key: cord-1025400-iyp4xdqj
authors: Patkar, Shraddha; Voppuru, Saiesh R.; Thiagarajan, Shivakumar; Niyogi, Devayani; Niranjan, Hemant S.; Nadkarni, Shravan; Singh, Tejpratap; Bhandare, Manish; Thakkar, Purvi; Rohila, Jitender; Biswas, Sanjay; Epari, Sridhar; Shetty, Omshree; Gurav, Mamta; Bapat, Prachi; Puri, Ajay; Pramesh, C. S.
title: Incidence of SARS‐CoV‐2 infection among asymptomatic patients undergoing preoperative COVID testing prior to cancer surgery: ASPECT study
date: 2021-11-16
journal: J Surg Oncol
DOI: 10.1002/jso.26753
sha: 8174c151df560e19919ddcd8c0bf2851c90c66c4
doc_id: 1025400
cord_uid: iyp4xdqj

BACKGROUND AND OBJECTIVES: The COVID‐19 pandemic, with high rate of asymptomatic infections and increased perioperative complications, prompted widespread adoption of screening methods. We analyzed the incidence of asymptomatic infection and perioperative outcomes in patients undergoing cancer surgery. We also studied the impact on subsequent cancer treatment in those with COVID‐19. METHODS: All patients who underwent elective and emergency cancer surgery from April to September 2020 were included. After screening for symptoms, a preoperative test was performed from nasopharyngeal and oropharyngeal swabs before the procedure. Patients were followed up for 30 days postoperatively and complications were noted. RESULTS: 2108 asymptomatic patients were tested, of which 200 (9.5%) tested positive. Of those who tested positive, 140 (70%) underwent the planned surgery at a median of 30 days from testing positive, and 20 (14.3%) had ≥ Grade III complications. Forty (20%) patients did not receive the intended treatment; 110 patients were retested in the Postoperative period, and 41 (37.3%) tested positive and 9(22%) patients died of COVID‐related complications. CONCLUSION: Routine preoperative testing for COVID‐19 helps to segregate patients with asymptomatic infection. Higher complications occur in those who develop COVID‐19 in postoperative period. Prolonged delay in surgery after COVID infection may influence planned treatment.

The COVID-19 pandemic has had a major impact on the conduct of cancer surgeries, with an estimated 2.3 million procedures being canceled worldwide. 1 Studies have documented higher pulmonary complications and mortality in patients with perioperative severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection. 2 Aerosol-generating procedures in infected patients place operating room staff at greater risk of infection. As the pandemic progressed, it became apparent that many of the infections were asymptomatic, and these asymptomatic individuals could still transmit the infection to other patients and healthcare workers. Studies have shown the incidence of asymptomatic infection in the range of 1.6%-56.5%. 3, 4 This has important clinical implications, as asymptomatic individuals are also infectious, 5 besides being at risk of developing the severe disease later. Early detection may reduce cross-infection and, also help manage resources more effectively. 6 To continue time-sensitive cancer surgeries while minimizing the risk of postoperative morbidity in patients, and the risk of infection in hospital personnel, we implemented routine preoperative testing for SARS-CoV-2 for all elective and emergency surgical procedures at our institute.

Currently, data from routine preoperative testing of asymptomatic individuals is available from small studies only. [6] [7] [8] Moreover, there is scarce data on the impact of a positive COVID-19 diagnosis, on treatment for patients with cancer originally planned for surgical resection. In our study, we sought to ascertain the incidence of asymptomatic COVID-19 infection in patients scheduled for elective and emergency cancer surgery in a high-volume cancer center. We also assessed the early postoperative (30-day) complications and the impact on subsequent cancer treatment in those who tested positive.

We conducted a retrospective analysis of a prospectively maintained database of patients who underwent preoperative testing for COVID-19 infection at the Tata Memorial Hospital, between April 2020 and September 2020. All patients who were scheduled to undergo elective and emergency cancer surgery under general anesthesia during this period were included in the study.

Patients planned for elective cancer surgery were contacted telephonically and screened for symptoms at a dedicated "fever clinic" in the out-patient department (OPD). Only those who were asymptomatic were planned for surgery and underwent a mandatory preoperative test from nasopharyngeal and oropharyngeal swabs collected in the viral transport medium (VTM) within 48 h before the scheduled surgery. The samples were subjected to ribonucleic acid (RNA) extraction and subsequent one-step reverse transcriptionpolymerase chain reaction (RT-PCR) using the Indian Council of Medical Research (ICMR) approved viral RNA extraction and COVID PCR kits (with primers for at least two target viral genes-S/N/E/ORF genes). The tests were run with at least one known (kit provided) positive control, no template (plain VTM) control, and one control of water, that is, no template no VTM control. The tests were interpreted as negative, inconclusive, and positive as per standard criteria laid by the kit protocol.

Patients with negative tests were admitted and underwent surgery as planned in the same indoor admission. Patients with an inconclusive report had a repeat test and two consecutive inconclusive reports were considered as a positive result according to institute protocol. Patients who tested positive, and were scheduled to undergo elective surgery, were admitted to a dedicated COVID-19 isolation ward and monitored for symptoms and disease severity, or isolated at home if they had the facility. Patients opting for home isolation were counseled to report telephonically in case of worsening of symptoms. After an isolation period of 15 days, patients were retested and those with two consecutive negative results more than 24 h apart without symptoms were considered suitable to resume surgical treatment as planned. In the event of a persistent positive result, the test was repeated at weekly intervals till the patient tested negative twice.

Patients who required emergency surgery had the swabs collected and the surgery was performed in a designated "COVID" 

A total of 2108 asymptomatic patients were tested preoperatively for SARS-CoV-2 by RT-PCR between April 21st and September 30th, 2020. Of these, 2034 (96.5%) were planned for elective surgery and 74 (3.5%) needed to undergo emergency surgery. One hundred and ninety-four (9.2%) patients tested positive, and 15 patients (0.7%) had inconclusive reports (Table 1) . Of the 15 patients with inconclusive results, a repeat swab was performed in all, of which six tested inconclusive again, and hence were considered positive as per institute protocol and advised isolation. Nine patients tested negative and were admitted for the planned surgery. Therefore, the overall asymptomatic positivity rate was 9.5%. (200/2108). Adults (>15 years) had a positivity rate of 9.7% (198/2032) while the lowest positivity rate was seen among pediatric patients (n = 2/76; 2.6%)

Of the 200 patients who tested positive, 140 (70%) underwent the prior planned surgery at our institute during the study period; Table 3 .

Our study showed that a substantial proportion of asymptomatic Being a high-volume cancer center, the endeavor to sustain ongoing cancer care at our hospital relied on the implementation of a multipronged strategy. 14 Our study should be interpreted with some caveats. The period when the testing was done coincided with the peak incidence of COVID-19 infection in the region. 17 Our results may therefore not be applicable in regions or periods when prevalence is low. Despite this 

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Incidence of SARS-CoV-2 infection among asymptomatic patients undergoing preoperative COVID testing prior to cancer surgery: ASPECT study

The authors would like to acknowledge the Central Research Secretariat (CRS) for aiding with statistical analysis used in the study.

The authors declare that there are no conflict of interests.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

http://orcid.org/0000-0001-8489-6825Saiesh R. Voppuru http://orcid.org/0000-0003-1521-1145Devayani Niyogi http://orcid.org/0000-0002-9767-3046Ajay Puri http://orcid.org/0000-0002-4323-753X