key: cord-0894566-w574amkw
authors: Nunoo-Mensah, Joseph W.; Rizk, Mariam; Caushaj, Philip F.; Giordano, Pasquale; Fortunato, Richard; Dulskas, Audrius; Bugra, Dursun; da Costa Pereira, Joaquim M.; Escalante, Ricardo; Koda, Keiji; Samalavicius, Narimantas E.; Kotaro, Maeda; Chun, Ho-Kyung
title: COVID-19 AND THE GLOBAL IMPACT ON COLORECTAL PRACTICE AND SURGERY
date: 2020-06-07
journal: Clin Colorectal Cancer
DOI: 10.1016/j.clcc.2020.05.011
sha: ead4eb0d9efefd60ae894fc2f3e685f1d47128bb
doc_id: 894566
cord_uid: w574amkw

BACKGROUND: The novel SARS-Cov-2 virus that emerged in December 2019 causing the COVID-19 disease has led to sudden national reorganization and delivery of health care systems globally. The purpose of this survey was to assess the global impact of the coronavirus on the delivery of colorectal practice and surgery. Materials & Method: A panel of International Society of University Colon & Rectal Surgeons selected 22 questions that were included into a questionnaire. The questionnaire was distributed electronically to ISUCRS fellows, other surgeons on our database and on social media. The questionnaire remained open from April 16-28, 2020. RESULTS: 287 surgeons completed the survey. 90% were colorectal specialists or general surgeons with an interest in colorectal diseases. COVID-19 had impacted the practice of 96% surgeons and 52% were now using telemedicine. 66% stated that elective colorectal cancer surgery (ECCS) could proceed but with perioperative precautions. 19.5% of respondents stated that provision of personal protection equipment was the most important perioperative precaution, however, this was only being provided in 9.1% of hospitals. 64% of surgeons were offering minimally invasive surgery, however, 44% stated that there was not enough information about the safety of loss of intrabdominal CO2 gas during the COVID-19 pandemic. 61% of surgeons were prepared to defer ECCS, with 29% willing to defer for up to 8 weeks. CONCLUSIONS: Our survey has demonstrated that globally COVID-19 has affected the ability of colorectal surgeons to offer care to practice. Various practical adaptation strategies have been discussed in this manuscript.

The novel SARS-Cov-2 virus that emerged in December 2019 causing the COVID-19 disease has led to sudden national reorganization and delivery of health care systems globally. The purpose of this survey was to assess the global impact of the coronavirus on the delivery of colorectal practice and surgery. 

287 surgeons completed the survey. 90% were colorectal specialists or general surgeons with an interest in colorectal diseases. COVID-19 had impacted the practice of 96% surgeons and 52% were now using telemedicine. 66% stated that elective colorectal cancer surgery (ECCS) could proceed but with perioperative precautions. 19 .5% of respondents stated that provision of personal protection equipment was the most important perioperative precaution, however, this was only being provided in 9.1% of hospitals. 64% of surgeons were offering minimally invasive surgery, however, 44% stated that there was not enough information about the safety of loss of intrabdominal CO2 gas during the COVID-19

pandemic. 61% of surgeons were prepared to defer ECCS, with 29% willing to defer for up to 8 weeks.

The novel coronavirus that emerged in Wuhan in December 2019 has leaped across borders, sending ripples around an interdependent and highly mobile global population. Currently, with no specific therapeutic interventions or vaccines, the SARS-CoV-2 virus continues to cause a human and economic tragedy affecting millions of people. COVID-19 has wreaked havoc on cancer care, as most healthcare systems have had to reorganize their infrastructure and manpower to deal with this crisis. The COVIDSurg Collaborative study reported that over a 12-week period of peak COVID-19 disruption, 28.4 million elective surgeries worldwide will be cancelled or postponed in 2020. The non-emergent procedure cancellation rate would be 72.3% with 37.7% of cancer surgery operations affected. 1 With the pace of this viral spread and the lack of available clinical knowledge regarding the manifestations and natural history of those afflicted, many of our traditional ways of practicing surgery have come into question or been suspended. Critical questions for colorectal surgeons are how should we best offer care to patients whether in the inpatient or outpatient setting? How do we reassure our patients that coming to the hospital is safe, and how do we keep our staff and the patient safe? Is it safe to perform benign and malignant surgical procedures? With some patients requiring emergency colorectal surgery do we offer the same surgical or radiological intervention that we did pre-COVID- 19 [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] 2020 and was anonymous unless the respondent wanted to include their email to allow the investigators to be able to communicate with them and/or send results of the survey directly to them.

