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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 174-179

Gastrointestinal cancer surgery during COVID times


Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission03-Jul-2020
Date of Acceptance23-Jul-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Deepak Govil
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_79_20

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  Abstract 


COVID pandemic has taken the whole world off guard, and it has lasting serious implications on every aspect of human life. Surgical services for our elective cases are suffering. There are a lot of issues related to gastrointestinal (GI) cancer patients in these COVID times. It is difficult to decide whether to operate on these patients taking the risk or delay the surgery with attendant risk of cancer progression or use some alternative protocols. Here, we aim to offer guidance for the prioritization of surgical services to further minimize the effect of the COVID-19 pandemic across various overburdened surgical units and to preserve the surgical workforce with special emphasis on GI malignancy patients.

Keywords: Coronavirus, COVID, gastrointestinal cancer, gastrointestinal oncology, operative strategy, surgery


How to cite this article:
Dhankhar DS, Gupta R, Kumar S, Govil D. Gastrointestinal cancer surgery during COVID times. Apollo Med 2020;17:174-9

How to cite this URL:
Dhankhar DS, Gupta R, Kumar S, Govil D. Gastrointestinal cancer surgery during COVID times. Apollo Med [serial online] 2020 [cited 2020 Sep 19];17:174-9. Available from: http://www.apollomedicine.org/text.asp?2020/17/3/174/292704


  Introduction Top


Amid this COVID-19 pandemic, it is difficult to tell where we are at present. As of writing this article dated June 28, 2020, there are approximately 10 million cases worldwide with 5 lac deaths and 5.5 lac cases in India itself with already 16,500 deaths. How much the future holds promise, we are yet to see. With the disruption of normal surgical practices due to workforce shortages as well as resource limitations due to COVID-19, it is important to rationalize all surgeries undertaken. This is especially important in cancer surgery where a surgeon must balance risk of potential viral transmission to the surgical team, as well as of possible progression of cancer in the patient.[1]

In cancer patients, general considerations must also be taken into account. It is routine that most complex elective surgical procedures receive ward-based care postoperatively. Occasionally, patients may develop postoperative complications requiring intensive care unit admission and/or re-operation, which may prove to be a challenge with the increasing numbers of COVID-19 patients requiring critical care. It is recommended that the length of stay be decreased to a minimum, especially in critical care.[2],[3] Furthermore, it is prudent to identify cancer patients who are at most risk during this outbreak and likely to become seriously or critically unwell if they were to contract the virus. These include patients on active chemo- or radiotherapy and/or immunotherapy. In addition to the above, factors such as age above 60 and/or preexisting cardiovascular and/or respiratory disease have been associated with a worse prognosis. Following a multidisciplinary team (MDT) discussion, clinicians are encouraged to clearly outline the risks and benefits with patients before commencing or continuing any cancer treatment.[4]

At our institution, we are committed to offer telephone or video consultations when possible and cancel follow-ups which are deemed nonessential in an attempt to minimize patient contact. In cases where patients must attend hospital appointments, we aim that the time patients spend in services to be minimized.[2]

In our practice, strategies to minimize the risk of acquiring COVID-19 infection among healthcare workers are being contemplated in the form of organizing the surgical team into two groups: one that is active within hospitals and one that works remotely in isolation, both groups alternating with each other at 2-week intervals. This will ensure that any symptoms are identified within the incubation period of COVID-19.


  Oncological Work Top


During the COVID-19 pandemic, elective operating services will be greatly restricted, with the exception of cancer cases requiring surgical management. Stratification of patients into groups is crucial to prioritize the workload and offer the best available treatment under the circumstances, while simultaneously preserving resources to enable the battle against the deadly virus. As suggested very rightly by the NHS, patients may be classified into priorities 1–3 based on the clinical need.[4] Priority 1 patients should be further divided into 1a and 1b – 1a being patients requiring an emergency operation within 24 h to preserve life and 1b being patients with acute conditions secondary to their underlying issue which may cause irreversible harm if not operated on urgently, i.e., within 72 h, such as gastrointestinal (GI) obstructions and bleeding.

