key: cord-0996468-qmmt0s94
authors: Wang, Yiyang; Zhang, Yonghui; Bao, Feichao; Hao, Xiuxiu; Yu, Fenghao; Lin, Boyu; Gu, Zhitao; Fang, Wentao
title: The feasibility and safety of routine thoracic surgeries in the low risk areas during the COVID-19 pandemic
date: 2021-01-19
journal: JTO Clin Res Rep
DOI: 10.1016/j.jtocrr.2021.100144
sha: 32aabd66d89afd9de3a859e7967c1c1ef85f5f77
doc_id: 996468
cord_uid: qmmt0s94

Corona virus disease 2019 (COVID-19) has been under good control and work resumption has been gradually carried out in most parts of China including Shanghai after March 2020. However, intense focus and resources have been diverted to COVID-19 patients, leaving patients with diseases other than COVID-19 somehow neglected due to limited access to routine health care. And whether routine thoracic surgery service is safe in low risk areas of COVID-19 infection is still unknown. We hereby retrospectively analyzed the quantity and quality of thoracic surgeries performed by a single team from Shanghai Chest Hospital between January and May 2020, compared with the corresponding period last year. Results suggested that comparable qualities of diagnosis and surgical treatment as well as perioperative outcomes were safely and successfully achieved. Total number of surgical procedures gradually increased and surpassed the corresponding period last year when the situation of COVID-19 has been in good control in Shanghai by April. Importantly, neither medical staffs nor patients were diagnosed of COVID-19 infection. In conclusion, although COVID-19 has made significant impact on elective surgery for thoracic diseases, it is safe and feasible to carry out routine thoracic surgery services in low risk areas, provided that careful screening of COVID and thorough protection of medical staffs and patients are taken. Hopefully, these findings would serve as a useful reference for thoracic departments all over the world during the COVID-19 pandemic, especially after work resumption.

The outbreak of corona virus disease 2019 , caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), has infected more than 7 million people and caused more than 40 thousand confirmed deaths worldwide by the date of June 12, 2020 [1] . This unprecedented pandemic has imposed huge social and healthcare burdens and exacerbated the relative shortage of medical resources around the world. More importantly, patients with chronic diseases including various cancers are more susceptible to SARS-COV-2 infection for their systemic immunosuppressive state and have much worse prognosis [2, 3] . Therefore, treatments for cancer patients, especially those needing elective surgery, have become a dilemma and call for guidance during the COVID-19 pandemic.

After stringent and effective measures including city lockdown, personal quarantine, social distancing, and the general practice of using face masks, the situation of COVID-19 has been gradually under control in China [4] . However, since the beginning of work resumption in April, hospitals have been facing new challenges from a long waiting list of cancer patients plus the existing burdens of COVID-19 prevention and control.

In this report, we compared the quantity and quality of thoracic surgical procedures by a single team of thoracic surgeons at the Shanghai Chest Hospital from January to May 2020, with the corresponding period in last year. We tried to elucidate the safety for routine thoracic service at the time of COVID-19 outbreak and during work resumption in a low risk area.

Patients treated by a single team of surgeons at the Department of Thoracic Surgery, Shanghai Chest Hospital, during January 1, 2020 to May 31, 2020 and those treated during January 1, 2019 to May 31, 2019, whose data were retrieved from our database.

Patients receiving surgical operation during these two intervals were included in this analysis.

The primary objective was to analyze the number of elective procedures between these two time periods. And the secondary objectives were to compare the clinicopathological characteristics, surgical procedures and perioperative results of this year with the corresponding period last year.

In order to prevent potential COVID-19 infection, multiple measures were undertaken and adjusted according to the situation of COVID-19 in Shanghai ( Figure 1 ).

1. After February 2020, when the COVID-19 pandemic was raging all around China, chest computed tomography (CT) and routine blood examination (white blood cell count) as well as a 14-day quarantine were required for every patient before thoracic operation to rule out COVID-19 infection. Importantly, patients from epidemic areas as well as patients with suspected symptoms including fever, aspiration difficulty, etc, were not permitted into the hospital. After admission, each patient was required to put on face mask and keep social distance. Each room was only allowed for 2 patients in maximum. Surgeries for patients with small subcentimeter lesions or pure GGO who were considered at low risk were postponed. As for protection for medical staffs, face masks were a must for medical staff inside the hospital. Isolation gowns and eye protections were encouraged during invasive examinations and surgical procedures.

