COVID-19 pandemic and clinicopathologic characteristics of colorectal cancer in Korea: A multicenter, retrospective study

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected not only the control and management of infectious diseases, but also those of other diseases by deteriorating the general healthcare systems worldwide. In accordance with the suggestion by the WHO for postponement of non-urgent procedures, diagnosis and treatment strategies for the patients with malignancy have been changed. The aim of this study was to investigate the impact of COVID-19 pandemic on primary colorectal cancer (CRC) from multi-institutions in Korea. Methods: Medical records of consecutive patients with CRC between March 2019 and February 2021 in six university hospitals were reviewed. Recurrent diseases, admission for management of complications or enterostomy repair, and other pathologies than adenocarcinoma were excluded. Baseline characteristics and perioperative outcomes were compared after a cohort was divided into the two groups: before and after around March 2020, when the COVID-19 test has been mandatory for all admitted patients in most institutions. Treatment characteristics and pathologic outcomes were also compared between the two groups. Results: A total of 3895 patients with CRC admitted during the study period. After 454 patients were excluded, 1820 and 1621 patients were assigned to the pre-pandemic and pandemic groups. The proportion of patients who could not receive curative or palliative surgery for stage IV diseases was not different (88 vs. 91, P>0.999), and 3262 patients underwent surgery for primary CRC. Among them, the pandemic group showed more previous abdominal surgery (21.2% vs. 15.4%, P<0.001), higher preoperative CEA level (46.7 vs. 16.0 ng/mL, P=0.021), and less stent insertion for obstructive lesion (33% vs. 46.4%, P=0.043). There was no difference in sex, age, the ASA grade, and tumor location between the groups. Perioperative outcomes including operation time, operation method, operation type, and postoperative complication rates were not different, whereas more stoma formation was performed in the pandemic group (15.3% vs. 12.4%, P=0.024). Pathologic outcomes including TNM stage, tumor diameter, harvested lymph nodes, and lymphovascular invasion were not different. However, the pandemic group showed higher tendency of lymph node metastasis (44% vs. 40.6%, P=0.070) and more adjuvant chemotherapy (26.4% vs. 20.1%, P<0.001). Conclusions: Although a few factors indicated more advanced CRC, clinical features and perioperative outcomes of the patients in COVID-19 pandemic seemed not to be aggravated in Korea. The national healthcare system which was not shut down in the pandemic, and relatively small number of COVID-19 prevalence might influence these results, although patients' access and medical checkup seemed to decrease slightly. The cause and effect of decreased medical access would be clarified by long-term follow up data.

OPTN/SRTR 2020 Annual Data Report: Liver.

This year was marked by the COVID-19 pandemic, which altered transplant program activity and affected waitlist and transplant outcomes. Still, 8906 liver transplants were performed, an all-time high, across 142 centers in the United States, and pretransplant as well as graft and patient survival metrics, continued to improve. Living donation activity decreased after several years of growth. As of June 30, 2020, 98989 liver transplant recipients were alive with a functioning graft, and in the context of increasing liver transplant volume, the size of both the adult and pediatric liver transplant waitlists have decreased. On February 4, 2020, shortly before the pandemic began, a new liver distribution policy based on acuity circles was implemented, replacing donor service area- and region-based boundaries. A policy change to direct pediatric livers to pediatric recipients led to an increase in deceased donor transplant rates and a decrease in pretransplant mortality rate among children, although the absolute number of pediatric transplants did not increase in 2020. Among adults, alcohol-associated liver disease became the predominant indication for liver transplant in 2020. After implementation of the National Liver Review Board and lower waitlist priority for most exception cases in 2019, fewer liver transplants were being performed via exception points, and the transplant rate between those with and without hepatocellular carcinoma has equalized. Women continue to experience higher pretransplant mortality and lower rates of liver transplant than men.

Predictors of elevated liver tests during COVID-19 shelter in place in chronic liver disease patients

Background: Elevated liver tests (LTs) are associated with reduced liver related health. Our AIM was to determine the prevalence and predictors of LT elevations during COVID-19 shelter in place (SIP). Methods: Retrospective cohort study examining LTs in patients 18 years with/without chronic liver disease (CLD) including alcohol associated liver disease (ALD), NAFLD, HBV, and HCV obtained one month after SIP from 4/19/2020 until 12/31/2020. We extracted AST, ALT, TB, LDL, triglycerides (TG), platelets, and demographic data and compared these levels to results for the same patients from 4/19/2019 to 12/31/2019. AST/ALT ratios and FIB-4 indices were compared between 2019 and 2020. Predictors of higher LTs in 2020 compared to 2019 were analyzed by multiple linear regression models. Results: 75,121 subjects had LTs available in 2019 and 2020, 8024 with known CLD. Median ALT was higher in 2020 compared to 2019 in 46% patients with CLD, 47% patients without CLD with higher median ALT rise in CLD population (+8 IU/L;IQR 3-19) compared to no CLD (+4 IU/L;IQR 2-9) [p<0.001]. ALD had greatest ALT increase (+10 IU/L;IQR 4-25) followed by NAFLD (+9IU/L;IQR 3-22), compared to HBV (+5 IU/L;IQR 2-10) and HCV (+6 IU/L;IQR 2-14) [p<0.001]. AST elevations were noted in 54% of patients with CLD, 55% of patients with no CLD. ALD had the highest AST increase (+13 IU/L;IQR 4-46) compared to NAFLD (+7 IU/L;IQR 3-16), HCV (+5 IU/L;IQR 2-11) and HBV (+4 IU/L;IQR 2-8) [p<0.001]. Age, weight, Hispanic ethnicity predicted LT increase (Table). No differences in bilirubin levels were observed. More patients had AST/ALT ratio >2 in 2020 compared to 2019 in both patients with CLD (6.3% in 2020 vs 4.4% in 2019) and patients without CLD (5.5% in 2020 vs 3.6% in 2019) [P<0.001 for both comparisons]. Age predicted AST/ALT>2 in CLD patients in 2020 (OR 1.0007, 95% CI 1.0002-1.001, p=0.003) in multivariate analysis. No significant difference observed in FIB-4 in CLD patients in 2020 compared to 2019. Conclusion: During SIP, in patients with CLD, we observed greater increases in ALT compared to patients with no CLD. Patients with ALD and NAFLD had highest rates of LT increase compared to other etiologies. We observed an approximately 50% increase in the prevalence of AST/ALT>2 in CLD patients in 2020, which may suggest increased alcohol use, and/or progression of fibrosis. Further follow-up of this cohort will determine long-term effects of these observed changes.