Priority 2 patients should include patients aiming to be operated on within 4 weeks with the intention of cure and prevention of progression of the disease to an inoperable stage. These patients should be stratified based on clinical urgency, expected complications, and specific growth rate of the specific cancer. The NHS also recommends that complications be controlled utilizing interventional radiological or gastroenterological procedures (e.g., stents) in cases where operative intervention has been postponed.

Priority 3 patients are classified as those whose operations can be deferred for 10–12 weeks without negative consequences. Outpatient clinics and telemedicine should be preferred during the COVID-19 pandemic; face-to-face outpatient appointments should be avoided wherever possible. This is because it increases the risk of infection for the patient, as well as the medical professional conducting the clinic.

In face-to-face appointments, our institution is strictly following one-patient one-room policy to minimize risk of infection. However, telephone and video appointments are preferred wherever possible. Virtual clinics have run successfully for many years;[5],[6],[7] however, during the COVID-19 pandemic, regulations have been eased to allow greater usage.[8]


  Preoperative Risk Top


At our institution, we advise that any patients for prioritized planned surgery must have been asymptomatic for 7 days, must have been self-isolated for 14 days, and then have a negative swab within 48 h before planned admission as well as to be assessed for COVID-19. Any patients presenting to hospital requiring urgent or emergency surgery should be assessed for COVID-19 using history, RT-PCR COVID-19 testing, and chest X-ray.

Any patient receiving an emergency abdominal computed tomography (CT) scan for acute pain should also receive a high-resolution CT chest (unless a previous scan has been performed in the past 24 h) at the same time to exclude COVID-19.


  Intraoperative Risks Top


While operating on COVID positive cases, there is a risk of exposure to potential aerosolized virus particles through surgical smoke generated while using electrocautery. To minimize this risk, electrocautery, if required, should be kept on the lowest power setting (thereby decreasing smoke production) & used with a smoke evacuator.[9] Furthermore, surgical practitioners should pay extra attention to any needle-stick injuries or damage to personal protective equipment during the procedure. Single-use instruments should be used wherever possible. Surgical instruments should be decontaminated by the normal methods in practice.


  Disease-Specific Recommendations for Surgery for Malignancy of Gastrointestinal Tract, Especially Colorectal Cancer Top


Malignancies of the upper GI tract in themselves pose a major management dilemma for the surgeons, and during COVID times, it becomes all the more difficult for surgeons to have a clear go. The way forward is MDT meetings where treatment options for GI malignancies can be discussed keeping in mind the current pandemic. Medical and radiation oncologists should opine whether extended cycles of chemoradiotherapy can be added to the treatment plan so as to tide over the crisis of COVID and at the same time ensuring selection of tumors with good biology to go for definitive surgery.

For malignant tumors of the liver, gallbladder, pancreas, and bile ducts, brachytherapy along with chemotherapy should be utilized wherever possible and alternatives to surgery such as transarterial chemoembolization/transarterial radioembolization/percutaneous ethanol injection should be used in appropriate circumstances.

As a wasting disease, GI cancer and its corresponding treatment may weaken the immune response to respiratory bacteria and make patients more susceptible to the virus infection. A recent study showed that about 1% of severe acute respiratory syndrome coronavirus (SARS-CoV)-2-infected patients had a history of cancer, which seemed to be higher than the overall incidence (0.29%) of cancer in the Chinese population.[10],[11] Besides, SARS-CoV-2-infected patients accompanied with cancers may in turn make the COVID-19 worse. The case-fatality rate is reported higher in those with preexisting comorbid conditions. Patients with both COVID-19 infection and cancer have a 5.6% case-fatality rate, which is more than two times higher than the overall case-fatality rate (2.3%).[12],[13] Furthermore, SARS-CoV-2 is proved to be detected in the GI tract and urine; these potential routes of transmission cannot be ignored, especially in the diagnosis and treatment of digestive tract diseases.

