key: cord-1051644-r18dgzj0
authors: Fitzmaurice, Gerard J.; Ryan, Ronan J.; Young, Vincent K.; Wall, Carmel; Dunne, Eimhin; Dowd, Noreen; McDermott, Grainne; Broderick, Alan; Fanning, Niall
title: Thoracic Surgical Oncology –Maintaining a High-Volume Surgical Program during the Covid-19 Pandemic
date: 2020-06-05
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.05.017
sha: 9f6e79c97ce6c76aa290bcc38fce25a6f298430d
doc_id: 1051644
cord_uid: r18dgzj0

Abstract Thoracic surgical oncology is a time sensitive, high resource, complex surgical speciality to which Coronavirus has posed a unique challenge. In response to the evolving situation in mainland Europe, our department rapidly established a Covid-free site to maintain elective cancer surgery. This necessitated a strict admission pathway and perioperative patient management. It resulted in the maintenance of a high-volume, high-quality thoracic surgical oncology program with no Covid-19 positive cases to date. Maintaining satisfactory training levels amongst surgical and anaesthetic trainees has also been achieved. We suggest that this model could be adapted to local resource capabilities.

Thoracic surgical oncology is a time sensitive, high resource, complex surgical speciality to which Coronavirus has posed a unique challenge. In response to the evolving situation in mainland Europe, our department rapidly established a Covid-free site to maintain elective cancer surgery. This necessitated a strict admission pathway and perioperative patient management. It resulted in the maintenance of a high-volume, high-quality thoracic surgical oncology program with no Covid-19 positive cases to date. Maintaining satisfactory training levels amongst surgical and anaesthetic trainees has also been achieved. We suggest that this model could be adapted to local resource capabilities.

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The evolving Coronavirus pandemic presented a unique challenge in thoracic surgical oncology due to the increased potential for aerosolisation of Coronavirus peri-operatively. Consequently our department instituted an early transfer of all elective thoracic surgical oncology to a dedicated non-Covid private hospital. This was facilitated by the extension of clinical indemnity by the Irish State to cover public patients in private institutions and agreement by the Irish Medical Council to enable doctors in training to work across hospital sites.

The designated private healthcare institution was an established high volume cardiac surgical centre, however it had limited experience of high volume complex thoracic surgery. An intense training period for theatre, critical care, and ward staff was undertaken prior to transfer of patients. This involved moving a team of three Cardiothoracic Surgeons, three Cardiothoracic Anaesthetists, two Cardiothoracic Specialist Registrars, one Anaesthetic Specialist Registrar, and one Advanced Nurse Practitioner from their primary base hospital. In addition specific surgical equipment, in particular minimally invasive instruments and a Video-Assisted Thorascopic Surgery (VATS) camera stack, were transferred.

To comply with strict public health measures, in-person pre-admission patient assessments were limited. Consequently individual cases were discussed in a collaborative manner by the operating team to risk stratify cases. We instituted a strict admission pathway with the aim of establishing and maintaining a Covid-free environment. We developed our admission and Covid screening pathways following discussion with colleagues locally and internationally and in conjunction with evolving guidance from national surgical and anaesthetic societies [1] [2] [3] . Patients listed for surgery were asked to self-isolate within their household for up to 14 days pending admission. Those who passed a screening questionnaire (symptom screen including anosmia, contact history, previous test for Coronavirus, and recent travel history) were invited to attend hospital for admission 2-days preoperatively. They were assessed by a consultant physician and their temperature, white cell count (WCC) and C-reactive protein (CRP) were reviewed. They underwent a screening Computed Tomography (CT) Thorax and if there were no findings suggestive of Covid-19 infection, the patient was admitted to a single room on the cardiothoracic ward [1] . A nasopharygeal SARS-CoV-2 swab (PCR) was taken with a processing time of approximately 24 hours. Only patients with negative results for all tests proceeded to surgery. Staff have not been screened and were only tested for Coronavirus if symptomatic while self-isolating.

Intubation and extubation of all patients was performed in the operating room with the minimum necessary staff consisting of the anaesthetist, anaesthetic trainee, and anaesthetic nurse. As these were aerosol generating procedures, all staff wore PPE including an FFP-2 mask and visor.

Inhalational anaesthesia was provided using a double lumen endotracheal tube to facilitate lung isolation with placement confirmed using a disposable Ambu bronchoscope. Surgical bronchoscopic assessment was only undertaken in cases with potential for a sleeve resection. Following deflation of the operative lung, a closed airway circuit was maintained for the duration of the procedure. The surgical team wore FFP-2 masks and surgical gowns. A single chest drain was placed for all cases attached to a Thopaz electronic closed drainage system. The patients were managed throughout their stay in single rooms, including in the critical care area. Chest drains were removed within normal practice parameters by nursing staff wearing PPE and a surgical mask with visor. Patients were discharged via the traditional pathway. Maintaining satisfactory training levels amongst surgical and anaesthetic trainees has also been achieved.

We believe this demonstrates that a safe and rapidly scaled 'Covid-free' thoracic surgical oncology program can be instituted to optimise patient care during the Coronavirus pandemic. A strict admission pathway is central. The operative risk profile can be adjusted as experience develops. An additonal benefit has been the maintenance of training. We suggest that this model could be adapted to local resource capabilities.

RCSI Policy Statements: Intercollegiate Guidance for Pre-Operative Chest CT imaging for Elective Cancer Surgery during the COVID-19 Pandemic

NHS Clinical Guide for the Management of Essential Cancer Surgery for Adults during the Coronavirus Pandemic

Safe Reintroduction of Cardiovascular Services during the Covid-19 Pandemic: Guidance from North American Society Leadership