Surgical treatment of gastrointestinal tumors in a COVID-19 pandemic hospital: Can open versus minimally invasive surgery be safely performed?

PURPOSE: In order for patients with gastrointestinal cancer not to suffer the consequences of delayed treatment, they should be operated on in pandemic hospitals under adequate conditions. We aimed to discuss the outcomes of our gastrointestinal cancer surgery patients and to present our patient management recommendations to resume operative treatment during the ongoing COVID-19 pandemic while taking into account hospital facilities. MATERIALS AND METHODS: This study included 129 gastrointestinal cancer patients who underwent surgery between March 2020 and May 2021 in the gastrointestinal surgery clinic of our hospital, which was assigned as a pandemic hospital in March 2020. Patients' demographic characteristics and preoperative and postoperative findings were recorded. RESULTS: Among the patients, 42.6% (n = 55) were female and 57.3% (n = 74) were male. The mean age was 61.89 ± 3.4 years. The primary tumor organs were the stomach 37.2% (n = 48), pancreas 36.4% (n = 47), rectum 11.6% (n = 15), colon 8.5% (n = 11), and esophagus 6.2% (n = 8). The patients were treated with open (75.2%, n = 97) or minimally invasive surgery (24.8%, n = 32; laparoscopic 11.6%, n = 15; robotic 13.2%, n = 17). Eight patients tested positive for COVID-19 before surgery. No patients developed COVID-19 during postoperative intensive care or after being moved to the floor unit. There was no COVID-19-related morbidity or mortality. CONCLUSION: Failure to treat gastrointestinal cancer patients during the pandemic may result in undesirable consequences, such as stage shift and mortality. Cancer patients can be treated safely with conventional and minimally invasive surgery guided by current recommendations and experience.

Postoperative complications and mortality following emergency digestive surgery during the COVID-19 pandemic: A multicenter collaborative retrospective cohort study protocol (COVID-CIR).

ABSTRACT: Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).

Laparoscopic vs open surgery during the COVID-19 pandemic: what are the risks?

INTRODUCTION: The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic. METHODS: Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology. RESULTS: A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135-0.814). CONCLUSIONS: With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.

Management of digestive cancers during the COVID-19 second wave: A French intergroup point of view (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFR).

INTRODUCTION: The COVID-19 pandemic has major impact of healthcare systems, including cancer care pathways. The aim of this work is to discuss in a multidisciplinary approach the therapeutic and/or strategies adaptations for patients treated for a digestive cancer during the European second wave of COVID-19 pandemic. METHODS: A collaborative work was performed by several French societies to answer how to preserve digestive cancer care with no loss of chance during the second wave of COVID-19. In this context, all recommendations are graded as expert's agreement according to level evidence found in literature until October 2020 and the experience of the first wave of the COVID-19 pandemic. RESULTS: As far as possible, no therapeutic modification should be carried out. If necessary, therapeutic adjustments may be considered if they do not constitute a loss of chance for patients. Considering the level of evidence all therapeutic modifications need to be discussed in multidisciplinary tumor board meeting and with patient consent. By contrast to first wave cancer prevention, cancer screening, supportive care and clinical trials should be continued. CONCLUSION: Recommendations proposed could limit cancer excess mortality due to the COVID-19 pandemic but should be adapted according to the situation in each hospital.

The successful management of Thirty-six hepatopancreatobiliary surgeries under the intensive protective arrangements during the COVID-19 pandemic.

ackground: During the pandemic of COVID-19, the overwhelm of infected patients created an exponential surge for ICU and ward beds. As a result, a major proportion of elective surgeries was postponed. However, various emergency and urgent procedures were allowed. Due to the mortality complications of hepatopancreatobiliary issues, we decided to afford urgent procedures under intensive protective arrangements. Method and results: In our ward (liver transplant), 4 ICU beds and 16 ward beds were allocated to non-COVID-19 patients. A total of 36 hepatopancreatobiliary procedures were managed for one month. All the surgeries were afforded under personal protective equipment and other intensive protective arrangements for personnel and patients. During 6 weeks following the surgery, all patients were followed up through telemedicine and no new case of COVID-19 was detected. Conclusion: In general, it appears that intensive protections could significantly reduce the number of COVID-19 incidence among patients with co-morbidities who undergo invasive procedures.

