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Objectives: Our primary objective was to assess the association between symptoms at the time of surgery and postoperative pulmonary complications and mortality in patients with COVID-19. Our secondary objective was to compare postoperative outcomes between patients who had recovered from COVID-19 and asymptomatic patients and explore the effect of the time elapsed between infection and surgery in the former. Our hypotheses were that symptomatic patients had a higher risk of pulmonary complications, whereas patients who had recovered from the infection would exhibit outcomes similar to those of asymptomatic patients., Background: Managing COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce., Design: To address this gap, we conducted a multicentre observational cohort study., Setting: Across seven hospitals in the province of Québec, the Canadian province was most affected during the initial waves of the pandemic., Participants: We included adult surgical patients with either active COVID-19 at the time of surgery or those who had recovered from the disease, from March 22, 2020 to April 30, 2021., Outcomes: We evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. The primary outcome was a composite of any postoperative pulmonary complication (atelectasis, pneumonia, acute respiratory distress syndrome and pneumothorax). Our secondary outcome was hospital mortality, assessed from the date of surgery up to hospital discharge., Results: We included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) at the time of surgery and 206 who had recovered from COVID-19 prior to surgery in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (OR 3.19, 95% CI 1.12 to 9.68, p=0.03) and hospital mortality (HR 3.67, 95% CI 1.19 to 11.32, p=0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had recovered from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients., Interpretation: Symptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimise surgical care in this patient population., Study Registration: ClinicalTrials.gov Identifier: NCT04458337 registration date: 7 July 2020., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)