key: cord-307945-wkz43axo
authors: Baud, Grégory; Brunaud, Laurent; Lifante, Jean Christophe; Tresallet, Christophe; Sebag, Frédéric; Bizard, Jean Pierre; Mathonnet, Muriel; Menegaux, Fabrice; Caiazzo, Robert; Mirallié, Éric; Pattou, François
title: Endocrine surgery during and after the Covid-19 epidemic: Expert guidelines in France
date: 2020-04-30
journal: J Visc Surg
DOI: 10.1016/j.jviscsurg.2020.04.018
sha: 
doc_id: 307945
cord_uid: wkz43axo

Abstract The Covid-19 pandemic commands a major reorganization of the entire French healthcare system. In France, general rules have been issued nationally and implemented by each healthcare center, both public and private, throughout France. Guidelines drafted by an expert group led by the French-speaking Association of Endocrine Surgery (AFCE) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the Covid-19 epidemic.

The ongoing Covid-19 pandemic commands a major reorganization of the entire French healthcare system (1) . To respond to the present and expected influx of patients needing a period of intensive care (2) , the short-term priority has been directing available material and human resources toward sectors dispensing care for Covid-19 patients (3, 4) . This policy has entailed the almost complete de-scheduling of non-urgent surgery (5) . More than a month now after the start of the epidemic, there is a pressing need to manage other health disorders not linked to Covid-19 but for which deferral of surgery until after the epidemic is over could worsen prognosis or be life-threatening. It is also important to be thinking now about the conditions under which surgery can be resumed at a normal pace after the epidemic. General rules have been put out nationally and implemented by each healthcare center, both public and private, throughout France. Specific guidelines have been proposed for visceral surgery (6) . Likewise, to meet their need for specific guidelines, the Frenchspeaking Association of Endocrine Surgery (AFCE) brought together a group of experts to propose principles for the surgical management of thyroid, parathyroid, endocrine pancreas and adrenal pathologies during the Covid-19 epidemic and afterwards, when surgical activity will be able to return gradually to its normal pattern. These guidelines were drafted in the light of the existing literature. They will be updated as knowledge advances.

Four scheduling levels were defined to help prioritize patients (these levels may change according to how the epidemic setting evolves):

Urgent surgery that must be carried out as soon as possible because even a short deferral would be life-threatening.

(ii) Semi-urgent surgery that can be deferred for a few weeks but not beyond 3 months without threat to life or adverse effects on cancer or functional prognosis.

(iii) High-priority elective surgery that can wait for several months but must be given scheduling priority as soon as the epidemic is over.

(iv) Distant elective surgery that can be deferred until well after the epidemic is over, even more than 6 months, without compromising the indication.

For urgent surgery, the ratio of the benefit expected from surgery to the risks incurred by scheduling it during the epidemic must always be evaluated according to how both the national and local contexts are evolving, in particular the resources available: operating room, consumables and hospital capacities, particular if intensive care may be needed.

When surgery is prescribed in the epidemic setting, short hospital stays or outpatient care are recommended (7) , provided this does not increase the risk of rehospitalization. To limit operating time and the risk of post-operative complications, the surgery should also be performed by one or more experienced surgeons. Even if no symptoms of Covid-19 are apparent, the risk of infection should be assessed beforehand as it may be associated with unfavorable prognosis (8, 9) . Any surgery on a patient infected or suspected of being infected must be performed according to the rules laid down by the hospital's hygiene teams and infectiologists (10).

a. Thyroid cancers (Fig. 2) control those of thyroxine (T4) at the time of surgery. Non-suspect goiters responsible for severe compressive symptoms (inspiratory dyspnea due to tracheal compression, dysphagia due to esophageal compression, superior vena cava syndrome due to deep vein compression) must also be scheduled for semi-urgent surgery before the epidemic ends.