287 surgeons completed the survey of which 90% were colorectal specialists or general surgeons with an interest in colorectal diseases, 6% general surgeons and 4% general or colorectal surgical trainees. The largest group of responders were from the European Union (49%) of which 63 (22%) were from the UK - Figure 2 . 95% of the respondents reported a national lockdown of the population with a restriction on social movement and social distancing in their countries. 82% stated that they have been guided by visiting national organizations or their surgical societies websites or had received some guidance information from their surgical college or societies about how to manage their colorectal patients.

96% stated that the pandemic had negatively impacted on their ability to practice colorectal surgery. 10% were offering all patients actual face-to-face physical consultations and 7% had stopped offering any type of outpatient's consultation. 31% were only offering outpatient physical consultations for essential time-critical patients e.g. cancers. 52% of surgeons were now using telemedicine in their practice of which 16% were offering a telephone/virtual consultation for all patients and 36% were offering a telephone/virtual consultation for most patients and a physical consultation only if required for essential timecritical patients e.g. cancers - Figure 3 .

There appears to be a reduction in the availability of colorectal diagnostic services with limitations in CT colonoscopy, colonoscopy, and staging CT and MRI scan now not being provided by 82%, 64%, 13% responders practices.

12% of surgeons did not feel that all major elective colorectal cancer surgical procedures should continue. Moreover, 66% thought that colorectal cancer procedures could proceed however with the caveat of perioperative and intraoperative precautions.

22% of responders felt that currently, all major elective colorectal cancer surgical procedures should continue as normal. 60% of surgeons did not believe that all major, elective, benign colorectal surgical procedures should continue however 32% thought these types of procedures could proceed but with PIP, A minority of 8% respondents felt that benign elective surgery should proceed as normal.

Important perioperative and intraoperative precautions which responders thought were prudent to consider, and what was currently being provided at their local hospitals for elective surgical patients with colorectal cancer, are also shown in Figure 4 . The most important precaution which the respondents recommended was the provision of PPE for all operating staff (19.5% adjusted for all responses -actually 81% respondents), however, this was only being achieved in 9.1% of hospitals. 23.3% of responders' hospitals were able to provide elective surgical care in relatively 'free' COVID-19 hospitals i.e. hospitals not accepting COVID-19 patients and following strategies to ensure a SARS-CoV-2 virus free hospital environment. 18.5% and 9.9% of respondents thought the oronasopharyngeal SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) swab test was important for testing patients and hospital staff respectively, but this was currently only being achieved in 15.8% and 4.1% of hospitals, respectively.

For those surgeons who were still performing procedures, the factors used to prioritize their major elective cancer patients are shown in Figure 5 . 20.7% of respondents stated that obstructive bowel symptoms were the most important factor for prioritizing their patients followed by radiological evidence of obstruction in 15.9% and endoscopic evidence of imminent obstruction in 13.9%. 26% of surgeons had stopped operating on elective colorectal patients until safe or allowed to do so. Of the 74% who were still operating, 51% were still performing elective colorectal cancer surgery in their current hospital which was also admitting COVID-19 affected patients. 35% were preforming this surgery in relatively 'free' COVID-19 hospitals and the rest 14% were providing surgeries in both hospitals. Of those who were still operating on colorectal cancer patients, 61% of responders stated that they were providing surgery in hospitals that were able to provide dedicated operating rooms for COVID-19 positive/suspected patients and dedicated operating room for COVID-19 negative patients. 26% stated their hospitals could not provide this separation and 14% were not sure what their hospitals were able to provide. surgeons stated that there was not enough information about the effects/safety of the loss of intrabdominal insufflation CO2 gas into the operating room during MIS and that this approach should be stopped until further convincing and safe information is available. 28%

were convinced there was enough information to continue supporting MIS surgery and 28%

were not sure if it was safe to perform surgery during this climate of the COVID-19

pandemic. 72% of surgeons were still operating with their usual setup of assistance i.e. surgical residents, however, the others had been advised/ordered to operate with another specialist/consultant. 26% of operating surgeons had now modified their surgical approaches by creating stomas/proximal diversionary stomas in cases which they would not typically have done so.