2. In late March and early April, when facing an increasing number of imported cases and potential secondary outbreak during work resumption, viral nucleic acid detection was added to our requirement lists for both patients and visiting family members apart from those procedures mentioned above. However personal quarantine was no longer required for patients from out of Shanghai with negative viral nucleic acid results.

J o u r n a l P r e -p r o o f 3. After May 2020, chest CT scan and routine blood exams as well as s viral nucleic acid detection were still definitely required, but there was no more any limitation on surgical indications. A 14-day personal quarantine was no longer required for those patients not from epidemic areas. Necessary protection for medical staffs were still considered of great importance for the prevention of COVID-19 hospital infection.

Categorical variables and continuous variables were presented as frequencies (percentages, %) and mean values ± standard deviation (SD), respectively.

Differences of categorical variables were testified by Pearson χ2 or Fisher's exact test, when appropriate. And differences of continuous variables were tested by the Student t test, using SPSS (version 22.0). Statistical differences were set as two-sided p<0.05.

year were plotted by the broken line graph using GraphPad (Prism 5). (Table 1) . More importantly, surgery-related characteristics and perioperative outcomes were consistent with or even better than those of the corresponding period last year (Table 2) Hospital has made great efforts and had zero infection after February 2020. According to our initial experience, chest CT scan and routine blood exams as well as s viral nucleic acid detection were all of great importance for the screening of potential COVID-19 infected persons and carriers before admissions. Wearing face masks and keeping social distance were also of significance for those in-patients. Besides, it was safe for our medical staffs to perform surgical operations as well as invasive examinations including bronchoscopy, esophagoscopy, etc, as long as necessary personal protection and pre-screening were done. As for the surgical safety, rescheduling elective surgeries, especially those early-stage lung cancers, may have helped prevent the risk of COVID-19 infection during the pandemic [7, 8] . Usually over 90% of thoracic surgeries in Shanghai Chest Hospital were conducted via minimally invasive surgery, large amount of which were for early stage lesions.

During the peak of the COVID-19 pandemic, the indication for thoracic surgery, especially pulmonary surgery was carefully re-considered. Therefore, when surgery for those patients with small subcentimeter lesions or pure GGO were re-considered and temporarily withhold, the proportion of patients with locally advanced diseases needing complex open procedures increased accordingly. However, from our own experience and statistics, it is safe to perform thoracic procedures especially open surgeries under corresponding regulation and protection and could achieve comparable perioperative outcomes compared with last year and the COVID-19 pandemic had limited impact on our treatment strategy, especially for locally advanced thoracic diseases. We are glad to find out that careful screening and examination as well as quarantine for COVID-19 did not compromise the quality of thoracic surgeries. And sustainable growth has been witnessed since February 2020 and especially since the full work resumption after April in Shanghai, China.

In the aspect of postoperative complications, when comparing between these two years, we noticed that postoperative complication rate was decreased in the first two month of 2020 during the peak of the COVID-19 pandemic, when surgical indication was strictly reconsidered and surgical volume was largely decreased. And complication rates in each month of 2020 was all lower than the same month of last J o u r n a l P r e -p r o o f year (Appendix Figure 1) . When referring to the pulmonary surgeries, there was not any serious postoperative complication in the first two months in 2020. As the situation of COVID-19 became well controlled since March 2020, postoperative complication rate was slightly elevated as the surgical volume gradually increased, becoming similar to the corresponding period of last year (Appendix Figure 2) . It would wrong and unethical to encourage the rest of the world to copy our method without discriminating. However, we are confident to say that we did set a successful example for hospitals that are on the similar scale of COVID-19 crisis.

In conclusion, the COVID-19 has a significant impact on the elective operations for thoracic disease for a delay of almost two months. However, routine thoracic surgery as well as invasive examinations could be performed safely as long as careful 

Coronavirus disease (COVID-19) outbreak situation

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Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

Active and Effective Measures for the Care of Patients With Cancer During the COVID-19 Spread in China

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic

Treatment Guidance for Patients With Lung Cancer During the Coronavirus

Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic

The authors thank all the patients for their courage and trust for receiving thoracic surgery in our Department of Thoracic Surgery during this unprecedented pandemic era.

Written informed consent was waived by the Institutional Review Board of Shanghai Chest Hospital.J o u r n a l P r e -p r o o f