c. Hyperparathyroidism (Fig. 4) Surgical treatment of primary hyperparathyroidism (HPT) is generally not urgent (16) . In the Covid-19 epidemic setting, its scheduling depends on the presence or absence of severe hypercalcemia, defined by a very high level of blood calcium > 3.5 mmol/l (140 mg/l) (17) , and/or the presence of clinical complications -acute pancreatitis secondary to HPT, brown tumor, calciphylaxis, fracture osteopenia, heart rhythm disorders (QT shortening on ECG, bradycardia with risk of asystole) with cardiac insufficiency (17) (18) (19) (20) . In all cases, hypocalcemia treatment must first be given. In the epidemic setting, the use of cinacalcet is recommended (21) . In cases of severe hypercalcemia, surgery must be scheduled as semiurgent, without waiting for the epidemic to end, or as urgent when it escapes control by the medical treatment. If there is no severe hypercalcemia, surgery can be deferred without risk until the epidemic is over. These guidelines are valid for cases of genetically determined primary HPT. For tertiary HPT, the blood calcium threshold defining severe hypercalcemia must be lowered to 2.8 mmol/l to protect renal grafts (nephrocalcinosis, acute tubular necrosis, lithiasis) and bone and vascular impact (22, 23) . For secondary HPT, surgical treatment is not recommended during the epidemic because of the higher risk of Covid-19

infection in dialyzed patients (24) . When indicated, surgery must be scheduled as a priority in the three months following the epidemic in cases of disabling bone pain, brown tumor or temporary contraindication for renal transplant (25).

6

Uni-or bilateral cervicotomy is the approach recommended for the surgical treatment of thyroid or parathyroid pathologies in the epidemic setting, so as to limit operating time and complication risk (26) . Surgery requiring a thoracic or mediastinal approach and/or postoperative intensive care (27) 

In the epidemic setting, the indication for the surgical treatment of a neuroendocrine tumor of the pancreas must be discussed in an MDT meeting to assess the balance between the risks of surgery and its oncological and/or secretory benefits (34) . The management of (36) . A pancreatectomy may be indicated when a curative resection can be considered after clinical and morphological reassessment (37) , in which case surgery is scheduled as semi-urgent before the epidemic has ended. Patients with a well-differentiated neuroendocrine tumor of the pancreas (Grades G1, G2 or G3) that is nonsecretory can be deferred until well after the epidemic is over. If there is an associated secretory syndrome, a medical treatment should first be given (38) . If this treatment fails to control the secretory syndrome satisfactorily, pancreatectomy must be scheduled as semi-urgent before the end of the epidemic. If the medical treatment is effective, surgery can be deferred until well after the epidemic has ended. When technically possible, laparoscopy is recommended for left pancreatectomies and enucleations to minimize postoperative impact on respiratory function and hospital length of stay (6).

In the epidemic setting, the indication for the surgical treatment of an adrenal lesion must be discussed at an MDT meeting to assess the balance of risk and its oncological and/or secretory benefits.

Lesions suspected to be malignant (cortico-adrenaloma, metastases) must undergo surgery when they are considered resectable (39, 40) . In cases of secretory syndrome, prior management by a medical treatment is recommended (metyrapone, ketoconazole). Surgery must be scheduled as semi-urgent, before the end of the epidemic, in an expert center (41).

Chromaffin lesions (pheochromocytoma and/or paraganglioma) must first receive an appropriate antihypertension treatment (alpha-blocking agents, beta-blocking agents, calcium inhibitors), and be monitored by an experienced care team (42) . If this treatment controls the secretory syndrome, close monitoring can be continued until the For other secretory adrenal lesions (in particular, hypercorticism and hyperaldosteronism), an appropriate medical treatment (steroidogenesis inhibitors, antialdosterone) must first be implemented. If the secretory syndrome is not controlled or if impact is marked, adrenalectomy can be scheduled as semi-urgent during the epidemic. In other cases, adrenalectomy can be scheduled well after the epidemic has ended. During the epidemic, laparoscopy remains the preferred approach for adrenalectomy. Conversely, for suspect lesions and/or those larger than 10 cm, laparotomy is recommended (43).

Post-operative follow-up consultations must be maintained during the epidemic.

Teleconsultation is recommended to ensure continuity of care while limiting the risks of coronavirus propagation in healthcare centers. For a consultation in which a diagnosis of cancer or a therapeutic strategy is to be announced, some form of video exchange is recommended. Whenever possible, blood tests and imaging must be performed outside hospitals.

In a situation where medical drugs of major therapeutic importance may be in short supply, Patients who are dependent on a hormone substitution treatment should be reminded never to interrupt their treatment longer than 24 h for corticoids (44) , longer than 48 h for calcium (45) , and longer than one week for thyroid hormones (46) . * Steroidogenesis inhibitors (metyrapone, ketoconazole), anti-hypertensive agents (alphablocking drugs, beta-blocking drugs, calcium inhibitors), antialdosterone diuretics, (TTT med = medical treatment, pheochr = pheochromocytoma)

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