39% of surgeons were not deferring surgery for asymptomatic, elective colorectal cancer patients. The large majority of 61% were prepared to defer surgery for different time periods with the largest group of 29% willing to defer up to 8 weeks - Figure 6 . 37% of surgeons stated that their colorectal multidisciplinary teams (MDT) had also not made any changes to neoadjuvant and adjuvant treatment during the pandemic, however in the others, the largest change to MDT was in 19% who had implemented short-course radiotherapy instead of long course chemoradiotherapy. Other oncological and practice MDT changes considered by the other surgeons are shown in Figure 7 .

To our knowledge, this is the first global survey of colon and rectal surgeons and specialists to assess the impact of COVID-19 on their practice. A response of 287 surgeons, with a wide global distribution of responders was a good representative sample to provide an impression of the current impact of this disease on our specialty of colon and rectal surgery and our patients. In line with national surgical and colorectal societies guidance and recommendation, most colorectal surgeons had modified their usual practices thereby reducing nonessential work that could be safely deferred.

36% were still providing outpatient services in the traditional face-to-face manner and one of the limitations of our survey is that we did not assess the rationale for this practice.

Reasons for this rationale include a lack of other methods to conduct outpatients e.g. lack of internet capacity, hospitals reorganizing their infrastructure to allow a safe flow of patients within the hospital setting to maintain social distancing institutionally, pressures by patients and hospital managers to still conduct normal services and financial pressures. In an age of advanced global telecommunications and video conferencing platforms, there is no doubt that most outpatient's colorectal consultations can be performed through easily accessible and inexpensive platforms in a manner which is surprisingly more efficient than our traditional ways. However, some patients secondary to socioeconomic status may not have access and some patients may have generational proclivity against internet-based communication. There are now platforms specific for medical practice with virtual waiting rooms etc. offering a robust and reliable way for doctors, clinicians & general practitioners to connect to patients via secure video link. However, some patients require education and help to access these platforms.

Despite a great deal of guidance from various colorectal organizations and societies, our survey shows that there is still a vast variation of opinions of surgeons in the preoperative, operative and oncological care of patients.

Preoperative identification of patients with COVID-19 disease or carriers of the SARS-CoV-2 virus is compounded by several factors. There is lack of uniformity regarding testing.

The positive rate of RT-PCR for a single oronasopharyngeal SARS-CoV-2 swab test is reported to be a range from 38-71% in COVID-19 positive disease and variable factors account for these inconsistencies. [2] [3] [4] [5] In a study of 73 hospitalized patients infected with SARS-CoV-2, 53% tested positive for SARS-CoV-2 RNA in stool. 23% of patients continued to have positive findings in their stool after showing negative results in respiratory samples. 6(p2) The prolonged fecal shedding of viral RNA was also demonstrated with SARS-CoV RNA which could be detected in the stool of patients for more than 10 weeks after symptom onset and giving the biological similarities to SARS-CoV-2, this is concerning because of the risk of transmission. 7 Although a combination of chest CT scans, serial oronasopharyngeal SARS-CoV-2 RT-PCR swabs or other biological samples can significantly improve the sensitivity for diagnosis of COVID-19 to 88-98% in symptomatic hospitalized patients, this may not be practical for the preoperative screening of elective colorectal patients. 3, 5 For urgent patients, the results may not be available, and some institutions treat these patients as though they are COVID-19 positive. For asymptomatic patients, the chest CT positive rate COVID-19 patients remain unknown and probably the current best preoperative assessment is the oronasopharyngeal SARS-CoV-2 RT-PCR swabs. For elective patients with historically proven COVID-19 disease and now cured, if the stage of their colorectal cancer permits a deferral of their definitive procedure, then it will probably be best to defer surgery to about 10 COVID-19 AND COLORECTAL SURGERY contamination and post-operative complications. 7 If it is necessary to operate within that time frame, then it is sensible to consider these patients as still being SARS-CoV-2 positiveirrespective of their screening test. For patients with no history of proven COVID-19 disease or symptoms consistent with this disease, it will be essential to exclude any history of contact with COVID-19 positive infected individuals as the disease has an asymptomatic incubation period estimated to be between 2 and 10 days with a mean incubation period of 5.2 days. [8] [9] [10] As the symptomatic window for COVID-19 is approximately 15 days, if preoperative self-isolation for a minimum number of 14 days is included in the preoperative planning, this will reduce the risk of admitting infected patients who are asymptomatic for surgery. 4 Ideally, arrangements should be in place for appropriate pre-assessment of patients at no less than 2-3 days prior to surgery to check for symptoms of SARS-CoV-2/COVID-19 infection and adherence to self-isolation requirements. Prior testing with oronasopharyngeal SARS-CoV-2 RT-PCR swabs just before surgery will be reassuring and prudent and is required by anesthesia in many institutions. The timing of this test will depend on the turnover time for laboratories, and ideally, a patient should be tested 1-2 days before surgery and patients are to maintain self-isolation thereafter. Postoperative patients will probably be best advised to continue self-isolate for 14 to 28 days after discharge.

