key: cord-0905358-basd97qk
authors: Özdemir, Yılmaz; Temiz, Ayetullah
title: Surgical treatment of gastrointestinal tumors in a COVID‐19 pandemic hospital: Can open versus minimally invasive surgery be safely performed?
date: 2021-08-19
journal: J Surg Oncol
DOI: 10.1002/jso.26653
sha: 5f30fe0876597a491087e1633d80c27f60168c39
doc_id: 905358
cord_uid: basd97qk

PURPOSE: In order for patients with gastrointestinal cancer not to suffer the consequences of delayed treatment, they should be operated on in pandemic hospitals under adequate conditions. We aimed to discuss the outcomes of our gastrointestinal cancer surgery patients and to present our patient management recommendations to resume operative treatment during the ongoing COVID‐19 pandemic while taking into account hospital facilities. MATERIALS AND METHODS: This study included 129 gastrointestinal cancer patients who underwent surgery between March 2020 and May 2021 in the gastrointestinal surgery clinic of our hospital, which was assigned as a pandemic hospital in March 2020. Patients' demographic characteristics and preoperative and postoperative findings were recorded. RESULTS: Among the patients, 42.6% (n = 55) were female and 57.3% (n = 74) were male. The mean age was 61.89 ± 3.4 years. The primary tumor organs were the stomach 37.2% (n = 48), pancreas 36.4% (n = 47), rectum 11.6% (n = 15), colon 8.5% (n = 11), and esophagus 6.2% (n = 8). The patients were treated with open (75.2%, n = 97) or minimally invasive surgery (24.8%, n = 32; laparoscopic 11.6%, n = 15; robotic 13.2%, n = 17). Eight patients tested positive for COVID‐19 before surgery. No patients developed COVID‐19 during postoperative intensive care or after being moved to the floor unit. There was no COVID‐19‐related morbidity or mortality. CONCLUSION: Failure to treat gastrointestinal cancer patients during the pandemic may result in undesirable consequences, such as stage shift and mortality. Cancer patients can be treated safely with conventional and minimally invasive surgery guided by current recommendations and experience.

COVID-19, the disease caused by a novel coronavirus (2019-nCoV), was declared a pandemic by the World Health Organization (WHO).

The agent causing COVID-19 pneumonia was established to be severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1 Following its rapid spread around the world, COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. 2 This agent infected host cells via the angiotensin-converting enzyme 2 (ACE2). The ACE2 receptor is expressed not only in pulmonary alveolar cells but also in the enterocytes of the intestinal mucosa. 3, 4 SARS-CoV-2 RNA has also been detected in feces. Due to the risk of disease transmission, gastrointestinal surgeons must meticulously follow adequate measures. Frontline healthcare workers are at increased risk of exposure to and illness from COVID-19, which may also compromise the workforce fighting the epidemic. 5 Open surgery and particularly extensive upper abdominal surgery are associated with an increased risk of pulmonary complications. 6 An open surgical approach should be avoided to reduce the length of hospital stay and possible postoperative morbidity, thereby reducing the in-hospital spread of COVID-19. Although minimally invasive surgery improves short-term patient outcomes and is associated with faster recovery compared to traditional surgery, there are concerns regarding the application of minimally invasive surgery in patients potentially infected with COVID-19. Infectious pathogens can potentially be transmitted via surgical smoke. 7, 8 There is no concrete evidence suggesting that SARS-CoV-2 can be transmitted to operating room staff during electrosurgery. Transmission of various diseases through surgical smoke has been reported 7 ; however, documented cases of RNA virus transmission are very few. 8 Healthcare workers should be protected against the possible risk of Clavien-Dindo classification score) and postoperative (tumor stage, mortality, and 30-day follow-up) findings were recorded. The duration of the operation was defined as the time that elapsed between the first skin incision and the last suture.

Nasopharyngeal swab (polymerase chain react [PCR]) results for samples obtained upon admission and on the day before the operation (>5 days after admission) were recorded. After surgery, the patients were not routinely tested for COVID-19 and PCR tests were performed only on clinical suspicion. The standard procedure was 5 days of hospital stay before surgery for all patients. The reasoning behind waiting for at least 5 days was to be able to identify patients who had unknowingly contracted COVID-19 but did not develop symptoms, to minimize risk. However, in exceptional cases in which the patients developed tumor-related complications and required emergency surgery, they were operated on without waiting for 5 days. Patients' symptoms were monitored throughout their hospital stay. Interventions were postponed for all patients with clinical suspicion. A second PCR test was performed on the day before the operation. Patients who tested negative and did not have any COVID-19 symptoms underwent elective surgery. Staff that transferred patients used personal protective equipment.