Implementation of a clinical pathway for the surgical treatment of colorectal cancer during the COVID-19 pandemic.

AIM: This report summarizes the early experience of implementing elective colorectal cancer surgery during the COVID-19 pandemic. METHODS: A pathway to minimize the risk of including COVID-19-positive patients for elective surgery was established. Prioritization and additional safety measures were introduced into clinical practice. Minimal invasive surgery was used where appropriate. RESULTS: Thirty-eight patients were prioritized, and 23 patients underwent surgery (eight colon, 14 rectal and one anal cancer). The minimal invasive surgery rate was 78%. There were no major postoperative complications or patients diagnosed with COVID-19. Histopathological outcomes were similar to normal practice. CONCLUSION: A safe pathway to offer standard high-quality surgery to colorectal cancer patients during the COVID-19 pandemic is feasible.

Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: an European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey.

BACKGROUND: The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery. METHODS: An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery. RESULTS: Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries. CONCLUSION: This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a "new" normal world with screening of patients and staff for COVID-19.

COVID-19: impact on colorectal surgery.

AIM: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and emergency colorectal surgery, including surgery for colorectal cancer, several questions pertaining to operating room (OR) utilization and techniques needed to be rapidly addressed. METHOD: This manuscript discusses knowledge related to the critical considerations of patient and caregiver safety relating to personal protective equipment (PPE) and the operating room environment. RESULTS: During the COVID-19 pandemic, additional personal protective equipment (PPE) may be required contingent upon local availability of COVID-19 testing and the incidence of known COVID-19 infection in the respective community. In addition to standard COVID-19 PPE precautions, a negative-pressure environment, including an OR, has been recommended, especially for the performance of aerosol-generating procedures (AGPs). Hospital spaces ranging from patient wards to ORs to endoscopy rooms have been successfully converted from standard positive-pressure to negative-pressure spaces. Another important consideration is the method of surgical access; specifically, minimally invasive surgery with pneumoperitoneum is an AGP and thus must be carefully considered. Current debate centres around whether it should be avoided in patients known to be infected with SARS-CoV-2 or whether it can be performed under precautions with safety measures in place to minimize exposure to aerosolized virus particles. Several important lessons learned from pressurized intraperitoneal aerosolized chemotherapy procedures are demonstrated to help improve our understanding and management. CONCLUSION: This paper evaluates the issues surrounding these challenges including the OR environment and AGPs which are germane to surgical practices around the world. Although there is no single universally agreed upon set of answers, we have presented what we think is a balanced cogent description of logical safe approaches to colorectal surgery during the COVID-19 pandemic.

Coronavirus pandemic and colorectal surgery: practical advice based on the Italian experience.

AIM: The current COVID-19 pandemic is challenging healthcare systems at a global level. We provide a practical strategy to reorganize pathways of emergency and elective colorectal surgery during the COVID-19 pandemic. METHOD: The authors, all from areas affected by the COVID-19 emergency, brainstormed remotely to define the key-points to be discussed. Tasks were assigned, concerning specific aspects of colorectal surgery during the pandemic, including the administrative management of the crisis in Italy. The recommendations (based on experience and on the limited evidence available) were collated and summarized. RESULTS: Little is known about the transmission of COVID-19, but it has shown a rapid spread. It is prudent to stop non-cancer procedures and prioritize urgent cancer treatment. Endoscopy and proctological procedures should be performed highly selectively. When dealing with colorectal emergencies, a conservative approach is advised. Specific procedures should be followed when operating on COVID-19-patients, using dedicated personal protective equipment and adhering to specific rules. Some policies are described, including minimally-invasive surgery. These policies outline the strict regulation of entry/ exit into theatres and operating building as well as advice on performing procedures safely to reduce risk of spreading the virus. It is likely that a reorganization of health system is required, both at central and local levels. A description of the strategy adopted in Italy is provided. CONCLUSION: Evidence on the management of patients needing surgery for colorectal conditions during the COVID-19 pandemic is currently lacking. Lessons learnt from healthcare professionals that have managed high volumes of surgical patients during the pandemic could be useful to mitigate some risks and reduce exposure to other patients, public and healthcare staff.