To reduce the likelihood of COVID-19 infection following major colorectal cancer Apart from aerosolizing procedures, which are classed as high-risk situations, the use of simple surgical masks should therefore be encouraged in the hospital when a social distancing of 2 meters or more cannot be maintained. 11 Apart from aerosolizing procedures, which are classed as high-risk situations, the use of simple surgical masks should therefore be encouraged in the hospital when a social distancing of 2 meters or more cannot be maintained.

Although random oronasopharyngeal SARS-CoV-2 RT-PCR swab testing of hospital staff may be ineffective, staff education and vigilance to advise members of staff to follow general governmental advice as in the UK and USA, for individuals with symptoms suggestive of coronavirus should be strongly encouraged. Swab RT-PCR testing of healthcare workers who are now ready for work may be the best use of this test to confirm and prevent asymptomatic healthcare workers returning to the workplace. The caveat is the 38-71% accuracy of these single swab test however many institutions are now screening their at risk health care providers. [2] [3] [4] [5] There is mounting and convincing evidence that apart from the major route of transmission of COVID-19 being droplet transmission and contact of contaminated fomites, aerosols may be another route of transmission. 12-15 SARS-CoV-2 virion with a size of 0.07 to 0.09 μm has the potential to be transmitted as an aerosol and may behave like its other close relatives SARS and MERS. 16 In a recent publication by van Doremalen et al SARS-CoV-2 virion was reported to be a viable virus that could be detected in aerosols up to 3 hours. 17 Electrosurgery produces surgical smoke which contains water vapor (95%), inorganic and organic pollutants and biological pollutants such as cancerous cells, bacteria and viruses 18 .