Therefore, for confirmed/suspected patients with SARS-CoV-2 infection, endoscopic procedures should be performed in a special isolated room or negative pressure operation room (OR); the instruments and the endoscopic room should be sterilized strictly after the examination (by vaporized hydrogen peroxide sterilizer for at least 2 h).[14]


  Treatment Strategies for Colorectal Cancer during Covid-19 Epidemic Top


Management of nonemergency cases

Nonemergency cases with confirmed/suspected COVID-19

For colorectal cancer (CRC) patients with confirmed/suspected COVID-19 but without presenting as surgical emergency, the treatment should be more focused on SARS-CoV-2-infection-related diseases. A short delay in CRC therapy may have no remarkable influence on the prognosis of the patients with CRC; if necessary, CRC therapy could be suspended.[15]

Nonemergency cases without COVID-19

Treatment strategies for patients with early-stage colorectal cancer

Tumor at an early stage often confined to the mucosa or submucosa can very well be offered endoscopic mucosal resection or endoscopic submucosal dissection, with the expectations of near-equivalent outcomes with limitations in the form of inability to sample lymph nodes with satisfactory outcomes.[16] Transanal excision is another suitable technique for patients with early rectal tumors whose diameter is <3 cm and are within 8 cm from the anal margin.[17]

Radical surgery is the major treatment option for patients with CRC staged cT2N0M0. In the epidemic of COVID-19, however, surgery is recommended to be suspended, especially in areas with limited protection or severe epidemic situations. As mentioned previously, a brief delay in surgery may not exacerbate the disease.

Treatment strategies for patients with locally advanced colorectal cancer

During the epidemic period, as an effective “bridge” therapy, neoadjuvant chemoradiotherapy (NACT) with CapOX or FOLFOX regimen could be recommended for treating patients with cT3-4b stage of colon cancer. Besides, the Chinese Society of Clinical Oncology guideline recommends that mid-low rectal cancer with cT3-4N0 or cTanyN + can be treated with concurrent chemoradiotherapy before radical resection.[18] Similarly, in this special period, NACT is strongly recommended for locally advanced mid-low rectal cancer. In brief, radiotherapy (45–50.4 Gy/25–28 F) and NACT (capecitabine or mFOLFOX6) could be chosen for mid-low advanced rectal cancer patients with T4 stage. Moreover, for rectal cancer patients with T3 stage, short-term radiotherapy with lower radiation dose (25 Gy/5 F) may be an option.

The optimal timing for surgery and the “wait and watch” strategy for rectal cancer during COVID-19 epidemic

Although total mesorectal excision has been used for a long time as a cornerstone for rectal cancer treatment, the concept of “wait and watch (W&W)” has gained popularity in recent years, representing a divergence from the traditional treatment.[19] Previous study has proved that about 15%–30% of patients with rectal cancer treated with neoadjuvant treatment develop pathologic complete response (pCR). Clinical complete response (cCR) may also be common in those low rectal cancer patients who finish NACT. A recent research from the International Watch and Wait Database reported 1009 cases who underwent “W&W” strategy after neoadjuvant treatment between 2015 and 2017. The 5-year overall and disease-free survival were 85% and 94%, respectively, and cCR was found in 880 (80.7%) patients.[20] Another report showed that although 89 out of 385 patients developed a local regrowth after a median of 9 months, most of them (94%) could still undergo surgical treatment with relatively good prognosis (2-year overall and disease-free survival were 90.3%, and 98.4%, respectively).[21] The consensus of Chinese experts on the “W&W” policy (2020 version) also recommended that rectal cancer patients who achieve cCR or near-cCR after neoadjuvant treatment could enroll in the W&W strategy.[22],[23] Therefore, during the outbreak, W&W strategies may be more suitable for rectal cancer patients, especially the elderly.

The NCCN Clinical Practice Guidelines recommended that assessing for tumor response at week 5–12 from the end of neoadjuvant treatment.[23] In the present situation, it may be worthwhile waiting for 12 weeks after neoadjuvant treatment before further investigations are carried out for response assessment. In the epidemic of COVID-19, the timing for the operation could be appropriately delayed, which may be extended to 16–24 weeks after neoadjuvant treatment.[24] Additional 2–4 cycles of CapeOX may be scheduled for selected rectal cancer patients to increase the odds of pCR when waiting for the surgery.[25]

Treatment strategies for patients with metastatic colorectal cancer

The liver is the most common CRC metastatic site, accounting for about 15%–25% of CRC patients.[26] During the epidemic period, initially diagnosed metastatic colorectal cancer (mCRC) patients without presenting a surgical emergency could be recommended to receive neoadjuvant therapy (such as CapeOX regimen and targeted therapy).[27] After neoadjuvant therapy, MDT is responsible for deciding the timing of surgery for patients with mCRC and the surgery could be appropriately delayed. Since patients with mCRC always have larger tumor burden with relatively worse performance status, single stage surgery (i.e. simultaneous resection of primary and metastatic lesion) is not recommended by some researches during the epidemic period of COVID-19.[27] It is recommended that patients take oral chemotherapy instead of intravenous chemotherapy and patients choose the nearest hospital to receive necessary treatment. Moreover, the interval of NACT could be extended appropriately.

