key: cord-0807903-ulh4nq77 authors: Oba, Atsushi; Stoop, Thomas F.; Löhr, Matthias; Hackert, Thilo; Zyromski, Nicholas; Nealon, William H.; Unno, Michiaki; Schulick, Richard D.; Al-Musawi, Mohammed H.; Wu, Wenming; Zhao, Yupei; Satoi, Sohei; Wolfgang, Christopher L.; Abu Hilal, Mohammad; Besselink, Marc G.; Del Chiaro, Marco title: Global Survey on Pancreatic Surgery During the COVID-19 Pandemic date: 2020-05-01 journal: Ann Surg DOI: 10.1097/sla.0000000000004006 sha: bad9b6fe1cf3695cdaa8d5c2bd2cd419bb2984ec doc_id: 807903 cord_uid: ulh4nq77 The aim of this study was to clarify the role of pancreatic surgery during the COVID-19 pandemic to optimize patients’ and clinicians’ safety and safeguard health care capacity. SUMMARY BACKGROUND DATA: The COVID-19 pandemic heavily impacts health care systems worldwide. Cancer patients appear to have an increased risk for adverse events when infected by COVID-19, but the inability to receive oncological care seems may be an even larger threat, particularly in case of pancreatic cancer. METHODS: An online survey was submitted to all members of seven international pancreatic associations and study groups, investigating the impact of the COVID-19 pandemic on pancreatic surgery using 21 statements (April, 2020). Consensus was defined as >80% agreement among respondents and moderate agreement as 60% to 80% agreement. RESULTS: A total of 337 respondents from 267 centers and 37 countries spanning 5 continents completed the survey. Most respondents were surgeons (n = 302, 89.6%) and working in an academic center (n = 286, 84.9%). The majority of centers (n = 166, 62.2%) performed less pancreatic surgery because of the COVID-19 pandemic, reducing the weekly pancreatic resection rate from 3 [interquartile range (IQR) 2–5] to 1 (IQR 0–2) (P < 0.001). Most centers screened for COVID-19 before pancreatic surgery (n = 233, 87.3%). Consensus was reached on 13 statements and 5 statements achieved moderate agreement. CONCLUSIONS: This global survey elucidates the role of pancreatic surgery during the COVID-19 pandemic, regarding patient selection for the surgical and oncological treatment of pancreatic diseases to support clinical decision-making and creating a starting point for further discussion. The World Health Organization (WHO) declared a pandemic of coronavirus disease (COVID-19) (SARS-CoV-2) on March 11, 2020. 1 The rapid spread of COVID-19 infections heavily impacts health care systems worldwide, resulting in limitations in both hospital and intensive care unit (ICU) capacity. 2 As a result, this pandemic not only affects patients, but strikes the entire health care system including the care for patients with pancreatic cancer and other pancreatic diseases. 3 Recent large series suggest an increased risk for cancer patients to develop severe complications when infected by COVID-19, including those who were treated with surgery or chemotherapy in the last month. 4 Pursuing oncological care exposes both health care professionals and vulnerable patients to become infected by COVID-19. However, the inability to receive medical and/or surgical care seems to be an equal threat for cancer patients as well. 5 The highly aggressive biology of pancreatic cancer requires the continuation of oncological care during the COVID-19 pandemic, 6, 7 but an unambiguous strategy is needed to support health care professionals in clinical decision-making. Therefore, this international survey study aimed to clarify the role of pancreatic surgery http://links.lww.com/SLA/C199 for the survey. The survey was conducted in the first two weeks of April 2020. Non-respondents were reminded twice, because of the rapid developments in the current COVID-19 crisis and need for novel policy development a relatively short time window was used. Respondents were asked to register their name and institution to prevent overlap of members between the abovementioned associations. The response rate could not be calculated since associations submitted the survey themselves. All study procedures were reviewed and approved by the Colorado Multiple Institutional Review Board (COMIRB) (protocol #20-0843) at the University of Colorado. Pancreatic ductal adenocarcinoma, bile duct cancer, duodenal and ampullary adenocarcinomas, intraductal papillary mucinous neoplasms (IPMNs) and pancreatic neuroendocrine tumors (pNETs) were defined in accordance to the WHO definitions. 8,9 A hospital was defined as a high-volume pancreatic center when performing ≥20 Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. pancreatoduodenectomies annually. 10 Consensus was defined as >80% agreement among respondents and moderate agreement was defined as 60-80% agreement among them. Variables were processed and analyzed using IBM SPSS Statistics for Microsoft Windows version 26 (IBM Corp., Orchard Road Armonk, New York, US). Data were reported as number with percentage or as median with interquartile range (IQR). The weekly volume of pancreatic resections before and during the COVID-19 pandemic were compared, using the Wilcoxon signed-rank test for non-normally distributed variables. Sensitivity analyses were performed to investigate the influence of specialty, the type of center, and continent. Statistical significance was considered as two-tailed P-value < 0.050. A total of 337 respondents from 267 centers and 37 countries spanning five continents completed the online survey. See Figure 1 for the number of responses per country. Most respondents were working in an academic center (n = 286, 84.9%) and the majority of participants were surgeons (n = 302, 89.6%). See Table 1 for the characteristics of the