS: 95 patients were found to have micrometastasis or ITC in the axillary SNB over a period of 10 years. Of those, 38 patients had axillary clearance after SNB, while 57 did not. Lymphedema rate was 18.4% in the axillary clearance group versus 0% in the no axillary clearance group (p < 0.001). The LRR event was rare therefore not compared. Distant metastasis rate was 7.01% in the SNB group versus 2.6% in the axillary clearance group. There were no mortalities in the axillary clearance group. This compares to 7.01% among the patients who didn't have axillary clearance. All the patients who died had developed distant metastasis as a cause of death. There was a difference in OS between the two groups in favor of the axillary clearance group (p = 0.004).

DISCUSSION: Although not an indication for axillary clearance recent guidelines, micrometastasis and ITC found in the SNB are a sign of a biologically different disease. This important information should be taken in consideration when planning the adjuvant treatment in those patients among other factors considered.

Youssef, M. M. G., J. Rees-Lee, M. Burden, S. Olsen, D. Ferguson, and R. Tillett, "Re: Infection prevention in implant surgery - A review of the surgical evidence, guidelines and a checklist.", European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 2016 Jul 27.
Youssef, M. M. G., D. Cameron, S. Olsen, and D. Ferguson, "Does axillary lymph node dissection impact survival in patients with breast cancer and isolated tumour cells or micrometastasis in sentinel node?", European journal of cancer (Oxford, England : 1990), vol. 75, pp. 167-168, 2017 Feb 21.
Mylvaganam, S., E. Conroy, P. R. Williamson, N. L. P. Barnes, R. I. Cutress, M. D. Gardiner, A. Jain, J. M. Skillman, S. Thrush, L. J. Whisker, et al., "Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire.", Breast (Edinburgh, Scotland), vol. 35, pp. 182-190, 2017 Oct. Abstract

INTRODUCTION: The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

METHODS: A questionnaire investigating local practice and service provision of IBBR developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Summary data for each survey item were calculated and variation between centres and overall provision of care examined.

RESULTS: 81 units within 79 NHS-hospitals completed the questionnaire. Units offered a range of reconstructive techniques, with IBBR accounting for 70% (IQR:50-80%) of participating units' immediate procedures. Units on average were staffed by 2.5 breast surgeons (IQR:2.0-3.0) and 2.0 plastic surgeons (IQR:1.0-3.0) performing 35 IBBR cases per year (IQR:20-50). Variation was demonstrated in the provision of novel different techniques for IBBR especially the use of biological (n = 62) and synthetic (n = 25) meshes and in patient selection for these procedures.

CONCLUSIONS: The iBRA-NPQ has demonstrated marked variation in the provision and practice of IBBR in the UK. The prospective audit phase of the iBRA study will determine the safety and effectiveness of different approaches to IBBR and allow evidence-based best practice to be explored.

Manie, T., A. Farahat, T. Hashem, M. Youssef, A. Abdelwahab, I. Elattar, and T. Elbaradie, "Preoperative estimation of cosmetic outcomes after immediate breast reconstruction with extended latissimus dorsi flap: A simple prediction model", JPRAS Open, vol. 15, pp. 10-17, 2018.
Mylvaganam, S., E. J. Conroy, P. R. Williamson, N. L. P. Barnes, R. I. Cutress, M. D. Gardiner, A. Jain, J. M. Skillman, S. Thrush, L. J. Whisker, et al., "Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey.", European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, vol. 44, issue 5, pp. 708-716, 2018 05. Abstract

INTRODUCTION: The 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study.

METHODS: A questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines.

RESULTS: 81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable.

CONCLUSIONS: The iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.

Youssef, M. M. G., A. Namour, O. M. A. R. Z. Youssef, and A. Morsi, "Oncologic and Cosmetic Outcomes of Oncoplastic Breast Surgery in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy, Experience from a Developing Country.", Indian journal of surgical oncology, vol. 9, issue 3, pp. 300-306, 2018 Sep. Abstract