Management of patient presenting as emergency

Recent studies showed that approximately 1/4th–1/3rd of CRC cases underwent emergency surgery.[28],[29],[30] As previously mentioned, CRC patients presenting as an emergency tend to be older, have lower immunities, and have more advanced tumors, resulting in a prolonged recovery time and a relatively poor prognosis.[29]

Emergency cases without COVID-19

Most CRC with obstruction, perforation, or hemorrhage in late-stage patients has relatively low R0 resection rates in emergency surgery.[31] Before surgery, all patients will undergo respiratory specimen and blood sample detection to rule out SARS-CoV-2 infection. For patients with bowel obstruction in relatively good physical condition after the failure of the conservative therapy, the endoscopic colonic stenting procedure using self-expanding metallic stents may be considered first.[32] About 70%–80% of malignant bowel obstruction is located in the left-sided colon, which makes them more feasible for endoscopic intervention.[33] Continuing or starting NACT may further shrink the size of tumors even to achieve downstaging. In short, endoscopic colonic stenting acts as a bridge to curative surgery, represents an alternative to colostomy, and further reduces the risk of SARS-CoV-2 infection for patients with bowel obstruction, but we should pay attention to the incidence of colonic perforation during endoscopy for patients with ileus.[34] However, stenting is not recommended for patients with low rectal cancer because it may cause fecal incontinence, urgency, and tenesmus.[35]

Conservative and endoscopy treatment may be used as the first-line therapies for treating moderate and even massive bleeding when facing the epidemic of COVID-19 with surgical therapy as a last resort.

Emergent operation is still reserved for CRC patients with refractory bowel obstruction, massive hemorrhage, or perforation, despite other interventions of cessation. For these patients without SARS-CoV-2 infection, resolving the emergency event and simultaneously radical resection should be considered when possible.

Emergency cases with confirmed/suspected COVID-19

To date, agreed guidelines on how to deal with CRC patients with confirmed or suspected COVID-19 who present as emergency remain scarce and incomplete. For those patients with incomplete intestinal obstruction or mild-to-moderate bleeding, nonsurgical strategies including conservative treatment, endoscopic techniques, and endovascular embolization could be chosen first to lower stoma rate. Although the emergent operation may be an extremely risky practice in patients with concurrent severe SARS-CoV-2 infection, it may still be the only life-saving procedure for those who developed uncontrolled massive bleeding and acute diffuse peritonitis caused by intestinal perforation.

Emergency CRC surgical treatment is recommended to be performed in the designated hospital and operated in negative pressure (−5 Pa) OR. All treating team members should use enhanced grade-3 occupational protection (the highest level) including wearing medical caps, N95 or higher-level respirators, medical coverall, eye shield, surgical latex gloves, disposable operating coat, protective hood, waterproof shoe covers, and disposable shoe covers. Although transmission by air-borne droplets and contaminated hands are considered the major routes of SARS-CoV-2 spreading, the aerosol may be another contributing factor.[36] Surgeons should dissect meticulously to avoid splashing of body fluid during the operation. Energy-based surgical instruments (such as high-frequency electrotomes and ultrasonic shears) related smoke mixed with the blood and exudate of the patient could form into aerosol and diffuse into the surrounding air.[37] Although effective at removing exudate and blood, the surgical aspirator is not adequate for filtering surgical aerosol. As a possible solution, additional air purifiers may be placed in the OR. Likewise, the current consensus is that laparoscopic surgery without smoke evacuation filters is not recommended to SARS-CoV-2-infected patients because it is unclear whether laparoscopic surgery produces a higher density of aerosols which may increase the risk of infecting healthcare workers in case the air leaks from the pneumoperitoneum.[27]