All patients underwent surgery in the same operating room by the same surgical team, with the exception of robotic surgery patients, who underwent surgery in the robotic operating room. All operating rooms were maintained at negative pressure. The operating room staff was not assigned to any other hospital unit. The surgical staff used personal protective equipment including N95 masks, surgical caps, gloves, face and eye protection, and surgical shoe covers.

Although the patients tested negative for COVID-19, they were regarded as COVID-19-positive during the operation. All patients were extubated in the operating room.

The patients were transferred to an intensive care unit (ICU) postoperatively. The intensive care rooms were private isolated rooms maintained at negative pressure. The medical personnel took great care to adhere to isolation measures to prevent patient-to-patient transmission. The patients were transferred to the floor unit after stabilization in the ICU. In the floor unit, each patient was admitted to a private room, with only their caregiver being allowed to stay in the same room. The patient and caregiver were not allowed to leave the room. Visitors were not allowed until the patient was discharged.

PCR tests were performed when patients developed symptoms suggestive of COVID-19, such as a fever. Thoracic CT scans were performed when required. Before discharge, the patients were advised and trained about 15-day self-isolation, mask use, social distancing, and hygiene.

The data were analyzed using SPSS v.21.0. The results were presented as numbers and percentages for categorical variables and as mean ± standard deviation for continuous variables. istics of the patients who tested positive for COVID-19 before surgery are given in Table 3 .

No patients developed COVID-19 during postoperative intensive care or after being moved to the floor unit. There was no COVID-19related morbidity or mortality. None of the patients were readmitted due to COVID-19.

In the context of the COVID-19 pandemic, cancer patients deserve special attention due to their immunocompromised status and, therefore, higher vulnerability to infection. Emergency surgery for gastrointestinal tumors due to bleeding or obstruction is not up for discussion. However, considering that it is unknown how long the pandemic may last, to prevent the possible consequences of delayed treatment, patients who require elective operations should undergo treatment provided that the necessary measures are taken before, during, and after surgery. Untreated tumors can progress into more advanced and possibly inoperable stages. 9 Since the beginning of the pandemic, gastrointestinal cancer associations have published nonevidence-based recommendations. [10] [11] [12] [13] These early guidelines were characterized by a sense of panic. Hospitals in Wuhan, China, the United States, and multiple European countries operated at maximum capacity and many were forced to Both methods are associated with their own specific sets of risks, including the aerosol-generating procedures performed during laparoscopic surgery, and the increased risk of contact with the patient's bodily fluids in conventional surgery. 18 The relevant recommendations include using CO 2 filters in laparoscopy or robotic surgery, minimizing the size of port site incisions to prevent air leakage, minimizing the use of monopolar cautery, ultrasonic dissectors, and advanced bipolar devices in both laparoscopic and conventional surgery to prevent aerosolization, and using devices with attached smoke evacuators when possible. 5 the patients underwent open and 24.8% underwent minimally invasive surgery (11.6% laparoscopic and 13.2% robotic surgery). We performed minimally invasive surgery with maximum possible adherence to the recommendations mentioned above. Minimally invasive surgery is associated with longer operation times, as was the case in our study, and may increase the risk of COVID-19 transmission due to the factors listed above; that said, none of our patients or staff contracted COVID-19 during the described treatment process.

In the present study, we found that laparoscopic and robotic surgeries do not create any additional risk of infection compared to conventional surgery and can be performed safely provided that necessary measures are taken.

To conclude, failure to treat gastrointestinal cancer patients during the pandemic may result in undesirable consequences such as stage shift and mortality. In reference to our experience as a pandemic hospital during the COVID-19 pandemic, we think that cancer patients can be treated safely with conventional and minimally invasive surgery guided by current recommendations and experience. Although aerosolization during minimally invasive surgery creates a risk of disease transmission, minimally invasive surgery appears to be advantageous in terms of the safety of the operating room personnel, especially due to the shorter postoperative hospital stay and reduced exposure to contaminants such as surgical smoke and blood. There was no COVID-19-related morbidity or mortality among our participants. No participating hospital staff became infected during the study. The major limitation of our study is the lack of comparative analyses due to the small sample size.

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The authors declare that there are no conflict of interests.

Yılmaz Özdemir and Ayetullah Temiz conceived and designed the clinical trial, performed the experiments, analyzed the data, wrote the paper, conception of the manuscript, and critical revisions.

The data that support the findings of this study are available on request from the corresponding author.

https://orcid.org/0000-0002-5480-1140Ayetullah Temiz https://orcid.org/0000-0003-2178-3369