The safety and management of surgical smoke in the age of COVID-19 and laparoscopy is a possible additional source of aerosol airborne pollution generated by pneumoperitoneum however there has never been any documented cases of high-risk coronaviruses i.e. MERS-CoV, SARS-CoV, SARS-CoV-2 being transmitted to operating room staff during abdominal surgery. 19 The risk to operating staff for SARS-CoV-2 is likely to be related to aerosolgenerating ventilatory procedures (tracheal intubation, non-invasive ventilation, mask ventilation, head and neck surgery etc.) rather than the abdominal surgical procedure which probably have a negligible risk for operating staff although. This negligible risk may be due to the fact that during such epidemics/pandemics, heightened perioperative procedures may have prevented this occupational hazard from occurring. 20 For patients already on diagnostic pathways awaiting tests and those with worrying symptoms, this status quo may be concerning to patients and surgeons. For those already on diagnostic pathways and awaiting such diagnostic test, their priority will need to be readdressed with consideration to either postponing or offering other non-invasive diagnostic tests to exclude colorectal cancer. Non-invasive stool and blood tests to excluded colorectal cancer or inflammatory bowel disease may assist in re-prioritization for a confirmatory diagnostic invasive test. Patients with concerning symptoms for colorectal cancer may be offered a fecal immunochemical test (FIT) or multitarget stool DNA test (FIT-DNA) if they do not have rectal bleeding. Both these tests have proven excellent accuracy for excluding colon cancer. [29] [30] [31] Unpublished data from the NICE FIT 2020 Study of 9822 patients which examined specifically the role of FIT in 2WW patients with both high and low risk symptoms, found that FIT at a threshold of 10 μg Hb/g the negative predictive value (NPV) is 99.6%. A negative FIT test will give reassurance that the chances of not having a cancer is 99.6%. Therefore, for patients who are worried about their symptoms in the era of the pandemic, when services are already stretched and not in a position to provide timely review, this will give some reassurances. For patients with rectal bleeding, methylated SEPT9 test will be a better option to exclude colorectal cancer. 32 The multitarget stool DNA test performance has an increased sensitivity for detecting advanced precancerous lesions compared with FIT alone when screening an average-risk colorectal cancer population. 30 Introducing such non-invasive tests may reduce the burden on invasive tests by over 40% as shown in a study Mowat et al. 33 As most nations that have been debilitated with the COVID-19 pandemic are now beyond the curve, i.e. R<1 and in the recovery phase, a stepwise resumption of prioritized elective endoscopy services, guided by current hospital endoscopy space, availability of personnel, equipment supplies, increased infection prevention training for staff and self-protection. A practice statement from the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID) provides a thorough guide on how to implement endoscopy services. 34 The perioperative risk of colorectal surgery in the COVID-19 pandemic needs to be assessed. In a small retrospective analysis of 34 operative patients who developed COVID-19 pneumonia shortly after surgery, 15 (44.1%) patients required ICU care and the mortality rate was 20.5%. 35 As the impact of major surgery and contracting COVID-19 in the immediate postoperative phase may lead to significant increased morbidity and mortality, it will be prudent to defer surgery for patients with high risk factors. These include patients ≥70 years of age, history of COPD, diabetes, hypertension, cardiovascular disease, and cerebrovascular disease. 36 Further stratifying perioperative risk using the factors discussed above and the American Society of Anesthesiologists (ASA) will be recommended. 37 Patients with cancer are more susceptible to infection because of their immunosuppressive state caused by the malignancy and anticancer treatments and subsequently, one might expect these patients to have an increased risk of COVID-19 and a poorer outcome. 38(p2) It is accepted that colorectal cancer tumors typically grow over many months and years prior to clinical presentation, thus one would expect that the delays to surgery should not have a negative impact on patient outcomes. It is therefore unlikely that deferral of surgery for 8-12 weeks is likely to have any effect on the survival outcome of colon cancer patients as supported by a number of investigatory studies. [39] [40] [41] A study of 4,685 patients which showed no association between treatment delay and reduced overall survival in colon cancer patients. In this study when compared to patients undergoing surgery in the first week after diagnosis, there was no increased risk of death until a waiting time >84 days. 39 Their finding was also supportive in a systematic review by Hangaard patients. The treatment delay intervals ranged from 1-56 days and they concluded that the available data showed no association between treatment delay and reduced overall survival in colon cancer patients. 40 There is no consensus regarding the optimal time to initiate adjuvant chemotherapy after surgery for stage III colon cancer and most oncologist subject to postoperative complications prefer to initiate this treatment within a 12-week from surgery. For adjuvant chemotherapy for Stage III colon cancer, delay of therapy to less than 8 weeks will be desirable as a delays after 8 weeks may be associated with a significantly worse overall survival. 42 As the survival benefit of adjuvant therapy after 3 months is questionable, an analysis of the risk versus a gain of timely chemotherapy post-surgery in patients who may benefit from this therapy should be considered in each situation. 42 For rectal cancers (Stage I-II) a consideration for surgical deferral may be made.