respondents. The median annual hospital and individual surgeon volume of pancreatic resections were 75 (IQR 46-140) and 35 (IQR 20-60), respectively. During the peak of the COVID-19 pandemic, 67.8% (n = 181) of centers prioritized between different types of pancreatic resections. Prior to pancreatic surgery, most centers screened patients for COVID-19 (n = 233, 87.3%), whereas some centers did not (n = 31, 11.6%). See Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. Table 2 for the preoperative COVID-19 screening strategy. The majority of centers (n = 166, 62.2%) performed less pancreatic surgery as consequence of the COVID-19 pandemic. From these centers, the weekly numbers of pancreatic resections decreased from 3 (IQR 2-5) to 1 (IQR 0-2) (P < 0.001). In addition, 30.7% (n = 51) of responding centers performed no pancreatic surgery at all. Consensus was reached on 13 from the 21 statements (62%) and moderate agreement was achieved on five (24%) statements. The remaining three statements had an agreement <60%. See Table 3 -5 for the statement outcomes. The statement outcomes barely changed after excluding the non-academic centers, without This global survey study aimed to clarify the role of pancreatic surgery during the COVID-19 pandemic through 21 statements. The statements regarding patient selection for the oncological and surgical treatment of pancreatic diseases could assist clinicians in their clinical decision-making and create a starting point for further discussion. A literature review was performed (see Table - pandemic on local resources. 13 A reliable and objective model is needed to stratify patients and guide prioritization in accordance to hospital capabilities, such as the recently developed Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. respiratory failure risk score (RFRS) for elective abdominal and vascular surgery, that identified pancreatic surgery among others as an independent risk factor for postoperative respiratory failure. 14 Prior to pancreatic surgery, most centers represented in this survey screened their patients for symptoms of COVID-19. No consensus was reached to recommend COVID-19 preoperative testing/screening (statement 19). This seems a plea to obligate some type of screening, but not necessarily with PCR and/or CT chest, particularly considering SAGES. SAGES underlines the recommendation of the Corona Virus Global Surgical Collaborative (CVGSC) to perform some type of screening test for all patients (even if asymptomatic and without risk factors) who will undergo a surgical or interventional endoscopic procedure in institutions seeing high volumes of COVID-19 patients. 12 In addition, ACS advised to wait for the results of COVID-19 testing in patients who may be infected. 13 Based on consensus, patients who will undergo pancreatic surgery should be informed about the following additional risks: COVID-19 infection during hospitalization, possible nonoptimal postoperative management (i.e. shortage of ICU beds), increased risk of COVID-19 related mortality due to surgery or the cancer condition (statement 17). Furthermore, this survey convincingly recommends that operating room (OR) personnel have to wear adequate protective features during surgery, considering their increased risk for COVID-19 infection during surgical procedures (statement 20). 15, 16 Pancreatic cancer Italy has demonstrated the feasibility of continuing crucial cancer care during the COVID-19 pandemic, among others by appropriate resource allocation and separate health care pathways between COVID-19 patients and non-infected cancer patients, structured by performance criteria (e.g. hospital volume). 3, 18 Periampullary malignancies (without pancreatic cancer) Statement 8 proposed to manage distal bile duct cancer as equivalent to pancreatic cancer. However, the lack of consensus (71%) implies that surgery might have slightly less priority in comparison to pancreatic cancer since 23% of respondents disagreed on the other hand. The SSO stated that extrahepatic bile duct cancer and ampullary and duodenal adenocarcinomas should be operated as soon as feasible, regardless of the presence of symptoms. 11 However, a high disagreement rate (40%) was reached on statement 15 for postponing surgery or giving neoadjuvant chemotherapy for duodenal and ampullary cancers in absence of life threatening risks (i.e. bleeding, bowel obstruction). Since evidence is limited about the efficacy of neoadjuvant chemotherapy for these cancers so far and could not be deemed to stable diseases, 11 many physicians might thought these should be resected as indicated. Consensus was reached to postpone surgery for benign and premalignant pancreatic diseases, including IPMNs, pNETs, chronic pancreatitis, and infected pancreatic necrosis. Exceptions comprise life threatening complications of chronic pancreatitis or infected pancreatic necrosis, symptomatic pNETs without effective alternative treatment options, or pNETs or IPMNs with suspicion for malignancy (statements 9-14). Volume-outcome relationships in pancreatic surgery are well established with shorter hospital stay and lower mortality in high-volume centers. 10, 19, 20 Pancreatic surgery in high-risk patients should not be performed in low-volume centers during the COVID-19 pandemic, aiming to reduce the risk of long hospital stay and major complications requiring ICU care (statement 16). Remarkably, the sensitivity analysis revealed that only Europe reached consensus in contrast to Asia and the Americas. ealth rganization . oronavirus disease -: situation report, 51. 2020. 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