Oncoplastic surgery (OPS) has emerged as a new approach for extending breast conserving surgery (BCS) possibilities, reducing both mastectomy and re-excision rates, while avoiding breast deformities. OPS is based upon the integration of plastic surgery techniques for immediate reshaping after wide excision for breast cancer. This is a prospective feasibility cohort study of oncoplastic breast surgery after neoadjuvant chemotherapy that was carried at the National Cancer Institute, Cairo University and included 70 patients. The primary outcome was the local recurrence rate. Secondary outcomes included survival and margins obtained as well as cosmetic outcomes. Survival analysis was performed. Oncoplastic breast surgery did not compromise oncologic safety in the patients included in the study. It even allowed wider margins of resection which could be associated with better oncologic outcomes. At the same time, it gave a better cosmetic outcome and therefore higher patient satisfaction. Oncoplastic breast surgery includes a wide spectrum of surgical techniques, ranging from the basic level I techniques in breast conserving surgery to the more complex procedures of level II which are broadly classified into volume replacement (therapeutic mammoplasty) and volume displacement procedures. We suggest that oncoplastic breast surgery techniques should be the standard of care in breast surgery. They are the basis for breast conserving surgery techniques in early breast cancer. In our experience, oncoplastic surgery is feasible in locally advanced tumours after downstaging with neoadjuvant chemotherapy without compromising the oncologic safety.

Manie, T. M., M. M. G. Youssef, S. N. Taha, A. Rabea, and A. M. Farahat, "Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia.", Annals of the Royal College of Surgeons of England, pp. 1-5, 2019. Abstract

BACKGROUND: Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients.

MATERIALS AND METHODS: Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire.

RESULTS: All patients had a body mass index above 30 kg/m with a mean of 36.7 kg/m (range 31.6-44.9 kg/m). The mean distance from midclavicular point to nipple was 42 cm (range 38-50 cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2 kg (ranging from 1.035-1.63 kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40).

CONCLUSION: Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.

Rabie, M. A., A. Rankin, A. Burger, and M. M. G. Youssef, "The effect of Oncotype DX on adjuvant chemotherapy treatment decisions in early breast cancer.", Annals of the Royal College of Surgeons of England, pp. 1-6, 2019. Abstract

INTRODUCTION: The aim of this study was to objectively establish the value of the Oncotype DX (ODX) gene assay in adjuvant treatment decisions for intermediate risk patients with early, oestrogen receptor positive, human epidermal growth factor receptor 2 negative, lymph node negative breast cancer at a district general hospital.

METHODS: All patients who underwent surgery for breast cancer between January 2015 and December 2017 at Queen Elizabeth Hospital in King's Lynn were considered for inclusion in the study. Those who did not meet the criteria for ODX referral were excluded. Patients were divided into two cohorts based on whether they were treated before or after the introduction of ODX testing in this hospital (June 2016): the pre-ODX and post-ODX groups. The primary outcome was the percentage of patients for whom adjuvant chemotherapy (AC) was recommended in each group.

RESULTS: Of the 462 patients who underwent surgery during the study period, 43 met the eligibility criteria for ODX testing: 18 in the pre-ODX group and 25 in the post-ODX group. AC was recommended and given to 11 (61%) of the patients in the pre-ODX group. In the post-ODX group, AC was recommended for seven patients with an ODX Recurrence Score (RS) of >25; this was given to six patients (24%). One patient (with a RS of 26) declined AC. ODX testing led to a significant reduction in the proportion of patients who received AC (=0.015).

CONCLUSIONS: In intermediate risk patients with breast cancer, the results of the ODX gene assay may change the decision for adjuvant treatment. It represents a valuable tool to assist patients' and clinicians' decision making regarding adjuvant chemotherapy.

O'Connell, R. L., T. Rattay, R. V. Dave, A. Trickey, J. Skillman, N. L. P. Barnes, M. Gardiner, A. Harnett, S. Potter, and C. Holcombe, "The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study.", British journal of cancer, vol. 120, issue 9, pp. 883-895, 2019. Abstract

BACKGROUND: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy.

METHODS: Consecutive women undergoing mastectomy ± IBR for breast cancer July-December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored.

RESULTS: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays.

CONCLUSIONS: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients.

Ibraheem, M., M. M. G. Youssef, Y. Abdalla, R. Boutrus, A. Farouk, and A. Morsi, "The Use of Latissimus Dorsi Mini-Flap in Partial Breast Reconstruction", Journal of Cancer Science and Clinical Therapeutics, vol. 3, issue 4, pp. 240-250, 2019.
Potter, S., E. J. Conroy, R. I. Cutress, P. R. Williamson, L. Whisker, S. Thrush, J. Skillman, N. L. P. Barnes, S. Mylvaganam, E. Teasdale, et al., "Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study.", The Lancet. Oncology, 2019 Jan 09. Abstract

BACKGROUND: Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques.