Radical surgery should be chosen cautiously after a multidisciplinary assessment. Most specialists recommend not to perform complex anastomosis. Moreover, the indication for enterostomy should be broadened properly.[27] In emergency CRC patients with relatively severe organ damage, aggressive radical resection could further compromise the patient's immune system. If this is the case, ostomy may be a good option. Besides, recent researches demonstrating that both SARS-CoV and SARS-CoV-2 share the same host cell receptor (angiotensin-converting enzyme 2 [ACE2]), and the latter shows 10–20-fold higher affinity binding to ACE2 than the SARS-CoV.[38],[39] Although the amount of ACE2 protein in the colon tissue remains controversial,[38],[40] ACE2 expression and SARS-CoV replication are quite common in all parts of the small intestine, which could also be the potentially infected site of SARS-CoV-2.[41],[42],[43] Extrapulmonary manifestations such as watery diarrhea and vomiting in patients with SARS-CoV-2 infection have been reported.[44],[45],[46],[47]

Resection with fecal diversion may reduce the incidence of anastomotic complications related to GI symptoms induced by SARS-CoV-2 infection. It is worth noting that researchers from multiple organizations have successfully isolated novel coronavirus strains from stool specimens of infected patients.[48] Therefore, additional attention should be paid to the risk of fecal–oral transmission during postoperative stoma care.


  Intestinal Surgery in Covid-Positive Patients Who Have Recovered Top


An important point to be highlighted is that COVID patients, who have recovered & have tested negative after treatment, continue to excrete the virus in stools for prolonged periods, even if the nasopharyngeal swab shows a negative result. Therefore, while operating on these patients, the same precautions need to be taken by the operating team as they would have taken, had the patient been positive. This is especially true if opening bowel lumen and anastomosis or creation of stoma is anticipated.

Overall recommendations

  • Social distancing mandates that every in-person interaction between patients and the healthcare system be scrutinized and only essential physical contacts between patients and healthcare professionals occur to diminish the risk of viral exposure to patients
  • Whenever COVID-19 is clinically suspected or confirmed, systemic treatments should be suspended, and surgery should be postponed unless an urgent procedure is necessary
  • Whenever surgery is indicated, SARS-CoV-2 testing should be considered
  • There are insufficient data to recommend in favor or against open versus minimally invasive approach. Proven benefits of minimally invasive surgeries of reduced length of stay and complications should be considered individually.[10] Nevertheless, whenever minimally invasive surgeries are indicated, the use of devices to filter released CO2 for aerosolized particles or techniques to treat the intra-abdominal gas, whenever it should be emptied, is strongly advised[11]
  • For early-stage (cT1/2 cN0) colorectal, biliary, hepatocellular, esophagus, and gastric tumors, where neoadjuvant treatment is not standard, consider deferring surgical resection to up to 8 weeks. If delays beyond 8 weeks are expected, repeat staging examinations
  • Radiation schedules should be hypofractionated, whenever possible
  • Follow-up imaging and appointments should be reserved for those with symptoms, suggestive of disease relapse
  • Adjuvant treatment for colon[49] and other GI tumors, when recommended, should start in 4–8 weeks after primary tumor resection. Monitoring blood counts at every cycle can be done by telemedicine if patients are asymptomatic
  • Infusional 5FU should be substituted for capecitabine in the following regimens: FOLFOX, cisplatin, and 5FU; monotherapy; or when combined with radiotherapy.[50],[51],[52]
  • In the metastatic setting, consider dose-reduced chemotherapy instead of adding G-CSF
  • In the metastatic setting, omit bolus 5FU in FOLFOX or FOLFIRI regimens to minimize toxicity
  • Whenever possible, chemotherapy holidays may be considered in patients with low-volume metastatic disease, who are responding or experiencing tumor stabilization and when there is no major risk of complications for site-specific progression (e.g., peritoneum, biliary obstruction). If maintenance is considered to be beneficial instead of chemoholidays (e.g., more aggressive disease), prefer capecitabine alone, without bevacizumab
  • MDT discussions by web conferencing systems are highly encouraged. We think that MDT is the key to help with decisions about risks and benefits of cancer-directed therapies during the COVID-19 pandemic.


In all cases, clinical individual judgment is advised and decisions should be shared and discussed in detail with the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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