However, patients with T1 lesions of the rectum a strong argument may undergo transanal endoscopic microsurgery (TEMS) resection or endoscopic submucosal dissection (ESD) as an organ preservation procedure as deferral will likely cause progression of the tumor and subsequently requiring an anterior resection. In addition, in these COVID-19 times, one could also make an argument to offer all patients the non-standard approach of shortcourse preoperative radiotherapy (SCPRT) on the basis of a multicenter study of shortcourse radiotherapy and TEMS 8 weeks later for early rectal cancer on patients (T1/T2). In this study, patients who were generally considered high risk or who refused total mesorectal excision (TME) surgery underwent this approach with 32% obtaining a complete pathological response after TEMS resection of the residual lesion or scar. Since early rectal tumors appear to have a better response to neoadjuvant therapy than advanced lesions, the advantage of this approach is that it reduces the requirement for surgery or endoscopic resection during the peak and aftermath of the pandemic and therefore may avoid the need for any interventional procedures after radiotherapy. As this is a non-standard approach, a discussion and debate will be required in one's representative colorectal MDT group. 43 Both short course (5 x 5 Gy) preoperative radiotherapy (SCPRT) with immediate surgery and long-course (25-28 × 2-1. 44, 45 The approach in the RAPIDO trial for high risk rectal cancer patients of SCRT followed by chemotherapy (6 cycles CAPOX or alternatively 9 cycles FOLFOX4) and subsequent surgery may be a surgical option during the COVID-19 pandemic but the primary endpoint and long term outcomes of this approach are yet to be determined from the trial. 46 In patients who have completed chemoradiotherapy and now require surgery, an option may be to extend the time to surgery to 14-16 weeks if post neoadjuvant restaging MRI demonstrates a favorable tumor regression as this is generally associated with a good overall survival and disease-free survival. [47] [48] [49] [50] Sloothaak et al in-review of 1593 Dutch patients who underwent preoperative CRT for rectal cancer showed that the maximal benefit of neoadjuvant chemoradiotherapy was 16 weeks. 47 The role of adjuvant chemotherapy after preoperative is a controversial issue and a recent review from Glimelius, apart from the randomized phase II trial (ADORE) which was published in 2019, there has been no new randomized trials using current oncological drugs and protocols since 2015. 50 As previous studies were small and prematurely terminated because of poor patient compliance in completing the treatment, it is difficult to be certain if adjuvant chemotherapy significantly reduces the risks of recurrence in patients who have received neoadjuvant chemoradiotherapy. Therefore, during COVID-19 it may be very reasonable to be highly selective in recommending adjuvant chemotherapy thereby reducing unnecessary additional hospital visits and risky immunosuppressive therapy during the pandemic. patients, the guidelines do not recommended SEMS placement, as a bridge to elective surgery, for malignant colonic obstruction however during the pandemic this may be considered. However, stent perforation risk of approximately 5.88% in a recent Cochrane review, concern regarding micro perforation leading to increased incidence of perineural invasion, concerns of poorer oncological survival and overall systemic recurrence needs to be considered. [52] [53] [54] To reduce the risk of SEMS related complications, stent procedures are best performed in units that are currently providing this service otherwise patients are best managed with a resection or proximal diversion during the pandemic. Stenting of nonobstructive patients is not recommended even though it may not be able to traverse a malignant lesion endoscopically.

For patients receiving adjuvant or neoadjuvant chemotherapy, whenever possible treatment should continue. However, to prevent COVID-19 disease in these immunosuppressed patients, patients should be shielded and self-isolating. In patients who contract COVID-19 during therapy, treatment may recommence when they have clinically recovered from the disease and obtained at least two negative oronasopharyngeal SARS-CoV-2 RT-PCR swab test per protocol.

Our global colorectal surgical community has been greatly impacted by COVID-19

and we hope this manuscript gives some further guidance. While much of the world is now on the downside of the curve with the COVID-19 disease, we anticipate the pandemic to As respondents could select one or more options, the % provided above are the % of the whole number of ticked options for both preoperative and intraoperative options As respondents could select one or more options, the % provided above are the % of the whole number of selected options for factors of prioritizing patients for elective major surgery for colorectal cancer As respondents could select one or more options, the % provided above are the % of the whole number of selected options for changes to neoadjuvant and adjuvant treatment during the pandemic? 

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Elective major benign procedures are for patients who have not been acutely admitted into hospital and requiring urgent/emergent surgery. Perioperative precautions + intraoperative precautions i.e. preop COVID-19 testing (SARS-CoV-2 swab testing), perioperative self-isolation, preop chest CT scans, PPE for all operating staff, relatively 'free' COVID-19 hospitals, isolated COVID-19 surgical wards Yes No Continue but with perioperative precautions + intraoperative precautions 10. Do you think that currently ALL MAJOR ELECTIVE COLORECTAL CANCER surgical procedures should continue? Elective major colorectal cancer procedures are for patients who have not been acutely admitted into hospital and requiring urgent/emergent surgery. Yes No Continue but with perioperative precautions + intraoperative precautions consider? Select one or more options Perioperative self

SARS-CoV-2 swab testing) of hospital staff Preoperative chest CT Scan Only operating in a relatively 'Free' COVID-19 hospitals (i.e. hospitals not accepting COVID-19 patients and performing procedures to ensure a SARS-CoV-2 virus free hospital environment) Personal Protective Equipment (PPE) for all operating staff Isolated COVID 'Free' surgical wards Not applicable -I did not select the option

At the current moment what of these are you doing in your hospital for patients having ELECTIVE SURGERY FOR COLORECTAL CANCER? Select one or more options Perioperative self-isolation for a minimum number of days