METHODS: In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281.

FINDINGS: Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (<5% for re-operation, re-admission, and implant loss, and <10% for infection).

INTERPRETATION: Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction.

FUNDING: National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Rezk, M., A. Chandra, D. Addis, H. Møller, M. Youssef, P. Dasgupta, and H. Yamamoto, "() expression as a predictor of oncological outcomes in patients with high-grade prostate cancer treated with primary androgen deprivation therapy: a cohort study.", BMJ open, vol. 9, issue 3, pp. e025161, 2019 Mar 08. Abstract

OBJECTIVES: To determine whether () expression can be used as a biomarker to predict biochemical recurrence and prostate cancer-specific death in patients with high Gleason grade prostate cancer treated with androgen deprivation therapy (ADT) as monotherapy.

METHODS: A multicentre retrospective cohort study identifying 149 patients treated with primary ADT for metastatic or non-metastatic prostate cancer with Gleason score 8-10 between 1999 and 2006. Patients planned for adjuvant radiotherapy at diagnosis were excluded. Age at diagnosis, ethnicity, prostate-specific antigen and Charlson-comorbidity score were recorded. Prostatic tissue acquired at biopsy or transurethral resection surgery was assessed for immunohistochemical expression of . Failure of ADT defined as prostate specific antigen nadir +2. Vital status and death certification data determined using the UK National Cancer Registry. Primary outcome measures were overall survival (OS) and prostate cancer specific survival (CSS). Secondary outcome was biochemical recurrence-free survival (BRFS).

RESULTS: The median OS of our cohort was 60.2 months (CI 52.0 to 68.3). expression observed in 51/149 cases (34%). Multivariate Cox proportional hazards analysis showed no significant association between expression and OS (p=0.41), CSS (p=0.92) and BRFS (p=0.31). Cox regression analysis showed Gleason score (p=0.003) and metastatic status (p<1×10) to be the only significant predictors of prostate CSS.

CONCLUSIONS: No significant association was found between status and any of our outcome measures. Despite a limited sample size, our results suggest that does not appear to be a useful biomarker in predicting response to ADT in patients with high risk prostate cancer.

de Joode, K., D. W. Dumoulin, J. Tol, H. M. Westgeest, L. V. Beerepoot, F. W. P. J. van den Berkmortel, P. G. N. J. Mutsaers, N. G. J. van Diemen, O. J. Visser, E. Oomen-de Hoop, et al., "Dutch Oncology COVID-19 consortium: Outcome of COVID-19 in patients with cancer in a nationwide cohort study.", European journal of cancer (Oxford, England : 1990), vol. 141, pp. 171-184, 2020. Abstract

AIM OF THE STUDY: Patients with cancer might have an increased risk for severe outcome of coronavirus disease 2019 (COVID-19). To identify risk factors associated with a worse outcome of COVID-19, a nationwide registry was developed for patients with cancer and COVID-19.

METHODS: This observational cohort study has been designed as a quality of care registry and is executed by the Dutch Oncology COVID-19 Consortium (DOCC), a nationwide collaboration of oncology physicians in the Netherlands. A questionnaire has been developed to collect pseudonymised patient data on patients' characteristics, cancer diagnosis and treatment. All patients with COVID-19 and a cancer diagnosis or treatment in the past 5 years are eligible.

RESULTS: Between March 27th and May 4th, 442 patients were registered. For this first analysis, 351 patients were included of whom 114 patients died. In multivariable analyses, age ≥65 years (p < 0.001), male gender (p = 0.035), prior or other malignancy (p = 0.045) and active diagnosis of haematological malignancy (p = 0.046) or lung cancer (p = 0.003) were independent risk factors for a fatal outcome of COVID-19. In a subgroup analysis of patients with active malignancy, the risk for a fatal outcome was mainly determined by tumour type (haematological malignancy or lung cancer) and age (≥65 years).

CONCLUSION: The findings in this registry indicate that patients with a haematological malignancy or lung cancer have an increased risk of a worse outcome of COVID-19. During the ongoing COVID-19 pandemic, these vulnerable patients should avoid exposure to severe acute respiratory syndrome coronavirus 2, whereas treatment adjustments and prioritising vaccination, when available, should also be considered.

, "Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.", Lancet (London, England), vol. 396, issue 10243, pp. 27-38, 2020. Abstract

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<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), 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.