key: cord-0788268-9shc3a5q
authors: Muñoz-Largacha, Juan A.; Wei, Benjamin
title: Commentary: Lung surgery in the time of COVID-19.
date: 2020-05-04
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.04.088
sha: d6a678277ff453547f04bdeca178499b2a6757a2
doc_id: 788268
cord_uid: 9shc3a5q

nan

. In their report, Huang et al. present three patients undergoing video-assisted thoracoscopic surgery for the resection of lung nodules concerning for malignancy between January 14 th and 17 th , time during which COVID-19 cases steadily started to increase in China and around the globe (4, 5, 6) . Substantial amount of information related to this novel disease has been disseminated since the outbreak, however studies and guidelines specific to the risks and considerations of thoracic surgery to patients in this environment (as opposed to health care personnel and hospital systems) are lacking (7) . Here, the authors report highly concerning results regarding COVID-19 infection in three patients undergoing thoracoscopic lobectomy at their institution, located in Wuhan, China. All three patients were asymptomatic before the operation but developed typical signs and symptoms of COVID-19 infection such as fever, cough and dyspnea between post-operative day 1 and 6. Computed tomography scan showed bilateral, peripheral ground-glass opacities and lung consolidation, consistent with COVID-19 imaging findings reported in the literature (8) . RT-PCR testing was performed and was positive between post-operative day 5 and 9. One of the three patients recovered and was discharged home on post-operative day 46 (pathology showed atypical adenomatous hyperplasia). Unfortunately, the other two patients died on post-operative day 8 and 17 respectively (pathology confirmed T1bN0M0 adenocarcinoma). It is unknown whether these patients acquired the infection prior to or after hospital admission, as they were not tested for COVID-19 until developing signs and symptoms of pneumonia. There is a possibility, as described by the authors, that these patients contracted the infection before surgery and were in the incubation period at the time of operation. This illustrates the challenges in making a diagnosis given the absence of typical COVID-19 symptoms, non-existing policies for pre-operative testing, and limited test kits at that time. Universal pre-operative COVID-19 testing for patients undergoing surgery, a policy that is in place at many institutions, may not only to mitigate the risk of exposure to healthcare personnel, but also identify patients who could potentially develop pneumonia postoperatively.

In the lobectomy setting, developing a COVID-19 infection resulted in the deaths of two out of three previously fairly healthy patients, an alarming statistic even given a small "n" of 3.

Besides increasing awareness about the importance of pre-operative testing, this study by Huang et al also raises issues regarding the management of patients with known or suspected malignancy during the COVID-19 pandemic. Certain patients may benefit from delay of lung surgery, especially in hospital systems and geographical regions severely afflicted by COVID-19. Patients with pure ground-glass opacities or with known typical carcinoid tumors in peripheral locations can likely be safely delayed for at least a few months. Borderline candidates for lobectomy may be better served with sublobar resection or stereotactic radiosurgery instead.

Early postoperative discharge to a home quarantine setting (even when chest tubes remain in place) may be a more favorable option than an extended inpatient hospital stay. COVID-19

should be on the differential for surgical patients who develop pneumonia, even if they have previously tested negative for the virus, and especially if they demonstrate a decreasing lymphocyte count. On the other hand, surgeons can take some solace in the fact that among 126 patients in this study who underwent lobectomy between January 1 st and March 31 st in Wuhan, only 3 patients were discovered to contract COVID-19. It is also possible that there were a number of asymptomatic COVID-19 infections in this group, which would result in a lower calculated mortality rate. Hopefully, larger studies of the impact of COVID-19 on the risk of surgery will follow; in the meantime, the decision to embark on lung surgery in the time of COVID-19 will rely on physician judgment using the limited available data, assessment of the local situation with regards to COVID-19, and patient preference.

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Clinical Characteristics of Coronavirus Disease 2019 in China

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

A novel coronavirus from patients with pneumonia in China

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges

Clinical course of patients infected with SARS-CoV-2 soon after thoracoscopic lung surgery

COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period

CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)